2025 YOUTH BUREAU'S REGISTRATION FORM

2025 REGISTRATION FORM

City of Peekskill Youth Bureau

828 Main Street, Peekskill, New York 10566

Ph: (914) 734-4149 * Fax: (914) 864-0150

Tuesday Paige McDonald, Executive Director

THIS REGISTRATION FORM IS FOR PARENTS TO FILL OUT.

**APPLICATION IS NOT COMPLETE IF EVERY SECTION IS NOT FILLED OUT/AND OR SIGNED.
City of Peekskill Youth Bureau Statement of Policy

REQUIREMENTS: The City of Peekskill Youth Bureau is open to all school-age children in grades 5 through 12, who live in Peekskill and the surrounding area. All children are welcome without regard for sex, race, color, or national origin. In order for your child to start any program, all forms must be signed and completed.

HOURS:
Youth Bureau Operating Hours:
September-June: Monday through Friday, 9:00am-6:00pm
Summer Hours: 8:30am-4:00pm

Both the Youth Bureau administrative office and all programs will follow the City of Peekskill’s operating schedule. Holidays and school vacation programming operational hours will be announced 2 weeks in advance of said holiday or school vacation.

WITHDRAWAL: A child may be asked to withdraw from a Youth Bureau program if, in the judgment of the professional staff, he or she is not able to function positively in our group setting, or the program is unable to meet the special needs of that particular child. Parents agree to inform the Youth Bureau upon registration of any special needs that require modifications in the child’s program activities.

STAFF: The ratio of staff to children will be approximately 1 to 10 in the primary grades and 1 to 15 in the middle/high school. Children will be supervised at all times.

HEALTH: If it appears that a child’s health may pose a threat to other children, parents will be called and required to immediately pick up their child. Our staff will NOT administer medication of any kind to any child nor may a child self-administer medication while in our care. In any case of a medical emergency, we rely on the excellent local emergency services to provide urgent care.

FOOD SERVICE ARRANGEMENTS: On some days nutritional snacks are provided by the City of Peekskill Youth Bureau.

TRANSPORTATION: We do not provide transportation to and from the program.

DISMISSAL ARRANGEMENTS: If any person listed on this form is legally barred from having contact with, or picking up your child, you must notify the Youth Bureau staff of this in writing and provide legal documentation to that effect. Without such documentation, we cannot prevent a parent from seeing or picking up a child.
YOUTH BUREAU'S 2025 REGISTRATION

Register for the following programs below:
- Project ELEVATE (Preparing High School Students for post-high school) - Meets Monday - Friday - 3:30pm - 6:00pm
- Summer Youth Camp (6 weeks starting July 2025) - 10-13)
- Youth Council (14 -18)
- PEARLZ (Girls Empowerment Group) - Meets Tuesday and Thursdays from 3:30pm - 6:00pm (13 - 18)
- Woodworking - 1st Class (6 weeks) - March 19, 2025 - May 7, 2025, Wednesdays 4:00pm - 5:15pm.
- YOUTH High School Volunteers - Monday - Thursday (3:00pm - 5:00pm).
*ALL PROGRAMS AT THE YOUTH BUREAU ARE FREE!
Interested in WDAY (Workforce Development Academy) for Young Adults 16 - 24, who are out of school, please DO NOT fill out this form. Please contact, Devon Minceyat 914-862-5347 or dmincey@cityofpeekskill.com to learn more about this program.

Workforce Development Academy for Youth is a year-round program that provides educational and employment services to eligible youth ages 16-24, who are Out of School.
Youth Bureau Programming

Project ELEVATE (ages 14-18)PEARLZ (ages 13- 18)YOUTH High School Volunteers
REGISTRATION - STUDENT INFORMATION
Student's first and last Name*
Date of Birth*

MonthDayYear
Gender*
Full Home Address*
Apt#
Zip*
Home Phone*
Ethnicity/Race*
Age*
Grade*
School as of January of the current year:

HillcrestPMSPHS
Name of School if student is outside the District:
PARENT/GUARDIAN INFORMATION
Mother's Name*
Mother's Work Number*
Mother's Cell Phone*
Mother's EMAIL*
Father's Name
Father's Work Number
Father's Cell Phone
For notification purposes, please provide an Email address to be used to contact you:
example@example.com
EMERGENCY CONTACT INFORMATION (Person OTHER than parent/guardian required for emergency contact)
1st Emergency Contact's Name*
Phone*
Relationship to child*
2nd Emergency Contact's Name*
Phone*
Relationship to child*
MEDICAL HISTORY RELEASE
Child's Name*
Does your child have a primary physician now?*

YesNo
Is your child currently taking any prescribed medications?*

YesNo
If yes, please name the prescribed medications.*
Is your child allergic to any of the following?*

AspirinPenicillinCodeinePeanutsMetalAcrylicLocal AnestheticsOther
If yes, please explain:
Does your child have, or have they had, any of the following?

