Youth Services Network

Please note: Registration webpage has changed. Register using this link: YOCH Application

If you have any questions or concerns please email: youth@antiochca.gov
Phone Number:*
Please enter a valid phone number.
Allergies and Administration of Medicines
Asthmatic:*

YesNo
Medical Condition:
Food Allergies:*

YesNo
Please list down below:
Allergic reactions, signs or symptoms to look for:
Please list below:
Medical Authorization
Date:*

MonthDayYear
Date
Parent/Guardian Signature:*

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Reminders:

Participants are responsible for arriving at the program with all necessary medications, supplies, pumps, back-up medications and any other equipment necessary for the participant to safely self administer their medications.
Medical monitoring of blood sugar levels must be done by parent or guardians prior to attending the program each day, to ensure that they are within their target range.
Staff will not be responsible for identifying symptoms of hyperglycemia or hypoglycemia, but can assist the participant in checking blood sugar levels with proper training provided by parents or guardians.
Parents/guardians are responsible for providing all necessary information regarding dietary restrictions, food allergies or special diet considerations to staff.
Participants and parents/guardians shall be advised and reminded that it is the participants responsibility to administer the medication and that staff will only assist as needed. Staff will not give scheduled injections.
It is the responsibility of the parent/guardian to pick up any medications that remains at the conclusion program. Any medication not picked up with be disposed of in a safe manner.
Media Release
Date:*

MonthDayYear
Date
Parent/Guardian Signature:*

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Printed Name:*
Step 2: Required Documents

Note: This application does not automatically qualify you for the program. Staff will reach out once the application is turned in and completed.
Please provide/complete all documents listed below:
- Recent Report Card/Progress Report
- 1-9 Documents(ONLY IF YOU ARE 14 0R 15 YEARS OLD).
- W-9 Form(ONLY IF YOU ARE 14 0R 15 YEARS OLD).
- Yoch Form-Signed
- Yoch Contract-Signed
1. Most recent report card/progress report: Needs a B or higher in Math or English. *

Cancelof
2. 1-9 Documents (Please refer to the document for a list of eligible 1-9 Documents). *

Cancelof
Yoch Contract Signature:12-13 year olds. Sign N/A if it doesn't apply to you. *
Yoch Contract Signature:14-15 year olds. Sign N/A if it doesn't apply to you.
Yoch Form Signature:
Should be Empty:

Allergies and Administration of Medicines

Medical Authorization

Media Release

Step 2: Required Documents