Youth Guidance Child Application (2024)

In the interest of Type a label* (Student Name),
Permission
This gives my permission for the above-mentioned child to be involved in the Youth Guidance Mentoring Academy of Indian River County.
Transportation
Permission is also given to the Youth Guidance Mentoring Academy and to the volunteers to transport my child to and from school, recreational activities, etc.
Liability
I release the Youth Guidance Mentoring Academy and its volunteers for any liability of lost, stolen, and/or damaged items that may occur while my child participates in any Youth Guidance activity or personal activity with volunteer(s), employees, or board members. If my child needs any emergency medical treatment while in the volunteer's care, this is my authorization for such treatment (if I cannot be reached). This is also my authorization to the attending physician and emergency care facility. I assume the expense of any medical care.
Medical
I give permission for the Youth Guidance Mentoring Academy and its volunteers, employees, or board members to seek medical treatment for my child if they are unable to reach any parent or guardian. I also agree that I will be responsible for any financial debt that is accumulated by said action.

This is also the authorization of the child and parent/guardian for you to provide the Youth Guidance Mentoring Academy full particulars regarding the child's mental and/or psychological and psychiatric history and any other pertinent information requested.
Further, this authorizes all agencies involved with the child to release all information to the Youth Guidance Mentoring Academy.
Please review the following statement:*

I have read the foregoing and fully understand the meaning and effect thereof.

Photo/Video Release
Please enter your child's name:*

First NameLast Name
Please read and select one of the following statements:*

I hereby consent to the reproduction, publication and use of photographs/video footage taken of my child...I hereby DO NOT consent to the reproduction, publication and use of photographs/video footage taken of my child...
by Youth Guidance Mentoring Academy and other groups involved with Youth Guidance for advertising, sponsorship, educational and/or publicity purposes in all publications, Web sites, television, social media, advertisements and publicity materials, without limitations or reservation, as deemed appropriate by the organization.

I also consent to any testimony or text written about the person named above that may accompany said photographs or stand-alone in all publications, advertisements and publicity materials, without limitation or reservation, as deemed appropriate by the organization. I understand that I will receive no remuneration due to my child's photo.

I agree that I will not assert or maintain against Youth Guidance and other groups involved with Youth Guidance, their successors, assigns and licensees, any claim, action, suit or demand of any kind or nature whatsoever, including but not limited to, those grounded upon invasion of privacy, rights of publicity or other civil rights, or for any other reason in connection with the authorized use of my physical likeness and sound in the picture as herein provided.

I hereby release Youth Guidance and other groups involved with Youth Guidance, their successors, assigns and licensees, and each of them, from and against any and all claims, liabilities, demands, actions, causes of action(s), costs and expenses whatsoever, at law or in equity, known or unknown, anticipated or unanticipated, which I ever had, now have, or may, shall or hereafter have by reason, matter, cause or thing arising out of the use of any images as herein provided.
Please review the following statement:*

I have read the foregoing and fully understand the meaning and effect thereof.
Parent/Guardian Name*

Attendance Policy
by Youth Guidance Mentoring Academy and other groups involved with Youth Guidance for advertising, sponsorship, educational and/or publicity purposes in all publications, Web sites, television, social media, advertisements and publicity materials, without limitations or reservation, as deemed appropriate by the organization.

I also consent to any testimony or text written about the person named above that may accompany said photographs or stand-alone in all publications, advertisements and publicity materials, without limitation or reservation, as deemed appropriate by the organization. I understand that I will receive no remuneration due to my child's photo.

I agree that I will not assert or maintain against Youth Guidance and other groups involved with Youth Guidance, their successors, assigns and licensees, any claim, action, suit or demand of any kind or nature whatsoever, including but not limited to, those grounded upon invasion of privacy, rights of publicity or other civil rights, or for any other reason in connection with the authorized use of my physical likeness and sound in the picture as herein provided.

