Chicos House Youth Development Center registration form

Parent/Guardian Information

Youth Information

Youth 2 Information

Youth 3 Information

Youth 4 Information

Distance Learning

If you do not have access to internet, there is still an opportunity to participate in our programs. We will reach out directly to you for more information. We can help you get free access to tablet, phone, and WIFI. Again, for free. 

IF ANY OF THESE RULES ARE BROKEN EARLY TERMINATION WILL OCCUR AND EVEN HARSHER PENALTIES MAY OCCUR.

CONSENT FOR SERVICES/GENERAL RELEASE OF LIABILITY

I, the undersigned parent/guardian, agree that my child can participate in the Chico's House Youth Development Center, LLC youth program. (“ Chico's House Youth Development Center, LLC”). I understand and agree that my child’s participation in these services may be disclosed on a need to know basis to other entities engaged in providing services to my child.

I release  Chico's House Youth Development Center, LLC from all liabilities to my child for all damages, expenses (including attorney fees), claims, judgments, actions or causes of action as a result of any loss or injury to the person or property which my child may sustain or suffer during or arising out of services provided by Chico's House Youth Development Center, LLC     or transportation provided by Chico's House Youth Development Center, LLC, whether caused by the acts or omissions of Chico's House Youth Development Center, LLC officers, directors, employees, representatives, advisors, affiliates, divisions, departments, related entities, contractors, funding source and/or other agents (“Parties Released”). I agree to defend and indemnify the Parties Released from and against any and all liabilities.

I, the undersigned parent/guardian, hereby give my consent for the release of reports, stories, videos, or pictures (“Materials”) that may identify my child. These Materials may be used for educational, informational, promotional, marketing or other activities. I acknowledge Chico's House Youth Development Center, LLC’s right to Materials for publication or other use, including cropping, altering or changing the Materials at its discretion. I hereby release the Parties Released from all claims and liabilities arising out of or in connection with the use of the Materials. I understand that I do not have a right to royalties or payment in any form for these Materials, neither today nor at any future date.

I hereby give permission for the participant(s) listed on this application to take part in the Chico's House Youth Development Center, LLC , which may include off-site events, academic assistance, continuing education, and recreational programs. If a medical emergency arises, program staff will take all steps necessary to ensure the safety of the participant and will call, if necessary, a public emergency vehicle for transport to an emergency facility. I understand that I will be responsible for any transportation charges and medical expenses incurred. I understand that all of Chico's House Youth Development Center, LLC policies and procedures are to be adhered in this program. My child is expected to behave appropriately at all times and follow the rules of our program. I also acknowledge that I have received the Parent Handbook, which describes the Chico's House Youth Development Center, LLC Program Behavior Management Policy in more detail.

I further give my consent to the Chico's House Youth Development Center, LLC to share the participant’s youth records with each other for purposes of providing educational support and assistance. In addition, I understand that school district and /or Chico's House Youth Development Center, LLC will use participant records to evaluate individual progress and improvement, as well as to evaluate the impact of the program on youth achievement and to obtain continued funding for the program.

Audio/Video/Photo/Directory Waiver Release Form

To protect the privacy and safety of Chico’s House Youth Development Center’s the youth’s , personal information about the youth  (such as the youth’s home addresses, e-mail addresses and phone numbers) will not be published on any CHYDC’s web page or disseminated to any organizations or media outlets under any circumstances.  Enrollee directories, which include the youth’s name, address and phone number are available should you choose to have your child included. These directories are kept in a locked file cabinet.

The youth’s  names, photos of the youth, audio or video recordings of the youth and/or the youth’s work may be published on official flyers, center newsletters, or web pages, or shared with CHYDC’s approved news media, organizations or web services, with parent permission below.

Please note that no permission is required for large group photos in which the youth are not individually identified.

Release

I hereby grant Chico’s House Youth Development Center, LLC. the right to use and reproduce any and all photographs, video clips, and/or audio clips taken of my child in conjunction with their involvement at CHYDC in any center newsletters, brochures, web sites, flyers and publications, or any outside CHYDC approved publications such as newspaper, magazines, web sites promoting the center or reporting on activities associated with the Organization.

I waive the right to inspect or approve the finished version(s) of such images including written copy that may be created in connection therewith.

Consent is also granted for any use of my child’s name in any part of those publications listed above.

I understand that photos/audio/video used by Chico’s House Youth Development Center, LLC for the reasons stated above, are considered the property of Chico’s House Youth Development Center, LLC and may not be sold or reused without the express consent of center officials or administration.

I understand that there is no monetary compensation for use of my child’s image and that this waiver/release is good for the entire time that my child is receiving services through Chico’s House Youth Development Center, LLC.

I have read this document and am fully aware of the consent and implications, legal, and otherwise.

Text and Email Notifications

I give the staff permission to contact me through the Talking Points app and email for updates regarding programming, time/date changes, upcoming events, etc.

 Signature

I am the parent/legal guardian of the minor named above and have legal authority to execute this consent & release. Grievances related to the program may be addressed by a phone call or conference with, the Chico's House Youth Development Center, LLC and contracted vendors.

I agree that I have signed the consents on this form in exchange for my child’s participation in services provided by Chico's House Youth Development Center, LLC. Additionally, my signature affirms: (1) that I have read this document and have been offered a copy of this document; and (2) that the parent/guardian identified in this form is the parent or legal guardian of the child identified in this form.

Please be advised that your invoice will reflect your membership, discounts, and/or program fees. Once your form has been submitted a representative will reach out to you shorly. Prices and fees range per funding availability. Invoice will be sent after the completion of this application.