Youth Application Form

Youth Application
Your Name*

First NameLast Name
Parent/Guardian Name*

First NameLast Name
Parent/Guardian's Cell #*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Youth Cell
Current School
School Grade?*
What school do you attend?
Birthdate*

MonthDayYear
Date
How did you hear about City of Dreams (Choose one)
If you answered community organizer or other, please state down below:
Youth must attend two Saturday events per month (out of 3-4). Are you able to commit to this? (Choose one)
If not, why?
Would you like to have a mentor?

YesNo

Child Safety Survey

Complete one for each child in our program
Emergency Contact Name *

First NameLast Name
Emergency Contact Phone Number *
Please enter a valid phone number.
Relationship to Emergency Contact*
Is your child on any medication? Please Specify.
Does your child have any allergies? Please specify.
Does your child have any emotional issues that we should know about? Please specify.
Does your child have any learning disabilities that we should know about?

City of Dreams Youth Contract
I, name , understand that becoming a member of City of Dreams means that I am committing to becoming a responsible person who makes good decisions for myself, my family, and community.

I will:
- Choose a life free from drugs and alcohol.
- Choose to stay away from gang participation and violence.
- Choose to excel in school and graduate high school.
I will participate in at least 2 City of Dreams' events per month. I will sign up for two events at the beginning of each moth and make sure to RSVP (call, email, text message) City of Dreams' staff or my mentor by the Wednesday before each event. IF I CAN NOT attend at the last minute, I will call City of Dreams' staff to explain.

As a consequence of not attending two events per month, I understand that I may be suspended or removed from the program.

When City of dreams matches me with a mentor, I will:
- Be respectful, responsible, listen, and participate
- Return phone calls.
- Follow our mentor/mentee agreement
I understand that City of Dreams wants me to be successful and I will take responsibility for my success.
Name

First NameLast Name
Date

MonthDayYear
Date
Signature

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Liability Waiver
Enrollment Start Date:*

MonthDayYear
Date
Participant's Name:*

First NameLast Name
Participant's Parent/Guardian:*

First NameLast Name
Participants Age:*
Participants Birthday*

MonthDayYear
Date
Gender:*
Ethnicity:*
If other, please describe:
EXPRESS ASSUMPTION OF RISK, RLEASE, COVENANT NOT TO SUE AND INDEMNIFICATION AGREEMENT. PLEASE READ EACH PARAGRAPH OF THIS AGREEMENT, AS IT CONTAINS A NOTICE OF HAZARDOUS ACTIVITIES, ACKNOWLEDGE OF PERSONAL RESPONSIBILITY, RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT.

I agree as follows:

A. EXPRESS ASSUMPTION OF RISK.
There are significant elements of risk in the transportation of your child to an outing, or in the participation of any sport or recreational activity associated with, but not limited to: snow skiing, ropes courses, baseball, bowling, ice skating, sailing, basketball, and going to the park or attending movies (referred to as Activities). I acknowledge that my child runs a risk in engaging in there activities and outings, or in the use of any sports-related equipment which may result in injury or death. Although City of Dreams has taken reasonable steps to provide my child with appropriate equipment and instruction, certain activities are not without inherent risks that cannot be eliminated. These inherent risks, whether known or unanticipated can be the cause of accidental injury, illness, or in extreme cases, permanent trauma or death. I voluntarily and freely agree to incur and assume all such inherent risks and dangers, including the rise of injury or death. Which might be associated with or result from my child's participation in these activities.

B. RELEASE FROM LIABILITY.
I agree, for my child, and for my heirs and assigns, fully and forever, to discharge and release City of Dreams and each other officers, directors, employees, agents, partners, contractors, sponsors, advertisers, and guests from any and all liability arising out of any damages, costs, loss of services, expenses, and any and all claims of damages whatsoever on account of, or in any way resulting from personal injuries, death, or property damages to my child or to any person or property in any way connected with my child's participant in these activities, even if caused by the PARTIES sole NEGLIGENCE. Nothing in the waiver releases City of Dreams for liability for their gross negligence, recklessness, and/or intentional conduct.

C. COVENANT NOT TO SUE.
I agree, for my child, for myself, and for my heirs, not to sure the PARTIES, nor to initiate or assist in the prosecution of any claim for damages or cause of action which I, my child, or my heirs may have by reason of personal injury, death, or destruction of personal property in any way connected with my child's participation in the Activity.

D. INDEMNITY AGREEMENT
I agree, for my child, for myself, and for my heirs, to indemnify and hold harmless the PARTIES from any losses, claims, causes of action, or proceedings of any kind which may be initiated by myself or any other person or organization including demands, judgements, costs, loss of services, expenses, or reimbursement of reasonable counsel fees incurred on my behalf or by the parties in any way connected with my child's participation in these Activities.

