Youth Participation Application

Youth Participation Application

K-6 Grade 2024/2025 School Year
Date
Bus Rider*

YesNo
Child's Name*

First NameLast Name
Child's Age*
School*
Grade Level*
Mother's Name

First NameLast Name
Mother's Phone Number
Father's Name

First NameLast Name
Father's Phone Number
Email*
example@example.com
My child was invited to the Harlan Christian Youth Center by:
Please fill out if applicable
Food Allergies
List any if applicable
Address*

Street Address

Mailing Address

CityState

Postal / Zip Code
I give permission to the following people to pick up my child if I am not available:*
Emergency Contacts*
Does your child regularly attend a church?*

YesNo
Where does your child attend church?
Please fill out if applicable
NOTE: In order to participate, Parent/Guardian must sign the agreement below.

Agreement

I understand that my Childs participation/membership in any program/event of the HCYC is a privilege and they represent the HCYC in the way that they act. I realize that they can lose any and all privileges at any time when their behavior is not in accordance with the posted policies and procedures of the HCYC. I further understand that any infraction can result in suspension of HCYC membership. I also give permission for my child’s photo/video to be used for any promotional advertising and understand that I will be added to automated texts about upcoming events.

By signing this form, I give permission for Harlan Christian Youth Center to release any contact information for my child to East Allen County Schools.
Printed Name*
Signature*

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