Register | Maine Youth Leadership

Seminar

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For Students

For Parents & Guardians

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Download Forms (PDF)

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Seminar Rules

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Registration Form

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Medical History

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Social Media Agreement

Please mail all completed paper forms to: Jim Cox, 14 Trudy Circle, Old Orchard Beach, ME 04064.

It’s time to register!

We are excited to have you join us at MYL this year! Both the student and a parent/guardian should complete this form together.

If you would prefer to complete the forms by paper, you may download them in the left column and mail to Jim Cox, 14 Trudy Circle, Old Orchard Beach, ME 04064.

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Please wait to complete this form until you have been invited to register.

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May 28th-31st, 2026

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University of Souther Maine, Gorham Maine

Registration Form

1Registration

2Seminar Rules

3Medical History

4Social Media Agreement

Instagram

This field is for validation purposes and should be left unchanged.

Ambassador Information

Name(Required)

First Last

Preferred Name

Date of Birth

MM slash DD slash YYYY

Gender

T-Shirt Size

High School

Phone

Home Address

Street Address Address Line 2 City State ZIP Code

Mailing Address (if different)

Street Address Address Line 2 City State ZIP Code

Mailing Address

My mailing address is different than my home address.

Please note: Your contact information will be included on our end-of-seminar contact sheet passed out to all participants unless you notify us in advance of April 30th, 2025 to remove it.

Legal Guardian Information 1

Name

First Last

Relationship

Address

Street Address Address Line 2 City State ZIP Code

Occupation

Employer

Primary Phone

Work Phone

Legal Guardian Information 2

Name

First Last

Relationship

Address

Street Address Address Line 2 City State ZIP Code

Occupation

Employer

Primary Phone #

Work Phone #

Please contact Jim Cox (207-221-3196), if any legal access restrictions apply to your family situation.

Emergency Contact Information

Please include a person not included above. NOTE: any emergency calls will be made in the following order: Legal Guardian 1, Legal Guardian 2, Emergency Contact.

Name

First Last

Relationship

Primary Phone #

Secondary Phone #

Ambassador's Primary Care Physician

PCP Phone #

Travel Itinerary

I will arrive at seminar by:

Car driven by another person

Car driven by myself

Bus or Train

Other

What time and terminal does your bus or train arrive?

Someone from the seminar staff will pick you up.

Image & Photo Release

Maine Youth Leadership will be taking pictures and video for editorial, publicity, advertising and promotional use. Many of theses pictures are group pictures and individuals are not identified. You should be aware your image may be shared in this manner. Your image will NOT be sold or used in any manner inconsistent with Maine Youth Leadership’s guiding principles.

Phone & Email Address Information

Maine Youth Leadership shares participant information only with other Seminar participants for purposes of networking and staying connected with others sharing this unique experience, Your information will never be shared by MYL outside of our organization nor will it be published on any MYL social media site. MYL may use your contact information to perform outreach from time to time.

Legal Guardian Signature

Printed Name

Date

MM slash DD slash YYYY

Seminar Rules & Expectations

You have been selected to attend the Maine Youth Leadership 4-day seminar because you are an outstanding young leader. To ensure that the weekend’s activities run smoothly and safely, we ask your full cooperation in adhering to the following rules and regulations. Infractions may result in our immediately notifying your parents and sending you home.

You are to attend all seminar sessions and meals. Facilitators will be noting attendance at all events.
Without express written approval by your parent/guardian you are not permitted to leave the facility without being accompanied by a staff member, except to use restrooms while in the same building as Seminar sessions.
No tobacco usage (e.g. smoking, vaping or chewing), drinking of alcoholic beverages or drug use is permitted at any time.
You are not to separate from your assigned group without the knowledge and permission of your facilitator.
You must be accompanied by at least two other Ambassadors or JCs should you leave your assigned group (with facilitator knowledge). Rule of Three
You are to be in your assigned dorm room at the times indicated in the program unless otherwise announced. Staff members will be making bed checks.
Be prompt for breakfast and all sessions. If you need a wake-up call please let your facilitator know.
All dorm floors are single sex, visitation on opposite sex floors is not permitted.
MYL Seminar focuses on leadership, character and volunteerism as a group; as such dating, or hooking up with other Ambassadors or JCs is not allowed during Seminar or any other MYL event.
Respect the facility and other facility guests; facility property is not to be taken for any reason, no trespassing in restricted areas, no access to floors or areas not assigned to MYL Seminar participants. Keep noise to a minimum.
Absolutely no climbing or hanging out of the windows. Persons caught hanging out of windows or sitting on window ledges will be sent home and may be assess a fine by the facility.
Senior Facilitators will be assigned to each same sex floor. You will be given their room number. Please notify him/her if you have a medical or any other problem during dorm hours.
Keep your room key and meal card in your possession at all times. Lost keys can cost up to $120.00 to replace, and you will be expected to pay for lost keys at Sunday check-out.
No personal digital devices (tablets, cell-phones, laptops, etc) are allowed at sessions during the seminar. They must remain in your dorm room at all times. If you are using these devices during sessions, they will be confiscated and returned to you at the end of Seminar on Sunday. Please note, dorm rooms do not provide safes; you bring these items at your own risk.

