Youth Centre Membership 2024-2025

Youth Centre Membership Form

Valid until August 2025
Youth Contact Information
Name*

First NameLast Name
Grade*
Age*
Address*

Street Address

Street Address Line 2

CityProvince

Postal code
Home phone number

Area CodePhone Number
School name*
Allergies or medical concerns?
Emergency Contacts (Parent / Guardian)
Name*

First NameLast Name
Contact number*

Area CodePhone Number
Email (parent/guardian)*
example@example.com
Name

First NameLast Name
Contact number

Area CodePhone Number
Email (parent/guardian)
example@example.com
Media Release / Photo Consent: Do you consent to having your child's photo taken at the Youth Centre to be used in CCSS promotional materials (Website, Facebook, Instagram, brochures, YC posters etc)?*

YesNo
Terms and Conditions of Membership

Please review the following Code of Conduct. Both youth and a guardian must provide a signature.
The CCSS Youth Centre is offered by the Cumberland Community Schools Society in partnership with Cumberland Community School (CCS) and School District No. 71.

Code of Conduct:

Youth are expected to be kind towards each other, to respect the space and to follow the direction of CCSS Staff.
- Inclusion: The Youth Centre is committed to the values of diversity and inclusion. We welcome the spectrum of human diversity including race, gender, socio-economic status, sexual orientation, gender identity, disability and religion. Youth share the responsibility of creating a safe and welcoming space.
- Safety: Youth must treat others with respect in regards to physical contact and personal space.
- Language: Youth must use appropriate and respectful language while attending the Youth Centre
- Screens: Computers should be used in a respectful manner. Inappropriate content (eg. pornography, gambling, hateful content) can not be shared on your personal screens. Time limits for video game time must be respected, and players must request access to other players Minecraft worlds before playing in them.
- Smoking Policy: The CCSS Youth Centre and Cumberland Community School grounds are a non-smoking area. Youth who choose to smoke must do so off School District property.
- Drug and Alcohol Use: Alcohol, drugs, or being under the influence will not be tolerated in the Youth Centre, on the surrounding grounds, or while involved in programs or events connected to the CCSS Youth Centre.
Youth will be asked to leave the Youth Centre if they are unable to follow this Code of Conduct. If their behaviour is ongoing, youth will be asked to take a break from attending the Youth Centre.
Note to Parents/Guardians:
- Youth Centre staff are only responsible for supervising students when they are in the Youth Centre building. They are NOT responsible for supervising students if they leave the building and hang out on the school grounds.
- Creating a safe space for all is very important to us. If youth are not abiding by our code of conduct they will be asked to leave immediately. If the behaviour continues they will be asked to take a week or more away from the CCSS Youth Centre. If it still continues their membership will be revoked without reimbursement.
- Occasionally there are unexpected Youth Centre closures. Please discuss a back up plan with your youth in case of this eventuality.
Agreement and signatures
I have read, understood and agree to all the terms and conditions above.
Youth signature*
Parent/guardian signature*
Annual Membership Fee - $20/youth*

Pay $20 by e-transfer to director@ccssociety.orgPay $20 by cash or cheque (payable to CCSS)
Questions or concerns? Please contact us at director@ccssociety.org or call us at 250-336-8511
Should be Empty:

Youth Centre Membership Form

Youth Contact Information

Emergency Contacts (Parent / Guardian)

Terms and Conditions of Membership

Agreement and signatures