Event Registration

You may fill out this registration form yourself if you’re a young adult age 18 or older and would like to register for a Project LIFE event. If you’re younger than 18 and would like to register, please have your social worker or independent living coordinator fill out this form for you.

Event Registration

For Young Adults

Title of Event*
Date/Dates of Event*
If this is a workshop series, please list all dates the youth will be attending.
Region Youth Resides in*
Please enter the LDSS that holds custody for the youth:*
(Please do not use abbreviations).
Youth's First Name*
Youth's Last Name*
Youth's Gender*
- Male
- Female
Youth's Date of Birth*
Youth's Age*
Youth's Race*
If other, please specify:
Youth's Oasis Number
Youth's Type of Placement*
If other, please specify:
Youth's Address*
Street Address City State / Province / Region ZIP / Postal Code
Youth's Phone*
Youth's Email
Placement Contact Person's Name*
Placement Contact Person's Phone*
Placement Contact Person's Email*
Will the youth require medication(s) during this event?*
- Yes, the youth will require medications(s)
- No, the youth will not require medication(s)
Medications
Medications (if yes, the Project LIFE staff/volunteers will NOT be responsible for administering medication during this event. PLEASE NOTE: The agency/group home staff/guardian will need to administer.)
Family Services Specialist/Case Worker's Name*
Family Services Specialist/Case Worker's Phone Number*
Famly Services Specialist/Case Worker's Email*
Emergency Contact Person's Name*
Emergency Contact Person's Phone Number*
Relationship to Youth*
I understand that if the youth named on this form needs to be picked up early for any reason, it is my responsibility to do so. In instances involving illness or serious medical conditions which do not demand immediate medical treatment, I understand that United Methodist Family Services of Virginia will attempt to contact me at the telephone number(s) listed above. If United Methodist Family Services of Virginia is unable to contact me in such manner with promptness reasonable under the circumstances, I hereby give my consent and authorization to United Methodist Family Services of Virginia to provide any medical, surgical or psychological testing and/or treatment, which in the opinion of the medical department and doctor(s) selected by United Methodist Family Services of Virginia, is deemed appropriate for the well-being of the youth. UMFS frequently uses audio or visual recordings for a variety of publicity purposes. I realize that the use of such is strictly voluntary and at my discretion. My decision whether to grant consent or not will not affect services. I have been informed and understand the confidentiality policy and the confidential nature of information and will not hold UMFS liable for voluntarily or inadvertently disclosing information. Signatures (must be LDSS worker holding custody for youth) By typing my name below, I grant permission for the UMFS staff to transport (if necessary) this registered youth to and from offsite activities. I grant permission for the UMFS staff to contact this registered youth after this event through email, phone and/or Facebook. I recommend & grant permission for the youth listed on the registration form to attend this event.
Electronic Signature of Youth's LDSS Worker
If you do not wish to type your name as your signature, please print this page, sign it, and fax it to your regional Project LIFE Independent Living Consultant.
Date of Signature
Electronic Signature of Youth (If youth is 18 years of age or older)
If you do not wish to type your name as your signature, please print this page, sign it, and fax it to your regional Project LIFE Independent Living Consultant.
Date of Signature