This form is required for participation in KYCC center activities. Please complete each section thoroughly, sign and date.

To select another language, press on the icon on the top right corner. Para seleccionar otro idioma, presione el ícono en la esquina superior derecha. 다른 언어를 선택하려면 오른쪽 상단 모서리에 있는 아이콘을 누릅니다.

Mandated Reporting - I understand that all KYCC staff are mandated reporters by California Law, and must report suspected child abuse or neglect of a child under the age of 18 to the Department of Child and Family Services using the resources that we were taught in our trainings. The types of reportable suspected child abuse are physical abuse, sexual abuse, emotional abuse, or neglect. By law, KYCC staff are not allowed to investigate or make any kind of judgement about the particular family. Any reports made are kept confidential and only shared with members of the Supervisor team.

Liability - I hereby grant permission for my child to use all of the program equipment and participate in all activities of the center, and grant permission for my child to leave the premises under the supervision of a KYCC staff member. I do hereby, for my child/children, myself, my heirs, executors and administrators, release and hold harmless KYCC, and all officers, directors, employees, agents and volunteers of the organization, acting officially or otherwise, from any claims, demands, actions or causes of action which in any way arise related to my child's participation in KYCC programs.

By signing below, I certify that I am the parent and/or legal guardian of the child named in this application. I acknowledge that I have carefully read this document and understand the information therein. I agree to each of the terms and acknowledgments above, and agree to permit my child to participate in KYCC activities.

Occasionally, KYCC program activities may be photographed, videotaped, or audio taped for educational, publicity or fundraising purposes. Please indicate if you give permission for your child and/or their project work to appear in videos, photos or audio recordings without compensation (e.g., as part of brochures, slide shows or program websites).

If, in the judgment of the staff of KYCC the child named above needs immediate care and treatment as a result of any injury or sickness, I do hereby authorize and consent to any x-ray examination, anesthetic, medical, or surgical or dental diagnosis or treatment and hospital care are considered necessary in the best judgment of the attending physician, surgeon or dentist and performed by or under the supervision of the medical staff of the hospital or facility furnishing medical or dental services.

I do hereby agree to indemnify and hold harmless KYCC (including its officers, directors, members and/or volunteers) from any claim by any person whomsoever on account of such care and treatment of said child. It is understood that a good faith attempt shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. Further, it is understood that the undersigned will assume full responsibility for any such action, including payment of costs.