Community Works Registration Form

Community Works — Youth Leadership & Workforce Development Registration

Community Works helps young people ages 14–21 build leadership and workforce skills through hands-on experiences, mentoring, and community service. Led by the Winchendon CAC in collaboration with HEAL partners—including Growing Places, the City of Gardner, and the Town of Winchendon—the program offers opportunities to learn, lead, and make a difference.

Please complete this form to provide emergency contact information, participation consent, and media preferences. Participants under 18 must complete it with a parent or legal guardian. Participants ages 18–21 may complete and sign for themselves.

Participant First name

Participant Last name

Participant Email

Participant Phone

Participant Address

Country/Region

Address

City

Zip / Postal code

Participant Date of Birth

Month

Day

Year

Current grade or education status

School

Is there anything you'd like us to know about you, your family and/or children to make the experience the best it can be?

Parent/Guardian Info

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Email

Parent/Guardian Phone

Emergency Contact

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Relationship to Participant

Health Information

Please describe any allergies, dietary restrictions, health conditions, medications needed during program hours, emergency action plans, or accommodations we should know about to support safe participation. Enter “None” if none apply.

Allergies

Medications needed during program hours.

Dietary Needs / Restrictions

Other relevant health conditions or accommodations

Emergency Action Plan

Transportation & Pickup

Participants ages 18–21 are responsible for arranging their own transportation.

Participants under 18 must be picked up by a parent/legal guardian or another person authorized by their parent/legal guardian. Please list each authorized person’s full name, relationship to the participant, and phone number. Notify Miranda Jennings of any changes before pickup.

Who is authorized to pick up minors

Trips

Program activities may include supervised visits to partner worksites, community service locations, and educational or career exploration destinations. Families and adult participants will receive information about planned outings and transportation arrangements.

The permission below applies to routine program outings during the identified cohort. Overnight stays, out-of-state travel, and activities requiring additional consent will require separate trip-specific permission. This form does not authorize those trips.

Do you authorize routine off-site activities for yourself or your child, as applicable?

Code of Conduct

Community Works and participating HEAL Collaborative youth and young-adult programs provide safe, welcoming, and inclusive opportunities to learn, work, lead, and serve. These expectations apply at all program locations, partner worksites, trips, and program-related activities.

All participants agree to:

Treat others with respect. Be kind, inclusive, and respectful toward fellow participants, staff, mentors, volunteers, customers, and community members. Bullying, harassment, discrimination, threats, and fighting are not permitted.
Follow directions and safety procedures. Follow instructions from program staff and designated worksite supervisors. Use required protective equipment and ask for help when a task or instruction is unclear. Report injuries, unsafe conditions, or other safety concerns promptly.
Be dependable and communicate. Attend scheduled activities, arrive on time, and notify your supervisor or program staff if you will be late or absent. Complete assigned responsibilities and accurately record attendance and work hours when required.
Respect property and equipment. Take care of facilities, supplies, tools, and personal belongings. Use equipment only with permission and appropriate training or supervision. Clean up after yourself.
Maintain a substance-free environment. Do not bring, use, distribute, or be under the influence of alcohol, cannabis, illegal drugs, or other intoxicating substances during program activities. Tobacco and vaping products are prohibited. Medications must be used according to the participant’s agreed medication plan and applicable site procedures.
Do not bring weapons. Weapons and items intended to threaten or harm others are prohibited. Work tools may be used only for authorized tasks with appropriate training and supervision.
Use technology responsibly and protect privacy. Follow site rules for phones, computers, and other devices. Do not use technology to bully, harass, or share inappropriate content. Do not photograph, record, or share information about others without permission. Keep private information learned through your placement confidential, while reporting safety concerns to program staff.
Ask for support and take responsibility. Let program staff know if you need help, an accommodation, or support resolving a concern. Report mistreatment or behavior that makes you feel unsafe to your supervisor or Miranda Jennings. If the concern involves your supervisor, contact Miranda directly.

Violations may result in coaching, a warning, parent/guardian contact for participants under 18, restrictions on activities, suspension, or removal from the program, depending on the circumstances and severity. Serious safety concerns may result in immediate suspension while the situation is reviewed.

