Peace Corner Youth Center Enrollment

Amani Leadership Program Application Form
The Amani Leadership Program at the Peace Corner

From high-quality mentoring to awesome projects, immersive field trips, and inspiring guest speakers, we provide a holistic and enriching experience to amplify your child's development and find joy.

This program is open to all students who will be in 5th grade during the 2023-2024 school year. Once your application has been accepted, your child will be assigned to a cohort that meets twice a week throughout the school year. Because of private funding available to us through the Hilton Foundation and Catholic Sisters Initiative, the Amani Leadership Program at the Peace Corner is available to you at no cost.

Due to high demand, families must complete an application and will be selected through a computer-generated randomization process that allows all community members to enroll easily and equitably.

The Peace Corner Youth Center is a Catholic Charities Initiative

Located at 5022 W Madison, the Peace Corner is operated by Catholic Charities and provides a variety of programs for youth ages 8-18. All Catholic Charities services are available to anyone in need regardless of faith, gender, race or ethicity.

*** Youth who do not qualify/receive a spot in the Amani Leadership Program can participate in any other open programs offered at the Peace Corner.
Additional Documents + Program Orientation

After completing the online application, families must complete the following forms prior to attending. A member of the Peace Corner team can complete them over the phone or in-person at our office. A member of our team will contact you to schedule an orientation and complete all necessary paperwork.

Amani Leadership Program Forms (selective enrollment: open exclusively to 5th grade students during the 2023-2024 school year):
- Research Study Consent Form
- Research Study Assent Form
- Youth Survey
Peace Corner Programs (open enrollment: multiple programs and drop-in activities available to all youth ages 8-18)
- Consent Form
- Rights and Responsibilities Form
- Media Release Form
Youth Information
Name*

First NameLast Name
Program Options (select one):

I am interested in the Amani Leadership Program (open exclusively to 5th grade students)I am interested in other program at the Peace Corner Youth Center (open to all youth ages 8-18).I am interested in the Amani Leadership Program AND other Peace Corner programs.
Date of Birth*

MonthDayYear
Date
Gender*
Race*
Ethnicity*

Latino/aNon-Latino/a
Email Address
example@example.com
Phone Number
It is important to keep a current number on file. If your number changes please update staff.
Grade Level
School Name
Language Preference

EnglishSpanishOther
Current Residence Information
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information #1
Name*

First NameLast Name
Phone Number*
It is important to keep a current number on file. If your number changes please update staff.
Email
example@example.com
Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #2 Information (optional)
Name

First NameLast Name
Phone Number
It is important to keep a current number on file. If your number changes please update staff.
Email
example@example.com
Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

Must not be the same as the Parent/Guardian listed above.
Name*

First NameLast Name
Relationship
Phone Number*

Area CodePhone Number
Medical Information
Physical activity restrictions*
Preferred Hospital
Insurance/Health Coverage (Company)
Does your child have any behavior issues or health concerns that staff monitor? Please provide detailed information about any food or medication allergies, prescribed medications, chronic health concerns, behavior issues, disabilities or accommodations, or family situations to assist staff to best serve your family.*

Acknowledgements
Peace Corner Code of Conduct: All youth and parents/Guardians must adhere to the PCYC's code of conduct. By signing, you acknowledge that you understand a will adhere to these regulations. All families will receive a hardcopy of these agreements.
- Consistent attendance is required. Youth who demonstrate inconsistent attendance may be discharged and placed on a waiting list to re-enroll. Youth will be terminated from the program after an absence of one month.
- Youth who leave the PCYC premises after signing in will not be permitted back into the building and will be considered dismissed for the day.
- The PCYC reserves the right to limit capacity for health and safety reasons, as needed.
- Youth will speak to and treat staff, guests, and other youth in a respectful manner. Cursing, threats, bullying, and yelling are not allowed at the PCYC. Physical contact, including play fighting, is not allowed. This respectful treatment is expected both inside and outside of the building.
- Youth are expected to behave appropriately while attending the PCYC. If unacceptable behavior occurs, PCYC staff will inform parents/guardians. Depending on the severity of the behavior, PCYC may send youth home for the day, temporarily suspended, or required to complete an improvement plan with PCYC staff and the parent/guardian. After attempts have been made to meet their individual needs, youth who demonstrate behavior that is detrimental other youth, staff, or program operations shall be discharged from the program.
- Youth involved in a physical altercation will be subject to an automatic suspension. Youth and their parent/guardian will be required to meet with the PCYC staff in order to return.
- Youth who are ill or showing signs of illness should not attend the PCYC. Updated health and safety protocols are posted and available throughout the building.
- All contact information must remain up-to-date with PCYC staff. This includes address, phone number, email address, and emergency contact information. If information is found to be inaccurate, youth will not be allowed to attend programming until the information is updated.
- PCYC may collect and record data on my child including: surveys and/or interviews about my child’s knowledge, attitudes, skills, and behaviors and overall satisfaction with PCYC programming and staff.
General Guidelines: Program policies and procedures are subject to change at the discretion of PCYC management. Your signature confirms that you have read and agree to the statements detailed below.
- Upon entering the building, youth will follow the check-in process by signing in and storing their belongings in a locker. This includes bags, jackets, etc.
- Youth will treat staff, guests, and other youth in a respectful manner. Cursing, threats, bullying, and yelling are not allowed at the PCYC. Physical contact, including play fighting, is not allowed. This respectful treatment is expected both inside and outside of the building.Running is not permitted in the building, with the exception of the gym area.
- Youth must dress appropriately at all times. Youth will adhere to the dress code posted throughout the building.
- All food and drinks must be consumed in designated areas, unless staff have permitted otherwise.
Youth Signature*

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Parent/Guardian Signature*

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Notes
Please inform staff of any other vital information you think they may need to know in the event of an emergency. Thank you.
Should be Empty:

Amani Leadership Program Application Form

Youth Information

Current Residence Information

Parent/Guardian Information #1

Parent/Guardian #2 Information (optional)

Emergency Contact

Medical Information

Acknowledgements

Notes