By signing below, I am indicating that I have read, understood, and agree to the above.

Ambassador Signature

Date

MM slash DD slash YYYY

Parent/Guardian Signature

Date

MM slash DD slash YYYY

Medical History

Insurance

Insurance Company

Policy # / Group #

Name of Insured

Relationship to Participant

General Medical Information

All health information is kept strictly confidential.

Please indicate which, of any, of the below is true regarding the participant:

Ever been hospitalized?

Ever had surgery?

Have recurrent/chronic illness?

Had a recent infectious disease?

Had a recent injury?

Have asthma/breathing issues?

Have diabetes?

Had seizures?

Ever had back/joint issues?

Ever had difficulty sleeping?

Traveled outside the country in the past 9 months?

Had fainting or dizziness?

Have heart condition(s)?

Have hearing/sight loss?

Please explain any "yes" answers to the above question.

If you traveled outside of the country in the last 9 months, please list the countries visited and dates of travel.

Mental, Emotional, and Social Health

In the past 12 months, has the participant seen a professional to address mental/emotional health concerns?

Yes

Abstain from responding

Please explain:

Has the participant experienced a significant life event that continues to affect their daily life?

Yes

Abstain from responding

Please explain:

Medication

It is the policy of Maine Youth Leadership that all Participants of all ages be able to selfadminister any and all routine and/or emergency medications, as prescribed by their physician. “Routine” medications are those taken by the Participant daily or as needed. “Emergency” medications are those such as eli-pens for allergy, and inhalers for asthma.

Medications Taken Routinely

Please list ALL medications (including over the counter or non-prescription drugs) taken routinely.

Does your child use an Asthma Inhaler and/or Epinephrine Pen?

Yes

Inhaler/Epi Pen Consent

I, the parent or legal guardian of the participant, agree to the below.

I approve of the carrying and self-administering, as medically necessary of the medications listed above by my child. Further, I confirm that my child has the knowledge and the skills to safely carry and self administer the above listed emergency medication during Seminar.

Allergies

Please list all known medical and food allergies. Please describe past allergic reactions:

Dietary Considerations

Please list any dietary considerations, including but not limited to fasting, Kosher, vegan or vegetarian.

Immunizations

Please indicate current immunization status.

	Up to Date	Not Up to Date	Unsure
Tetanus
Hepatitis B
DPT Series
MMR
Polio
Varicella (chickenpox)

Restrictions / Accommodations

In general Seminar physicality approximates what the Participant would experience during school. Please consider that while responding to the following questions.

Please list any physical restrictions that may impact the Participant’s ability to participate in any activities.

Please list any accommodations the Participant needs to participate in Seminar activities.

While MYL will work with the Participant to try to make reasonable accommodations we cannot guarantee specific accommodations can be made.

Authorization

My child has permission to engage in all Seminar activities except as noted. The information provided on this form is accurate to the best of my knowledge. In the event I cannot be reached in an emergency, I herby give permission to Maine Youth Leadership staff to secure medical treatment. I hereby waive and release Maine Youth Leadership and its staff from any and all liability for any injury or illness incurred during Seminar.

Parent/Guardian Signature

Date

MM slash DD slash YYYY

Social Media Agreement

Online social media tools such as Twitter, Snapchat, Instagram, Facebook, YouTube, etc. have made it possible for anyone to create and be part of online communities where people can discuss MYL to share stories, photos, videos and other types of media. MYL has online presences on Twitter, Instagram, Facebook, among others. Alumni are encouraged to use any of these means to stay connected to your group, build your network and learn about what is happening with MYL and all our Alumni statewide.

To facilitate safe and positive connections and communications among the online community, MYL has adopted certain policies. As an alumni or staff member of Maine Youth Leadership I nearby agree to the following:

As a MYL alumni/staff member, I recognize that I and a role model and representative of MYL and will not publish inappropriate information, comments, photos, etc. on any social media platform.
I agree to be respectful of MYL, its policies, and members of the MYL community in all postings in profiles, blogs or any other electronic medium.
I agree not to use social networking in any form to post or discuss content that is prohibited by MYL policy and general code of behavior, including but not limited to, alcohol or drug use, illegal or inappropriate behavior (e.g. cyber bullying), or any communication of a sexual nature.

I understand that Maine Youth Leadership reserves the right to remove any content from MYL related social media sites for any reason. I also understand that posting content or communication not in accordance with MYL Policies and/or this agreement may result in, but not limited to, being prohibited from the future use of MYL related social media sites.

Signature

Date

MM slash DD slash YYYY