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Distinguished Youth Award - Application/Registration Form & Waiver

  1. DYA Application Registration Header
  2. Find your Suffolk County Legislator, by visiting the Legislators page.

  3. Participant Information
  4. Handwrite your DOB after printing the completed form.

  5. Examples: 4-H, Boy Scouts, Girl Scouts, YMCA, etc.

  6. Please sign after printing the completed form.

  7. Advisor Information
  8. Waiver & Agreement

    I agree to the following Distinguished Youth Award Program ("Program") rules and requirements:

    • I will select the activities I will perform in order to earn an award.
    • I will not attempt to perform an activity unless I am certain that I can perform it safely.
    • No one is authorized by the Program to: (1) advise a participant on the safety of an activity or whether a participant is prepared to perform it safely, or (2) supervise or exercise any control or authority over any participants.
    • I hereby release and hold harmless each of the individuals and legal entities involved in the Distinguished Youth Award Program from any and all liability of any kind for any injury I might suffer while performing an activity in connection with the Program.
    • Information about me and my participation in the Program may be publicized by the Program.
    • This agreement shall remain in effect as long as I am participating in the Program.
  9. Please sign after printing the completed form.

  10. Parents/Guardians Acknowledgement

    We are the parents or legal guardians of the Distinguished Youth Award participant listed above. We have read the foregoing Waiver and Agreement and agree on behalf of ourselves and the participant to the terms thereof. We will assure that the participant is aware of the risks involved in each activity and we will take full responsibility in lieu of the Program for each activity.

    Required for all candidates who are not considered adults under New York State Law - generally all who are under 18 years of age.

  11. Please sign after printing the completed form.

  12. I am registering for:
  13. Select the Program Area(s) that you will be participating in:
  14. Please print legibly or type (make copies as needed).

  15. Send Completed Form to:

    The Distinguished Youth Award
    Office of Presiding Officer Robert Calarco
    Suffolk County Legislature
    P.O. Box 6100
    Building 20
    Hauppauge, NY 11788-0099

    (Please fill out Date of Birth and signatures after printing the form)

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