E. OTHER PROVISIONS.
No payment or other consideration has been provided directly or indirectly to City of Dreams or to any other person or entity as a condition of or in connection with my child's participation in these activities. I understand and agree that this Agreement is intended to be as a broad and inclusive as is permitted by law, but it is not intended to assert any claims or defenses that are prohibited by law. If any portion i held invalid, the balance shall continue in full legal force and effect. I agree that no oral representations, statements, or inducement apart from this agreement have been made, and that this document contains the sole Agreement regarding all issues related to the subject of this agreement.

F. PHOTO, VIDEO & SURVEY AUTHORIZATION
I do hereby irrevocably consent to and authorize the use and reproduction by City of Dreams, or anyone authorized by City of Dreams, or any and all photographed and/or video taken of my child in all forms and media and for any purpose whatsoever without further consideration. I do hereby irrevocably consent to and authorize City of Dreams or any 3rd party selected by City of Dreams to conduct surveys and/or questionnaires with/from my child(ren).

I HEARBY ACKNOWLEDGE THAT I FULLY READ, UNDERSTOOD, AND ACCEPTED EACH OF THE ABOVE PROVISIONS, AND VOLUNTARILY SIGNED THIS AGREEMENT.
THIS WAIVER IS EFFECT FROM THE DATE OF SIGNATURE. WAIVER MUS BE SIGNED

I am the parent or legal guardian of the minor,Child's Name, and I am signing this EXPRESS ASSUMPTION OF RISK, RELEASE, COVENANT NOT TO SUE, AND INDEMNIFICATION AGREEMENT on behalf of said minor. BY signing, I am giving up the same rights for said minor as I would be giving up if I signed this document on my own behalf.
Parent/Guardian Signature

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Printed Name

First NameLast Name
Date

MonthDayYear
Date

Parent/Guardian Agreement
I understand that City of Dreams will build on following life lessons: Trust, Resilience, Accountability/Responsibility, Love without Limits, Teamworks, Respect, Choice, Hope, Self Esteem, Contribution, Integrity, and Gratitude.

In order to stay in City of Dreams,
My Child First and Last Name must:
- Attend a minimum of two events per month.
- Attend a minimum of five Super Saturday events before being matched with a mentor.
I agree to the following:
- I will choose attend one family event per year.
- I will ensure that my child RSVP's for Super Saturday events.
- I will share my child's grades with City of Dreams.
I understand that my child chooses to enroll in City of Dreams, and that full participation is required to stay in the program.

I will help my child be successful by encouraging them to demonstrate the values and skills practiced at City of Dreams such as, but not limited to:
- Listening
- Respecting others
- Participating fully at home and school
Will will help my child achieve the following goals:
- To excel in school
- To be teen pregnancy free
- To be drug and alcohol free
- To be free of gangs and violence
City of Dreams program staff agree to use their resources and skill set, in collaboration with your family, to add to the success of your child.

I,Full Name, agree to the above commitment, and will support City of Dreams, their staff and mentors in contributing to my child's future success. If my child and I DO NOT stick to these agreements, my child may be removed from the program.
Signature:

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Date:

MonthDayYear
Date

DCYF Photography Release Form
Participant's Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
You or your child participates in a youth program funded by the San Francisco Department of Children, Youth, and Their Families (DCYF). DCYF staff or contractors may on occasion visit this program to take photographs for public information projects.

The public information projects aim to educate civic leaders and the general public about programs and services available for San Francisco children, youth and families. Example projects include DCYF publications and exhibits, as well as the DCYF website (http://www.dcyf.org).

By signing this form, you authorize DCYF staff and contractors to take photographs of program activities that may include images of you or your child and to use these photographs for the public information projects described above.
Your Name*

First NameLast Name
Relationship to Participant*

ParentLegal GuardianParticipant 18 Years of Age or Older
Signature*

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Sign Date*

MonthDayYear
Date

We want to know a little about you! (Optional)
Do you have any siblings? If so, where do they live? What are their names? How old are they?
Favorite classes/subjects?
Do you have any favorite teachers?
What are your hobbies and interests?
Do you play any sports?
Who is a positive influence in your life? Why?
If your friends were to use three words to describe you, what would they be?
What three words describe who you are?
Do you want to go to college? If so, what do you want to study?
What is your favorite movie?
Who is your favorite singer?
Do you play a musical instrument? If so, which one?
What do you want to be when you grow up?
If you want a mentor, how could they help you?
Should be Empty:

Youth Application

Child Safety Survey

City of Dreams Youth Contract

Liability Waiver

Parent/Guardian Agreement

DCYF Photography Release Form

We want to know a little about you! (Optional)