I hereby release Youth Guidance and other groups involved with Youth Guidance, their successors, assigns and licensees, and each of them, from and against any and all claims, liabilities, demands, actions, causes of action(s), costs and expenses whatsoever, at law or in equity, known or unknown, anticipated or unanticipated, which I ever had, now have, or may, shall or hereafter have by reason, matter, cause or thing arising out of the use of any images as herein provided.
Please read the following statement:*

I have read and understand the above attendance policy for the Youth Guidance Mentoring Academy and agree to its terms and conditions.
Parent/Guardian Name*

Student Admission Policy
Youth Guidance Mentoring Academy is an after-school program that provides Academic Enrichment, Career Development/Life Skills and Vocational Training for the families who reside in OR attend school in Indian River County. Through group mentoring programs, the goal is to prepare students for success in and after high school.

For your child to participate and maintain their scholarship in the Youth Guidance Mentoring Academy Program, the following criteria requirements must be met by the student:

The STUDENT will/does (refer to Parent Handbook):
- Qualify for free or reduced lunch.
- Reside in or attend public, charter, private or homeschool in Indian River County.
- Attend and participate in all group activities enrolled in weekly.
- Adhere to the program expectations set by the Youth Guidance Staff on and off-site. Submit a copy of their report card QUARTERLY to Youth Guidance Staff.
- Adhere to the 3-Strike Policy and maintain reasonable behavior by being honest and respectful to staff members, volunteers, mentors, peers, and community partners while participating in Youth Guidance Programs. Behaviors to avoid include:
  - Fighting
  - Disrespecting Staff
  - Inappropriate language (ex: profanity and obscene gestures)
  - Stealing Vandalism/destruction of property
  - Inappropriate touching
  - Bullying
  - Illegal activity (ex: drug or alcohol use, possession of weapons)
- Dress in a manner that allows full participation in our programs. Clothing that is prohibited includes:
  - Clothing/jewelry that displays logos or images that promote drug use, alcohol, violence, or racism.
  - Open toed shoes (ex: crocs, sandals, or slides
  - Clothing that exposes the midriff or other parts of the body (ex: crop tops, spaghetti straps, booty shorts, see-through apparel, skintight clothing, etc
- Adhere to the Youth Guidance cellphone/electronics policy.
  - Students can use their cell phones during the time frame given by Youth Guidance program staff.
  - Additionally, staff may permit phone use at other times for Educational or Emergency purposes.
Please read the following statement:*

I have read and understood the above admissions policy for the Youth Guidance Mentoring Academy and agree to its terms and conditions.
Student Name:*
Parent Name:*

Parental Acknowledgement Form
For your child(ren) to participate and maintain their scholarship in the Youth Guidance Mentoring Academy Program, the following criteria requirements must be met by the parent:

1. Sign-up your child for Youth Guidance programs during the registration period. Registration is on a first come, first served basis. If there is no room available for your child, they will be placed on a wait list and will be contacted if space is made available.

2. Adhere to the Youth Guidance Attendance Policy and notify staff if your child will be early, late, or absent.

3. Ensure that your child meets the standards of behavior in all Youth Guidance related programs.

4. Provide QUARTERLY report cards if attending private or being home-schooled.

5. Will participate in QUARTERLY meetings if your child is failing (D or F) in subjects at school.

6. Make sure your child arrives and is picked up on time for programs. *Late fees will be applied

7. Walk in with your child and sign them in and out.

8. Inform staff of any special needs your child may have, when there is a change in your contact info and if your child changes schools.

9. Not go past the front lobby without the permission or escort of a Youth Guidance staff member.
Please review the following statement:*

I have received and read the Youth Guidance application. I understand that failure to follow any of the outlined policies and procedures could result in my child’s removal from the program. I fully understand and agree to all conditions stated on the application form. I have counseled my child to conform to the rules and the authority of the employees of Youth Guidance. I understand that my child’s scholarship in Youth Guidance programs may be suspended or canceled at any time. Actual consequences are determined on a case-by-case basis and are at the discretion of the Executive Director or Operations Manager.
Parent/Guardian Name*
Parent/Guardian Signature*

Powered by Jotform SignClear
A United Way Community Partner
Should be Empty:

Youth Guidance Student Application

Parent/Guardian/Caregiver Information

Emergency Contact #1

Emergency Contact #2

Permission

Transportation

Liability

Medical

Photo/Video Release

Attendance Policy

Student Admission Policy

Parental Acknowledgement Form