C4K Membership Application, FY26

C4K Membership Application
Completing this application is a indication that the youth will be joining our next 1:1 Mentoring cohort. If you are referring a youth that is interested but are not a parent / guardian, please fill out a New Member Interest Form. We will follow up with steps to complete the application.

If you have questions or concerns, please reach out C4K's Mentor Coordinator by calling / texting 434-214-0277 or join@c4kclubhouse.org.
Member Information
First Name*
Middle Name
Last Name*
Date of Birth*

MonthDayYear
Sex*
Grade*
If it's Summer, choose grade that member will be going into.
School*
If it's Summer, choose school that member will be going into.
Other - School Name
Please type in the name of the school that is not in the list.
Ethnicity (check all that apply)*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic, Latinx, or Spanish originMiddle Eastern or North AfricanNative Hawaiian or Other Pacific IslanderWhiteSome other race, ethnicity, or originPrefer not to say
Primary language spoken at home*
Other - Language
Please type in name of other language

Address
Street Address*
Street Address Line 2
City*
State*
Zip Code*
In which locality do you live?*
Other - Locality
Please type in the name of the locality that is not in the list.
Is this youth in foster care?

YesNo

Household Information
How many people (including member) live in the household?*
What is your family's annual income (2)?*
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.
What is your family's annual income (3)?*
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.
What is your family's annual income (4)?*
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.
What is your family's annual income (5)?*
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.
What is your family's annual income (6)?*
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.
What is your family's annual income (7)?*
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.
What is your family's annual income (8+)?*
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.
Does the member qualify for free or reduced meals at school? *
Have either the member's parents or legal guardians completed a four-year (bachelor's) college degree at an institution within the United States?

Program Agreements
Please review the following documents. Printed copies are available upon request.
- C4K Program Agreement
I have reviewed and agree to the C4K Program Agreement.*

YesNo
Parent / Guardian Signature*

Clear
Should be Empty:

C4K Membership Application

Member Information

Address

Household Information

Contact Information

Program Agreements