Acknowledgment

I have read and understand the Code of Conduct. As an adult participant, I agree to follow it. As a parent/legal guardian, I have reviewed it with my child and agree to support these expectations. I understand that violations may result in suspension or removal from the program.

Medical Information & Emergency Authorization

If the participant becomes ill or injured during a program activity, I authorize program staff and designated worksite supervisors to contact emergency services and arrange necessary emergency care and transportation.

For participants under 18, the parent or legal guardian authorizes emergency evaluation and treatment by qualified medical professionals when the parent or guardian cannot be reached. For participants ages 18–21, the participant provides this authorization for themselves if they are unable to communicate their wishes.

Staff will make reasonable efforts to promptly notify the parent/guardian or designated emergency contact. Contact attempts will not delay emergency assistance.

Please provide information about allergies, health conditions, dietary restrictions, medications needed during program hours, and accommodations relevant to safe participation. Notify Miranda Jennings whenever this information changes.

If medication or medical equipment may be needed during activities, please contact Miranda Jennings before participation to arrange a plan with the assigned worksite. Medication storage, self-administration, and staff assistance must follow the agreed plan and applicable site procedures. This form does not itself authorize routine medication administration by staff.

Relevant information may be shared with designated program staff, worksite supervisors, and emergency responders as needed to support the participant’s safety and care.

Acknowledgement

I have read and agree to the Emergency Authorization above as the participant age 18 or older, or as the parent/legal guardian of a participant under 18. I agree to notify Miranda Jennings of changes to the participant’s health information or emergency needs and to coordinate any necessary medication or medical equipment arrangements before participation.

Media Release

The Winchendon CAC/The HUB, Growing Places, the City of Gardner, and the Town of Winchendon may photograph, film, or audio-record program activities to share the work and impact of Community Works and other HEAL Collaborative youth and young-adult programs.

With your permission, photographs, video, and audio featuring the participant may be used in program websites, social media, newsletters, printed materials, news coverage, presentations, and impact reports. Separate permission will be requested before using the participant’s name or personal story.

Media permission is optional. Declining will not affect participation, placement, or compensation. Program staff will honor the participant’s media preference when arranging recordings and selecting materials for publication.

This choice applies to material recorded during the current cohort. You may change your choice by notifying Miranda Jennings in writing. Withdrawal applies to future recording and use; materials already printed, published, or shared may not be fully retrievable.

Media Permission — Select One.

YES — I authorize the media use described above for myself, if age 18 or older, or for my child, if under 18.

NO — I do not authorize the media use described above for myself or my child.

How did you hear about this program?

Participation Consent & Acknowledgment

By signing and submitting this form, I consent to participate, if I am age 18 or older, or give permission for my child, if under 18, to participate in the program and cohort identified in this registration.

This consent covers approved program activities offered through the Winchendon CAC/The HUB in collaboration with Growing Places, the City of Gardner, and the Town of Winchendon. Activities may include workforce development, supervised work experiences, leadership training, mentoring, and community service.

Participation is subject to the Code of Conduct, applicable worksite safety procedures, and the permissions selected in this form. Off-site activities are subject to the separate trip permission section. Overnight stays, out-of-state travel, and activities requiring additional consent require separate permission.

The Winchendon CAC/The HUB currently administers program employment or payments, where applicable. This registration does not replace required employment paperwork, work permits, or worksite-specific agreements.

I confirm that the information provided is accurate to the best of my knowledge and agree to notify Miranda Jennings of changes to contact information, health needs, or permissions. This consent applies to the identified cohort, and a new form must be completed for each subsequent cohort.

My signature confirms the acknowledgments and permissions I have provided. It does not override a “No” response to media or trip permission, and it does not waive workers’ compensation rights or other rights that cannot legally be waived.

I confirm that I am the participant age 18 or older, or the parent/legal guardian authorized to provide consent for the participant under 18.

Participation Consent

I have read and agree to the Participation Consent & Acknowledgment above.

Signer's Full Name

Signer information

Date Signed