I certify that my answers are true and complete to the best of my knowledge. If this application is approve for enrollment in LA CAUSA YouthBuild, I understand that false or misleading information in my application or interview may result in my release from the program.

Read each statement and select the statements that apply to you. All information is confidential for data purposes only.

LA CAUSA expects all participants to conduct themselves in the utmost professional manner for the good and well-being of other participants-so that each individual may be able to gain the most from their program experience. All Members of the program are EXPECTED to:

• Listen with respect and talk with respect
• Attend every day
• Be professional and courteous at all times
• Demonstrate positive leadership during the program
• Have a Great Time!

The following are UNACCEPTABLE behaviors:

• Drug or use or drug possession / Drinking or possession of alcohol
• Stealing
• Fighting / Bullying / Cyber Bullying
• Threatening others (physical or psychological), including sexual harassment
• Sexual activity of any kind
• Possession of weapons (gun, knife, sharp objects, etc)
• Damage to private property

LA CAUSA Inc. frequently uses the photograph and/or likeness of our student or other members of a client family in brochures, press releases, video, newsletters, on the LA CAUSA Inc. website, and other information or advertising media. In addition, news organizations may film or photograph Young adults and activities at LA CAUSA Inc. for use on television, website, or in print, for promotional, educational, education, or media purposes.

By signing this consent form, I hereby agree and give LA CAUSA Inc. or its authorized agents my permission, to record, film, photograph, audiotape, or videotape my image, photograph, likeness, spoke words, student work, performance, and movement, and/or voice (the "Information" I understand that I may revoke my consent and release by providing a letter to the Executive Director at LA CAUSA Inc. at any time prior to the use of the information.

By entering into this informed consent and release and granting the permission stated herein, I am expressly authorizing LA CAUSA Inc. to display, publish, distribute, exhibit or otherwise use, in whole or in part, in perpetuity the Information in all manner and media, as LA CAUSA Inc. determines in its sole discretion in connection with any material that may be created LA CAUSA and other partners (including, without limitation, in advertising, publicizing and otherwise promotion LA CAUSA Inc website or for broadcasting on television) and for any purpose including, without limitation, providing information to prospective clients, fundraising activities for LA CAUSA Inc. programs, grant funding application, distribution at sponsorship events, and presentation to news and publicity organization for the purpose of promotion public awareness and support of LA CAUSA Inc programs.

I further agree that I neither will receive any compensation for such use of the Information from LA CAUSA Inc or from any other source. By signing this I agree that I have been informed that my participation in any media event at LA CAUSA Inc. is strictly voluntary. I hereby further agree that LA CAUSA Inc is the sole owner of all rights, title, and interest, including copyrights in the use of Information and any parts thereof for all purpose, as LA CAUSA Inc. shall determine in its sole discretion, without limitation, reservation or compensation to me.

I hereby agree to release, defend, and hold harmless LA CAUSA Inc. from and against any claims, damages or liability arising from or relating to the use of the Information, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, uploading onto websites, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution.

What is discussed between you and the LA CAUSA YouthBuild and UnidosUs staff and what is contained in your portfolio file is confidential unless you give consent to release with these exceptions:

• The LA CAUSA YouthBuild will be compelled by law to inform an appropriate person(s) and/or authorities if they believe that you are in danger of hurting yourself or others, and/or if there is reasonable suspicion that a child, youth, or disabled adult has been abused or neglected.
• There may be an exchange of information directly related to your case between case management, educational, general, health, recreational, and mental health services of LA CAUSA YouthBuild and partnering staff who are directly involved in your case.

I have read the above, understand its content, and agree to the conditions stipulated therein.

I wish to add the following agencies or individuals to this release (e.g., probation or parole officers, public assistance caseworkers, social workers, placement coordinators, etc:

• PepsiCo
• American Job Center of California (HubCities)
• Archiocesan Youth Employment Services (AYE)

This information will be received for the express purpose of receiving or gaining access to services related to my current or future needs. Information will never be associated with a particular name or any other identifying characteristics (i.e. social security number, address, phone number, etc.)

This consent is valid for one year from the date it is signed.

I have been fully informed that as a requirement to enroll in LA CAUSA YouthBuild, I must present/submit a valid COVID-19 PCR test result on a weekly basis -due every Monday. The purpose of collecting this information is to help maintain ongoing public health and safety measures at the LA CAUSA YouthBuild site and classroom spaces, in effort to ensure my personal safety and the safety of others.

The COVID-19 PCR test results I provide to LA CAUSA YouthBuild will not be changed, altered, modified, and/or tampered with in any way and are accurate to the best of my knowledge. 

This document is strictly confidential all information I provide to LA CAUSA YouthBuild, will not be passed to any third party without my written consent/authorization - p.4 LCYB Consent to Release Information.

I hereby understand, that LA CAUSA YouthBuild requires that I complete this form and provide proof of vaccination. All personal information I provide to LA CAUSA YouthBuild is strictly confidential and will not be passed onto any third party without my written consent/authorization - p.4 LCYB Consent to Release Information. 

The following documents are required for enrollment:

Academic Documents:

1. High School Diploma / School Transcripts
   • Must have high school logo or signature stamp; this helps authenticate the validity of transcripts
2. College Degree / Certificates (if applicable)

Identification Documents:

1. Birth Certificate
   • If your birth certificate is missing, speak to an administrator
2. CA ID or Student ID
   • Other types of identification for non-US citizens are accepatable (ex: passport)
3. Drivers License/Permit
   • Must have a clean driving record

Other Required Documents:

1. Proof of Income for the Household (needs to be dated within the last month (Info required for the National School Lunch Program and for the other applicable program components as required for reporting purposes.)
   • Pay Stub, most recent tax return, Social Security Benefits Award Letter, or Verification Letter from Department of Public Social Services for cash-aid or food assistance program with a case number.
   • If there’s a non-source of income or someone in the household is self-employed, obtain the No-Income certification form or Self-Employed Certification form.
2. Utility Bill (Needs to be dated within the last 2 months)
   • Needs to provide a gas, water, or electricity bill with a current physical address
   • If a utility bill cannot be provided, the alternative is to get a receipt from landlord with address of residence. (May not be required for members who do not have permanent housing at the time of enrollment).
   • Credit Card or cell phone bills are not accepted. 
3. Social Security Card (if applicable)
4. Proof of Covid-19 Vaccination Card