AsthmaEpilepsy or SeizuresHearing LossBreathing ProblemsFainting Spells/DizzinessKidney ProblemsBruise EasilyRecurring Ear InfectionsPsychiatric CareCancerFrequent HeadachesShinglesHives or RashHeart MurmurSinus TroubleCongenital Heart FailureHepatitis AStomach/Intestinal DiseaseDiabetesHepatitis B or CTuberculosis
Has your child ever had any serious illness not listed above?*

YesNo
If Yes, please explain*
In the event of injury, I grant permission to take my child to a hospital for treatment, to include ambulance transportation, evaluation of injuries, x-rays and needed care.
YesNo
To the best of my knowledge, the questions on this Medical Form have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is my responsibility to inform the City of Peekskill Youth Bureau of any changes to my child's medical status.
Signature of Parent/Guardian *

Clear
Date

MonthDayYear
ARRANGEMENTS FOR DISMISSAL RELEASE
My child is to be dismissed in the following manner (Check all that apply):

Any changes to these arrangements must be made in writing to the Youth Bureau Director
A. My Child is allowed to walk home*

YesNo
My child may be released to the following person(s).
1st Name*
Contact Number:*
2nd Name
Contact Number:
DISMISSAL ARRANGEMENTS: If any person listed on this form is legally barred from having contact with or picking up your child, you must notify the Youth Bureau Director of this in writing and provide legal documentation to that effect. Without such documentation, we cannot prevent a parent from seeing or picking up a child.
I have read, understand and agree with the terms of this release. Please Initial*

Clear
RELEASE OF LIABLILTY
In consideration of your acceptance of my child for his/her participation in the activities/programs of the City of Peekskill Youth Bureau, I agree that I am aware of the inherent dangers and risks involved in these activities/programs including bodily injury which may be the result of strenuous activity or other causes related to these activities/programs. I agree to release and hold harmless the City of Peekskill, its officials, officers, agents, employees, and volunteers, from and against any and all liability, damage or claim of any nature arising out of, or in any way related to, my child's participation in these activities/programs except those things caused by the sole negligence of the City. I understand that the City of Peekskill does not provide accident or medical insurance and I am financially responsible for any and all medical expense whatsoever. I am advised to consult my child's physician before allowing my child to participate in any strenuous activity.
I have read, understand and agree with the terms of this release. Please initial*

Clear
PHOTO/VIDEO CONSENT RELEASE
I hereby consent that the City of Peekskill Youth Bureau may videotape/photograph my child and use such videotape/ photographs for publication/broadcast/website. I waive any claim I might have against the City of Peekskill Youth Bureau arising from the use of such videotape/photographs. I understand that such information could subsequently be used by other media.
I have read, understand and agree with the terms of this release. Please initial*

Clear
EDUCATIONAL INFORMATION RELEASE

I give permission for the release of the following information from my child's school to the staff of the City of Peekskill Youth Bureau: exchanges of information with teachers, social workers, guidance counselors, psychologists and school officials, as these relate to the student's behavior and academic needs. This information is strictly confidential and will be treated as such by the City of Peekskill Youth Bureau in working with my child.
I have read, understand and agree with the terms of this release. Please initial*

Clear
Is your child designated through the Committee on Special Education?*

YesNo
Does your child need a smaller class size or extra resources during the school day?*

YesNo
If yes, please describe these modifications
TRIP PERMISSION RELEASE

On occasion, and with advance notification, the City of Peekskill Youth Bureau may take a trip within the City of Peekskill (either by foot or bus). Please initial below if you give permission for your child to attend these trips.
I have read, understand and agree with the terms of this release. Please initial*

Clear
POLICIES ACKNOWLEDGEMENT

I have read and agree to all of the policies set forth within this registration form.

PARENT'S SIGNATURE
Clear
Date

MonthDayYear
Should be Empty:

REGISTRATION - STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

MEDICAL HISTORY RELEASE

ARRANGEMENTS FOR DISMISSAL RELEASE

My child may be released to the following person(s).

RELEASE OF LIABLILTY

PHOTO/VIDEO CONSENT RELEASE