Mentorship Matter Registration Form (2025- 2026)

Mentorship Matter

Cohort Registration Form
Date: September 2025 to June 2026
Location: 904 19 Street NE
Calgary, Albeta
Our team at Cornerstone Youth Centre (CYC) have been reevaluating our mission as an agency. In the past, Cornerstone aimed for high registration and attendance at the centre in hopes to help as many youth as possible. When we reopened our centre after the first COVID-19 lockdown, we naturally saw lower numbers of youth than pre-pandemic. Although not what we were used to, we began to realize that we had a greater impact on youth with smaller numbers. Therefore, CYC has decided to adjust the structure of our centre slightly, by focusing on a smaller cohort of youth.

The Cohort Program is to intentionally provide youth with programs and set goals to help build ont heir future life skills. By focusing on being supportive, engaging in meaningful programs,

Cornerstone Youth Centre's Cohort Program is changing. We will be implementing a set schedule where youth will be divided by grades. CYC believes this will help create programs based on their developmental needs to fit the youth in their respective grades. Grades 5, 6 and 7 will be on Tuesday, Thursday. Grades 8-9 will be on Monday and Wednesday. Friday will be open to ALL cohort youth. Youth must agree to attend Cornerstone as well as participate programs at least 8 times a month/twice a week minimum (programs are on Monday, Tuesday, Thursday and Friday. Wednesday and Thursday will be 1-on-1 mentorship days. However, one on ones can be any day you like). We belive consistency teaches stability and structure which youth need to thrive.

Youth must also attend weekly goal setting sessions with their mentor. Mentor will support youth establish goals as they will keep them accoutable in meeting goals. In the event that youth are not able to attend Cornerstone, they are enouraged to reach out via discord or phone to let a staff member know. An accumulation of unexplained absences may result in removal from the cohort.
Youth Personal Information
Youth Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Gender
Youths Phone Number

Area CodePhone Number
Youths Email
example@example.com
Primary Address

Street Address

Street Address Line 2 (Complete if live in two parent's home)

CityState / Province

Postal / Zip Code
Primary Community
ie: Mayland, Vista, Dover
School Name
Grade

56789
Does your child have any medical conditions we need to be aware of?
Medical Conditions
If Yes, please elaborate
We believe eating a hot meal together at the dinner table promote good youth development. Therefore, Cornerstone provides hot meals everyday at the centre and will introduce food that are from different cultures. Does your child have any allergies that we need to be aware of?
Allergies
If Yes, please elaborate
Parent/Guardian Details
Parent/Guardian Name

First NameLast NameRelationship (ie: Mother, Father, Grandma, Grandpa)
Phone Number

Work, Home, CellphonePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Parent/Guardian Name

First NameLast NameRelationship (ie: Mother, Father Grandma, Grandpa)
Phone Number

Work, Home, CellphonePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Emergency Contact Details

If parent/guardian cannot be reached.
Contact Name

First NameLast Name
Phone Number

Area CodePhone Number
Off Campus Consent
Cornerstone believes that youth doing programs in the community will build stronger community connection. Youth will then gain a sense of belonging and help develop their social skills. Therefore, Cornerstone will have programs that involve your child being taken off site.

By signing this I am aware that my youth will be taken offsite for programs. These will happen throughout the semester to give youth the opportunity to build on life skills. I give authorization for my child to engage in the activities outside and in the surrounding area.

As a parent/guardian of _____________________, registered at Cornerstone Youth Centre (CYC), I release Cornerstone as well as the directors, officers, agents, members, employees, participants, volunteers, sponsors, owners/operators of the facility, and representatives, from any and all actions, causes of action, claims or demands whatsoever from any, but not limited to, personal injury, including death, loss or damage property arising in any way whatsoever from my child's participation in activities and programs offered by CYC at the centre while attending events or engaging in offsite activities with empoyees and/or volunteers of Cornerstone.
Parent/Guardian Signature

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Date Signed

MonthDayYear
Date
Respectful Behaviour Policy
I understand that the Cornerstone Youth Centre is committed to providing a safe and respectful environment to all attendees, and that I/my child must follow the rules of respect for myself and others while attending Cornerstone. I also understand that failure to follow such rules will result in my/my child's removal from the program on a temporary or permanent basis, as the Cornerstone staff sees fit. I also understand that the staff of Cornerstone has fully discretion in making decisions about temporary or permanent removal from the program for the safety and sercurity of myself/my child and others. The Respectful Behaviour Policy also include when we are away/off campus from the centre.

Youth in the centre are expected to participate in any program or activity that Cornerstone has planned for the day. Youth who are not willing to participate and meet the expectation that day they will be asked to sign out and try again tomorrow or can be removed from the cohort program.
Parent/Guardian Signature

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Youth's Signature

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Date Signed

MonthDayYear
Date

Phone Policy
As of July 04, 2023 Cornerstone has implemented a "Cellphone Free Policy" within the centre. When youth enter the centre they will be asked to give their phone to a staff member to put away in a caddy, they will only receive it back from staff once they sign out of the centre. Phones will be kept in a locked office. Parents or guardians who need to contact their youth are invited to call the centre at 403-276-5360. This policy was introduced due to the high usage of cell phones in the centre and we believe social interaction will help support youth emotional intelligence. Below is a link to research supporting our stance on cellphone usage in the centre and its effects on a youths brain and development.

Social Media and Youth Mental Health
Youth's Signature

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Questionaire

This is to be done by the youth only!
How did you find out about Cornerstone Youth Centre?
Family and FriendsWalking around in the neighbourhoodCommunity MemberSocial MediaSchool
What skills are you trying to build while at Cornerstone? (Minimum 2)
Why do you want to be part of Cornerstone Youth Centre's Cohort Program?
What does commitment and consistency mean to you?
On a scale of 1-10 how much do you need this program? 1 being not at all and 10 being a high need. Please explain why.
What is your biggest dream? How can Cornerstone Youth Centre help you with this dream?
Are there times you feel anxious or depressed? If yes, explain why.
Finish this sentence. I am ____________________________________.
Acknowledgment, Authorization, and Photo Consent
I would like to register my child for this school year at Cornerstone Youth Centre. I give authorization to engage in the programs in and outside of Cornerstone Youth Centre.

I am aware that photographs and digital recordings may be taken at the Centre and outside of the Centre, during programs, field trips and may be used for promotion of Cornerstone Youth Centre in various media forms, including website, Facebook and Instagram. I consent taking photography and the use of of it and understand that I can revoke my consent at any time.

I authorized Cornerstone Youth Centre to apply judgment in regards to medical assistance in the event of an injury (scraps and cut from playing ouside or the basketball court) if they are unable to contact the parent/guardian. I allow them to apply first aid and treatment as necessary.

I release Cornerstone Youth Centre and any of its staff and volunteers for any responsibility in case of accident, illness, or injury during the youth's enrollment.

I have carefully read and understand that by signing this CONSENT and RELEASE OF LIABILITY that I am giving up certain legal rights which I may have, including the rights to sue the above mentioned organizations, their employees and volunteers. I have carefully read this Consent and Release and understand it, and signing it voluntarily and with full knowledge of its significant. This CONSENT and RELEASE OF LIABILITY shall be binding upon me and my heirs, executors, administrators, and personal representatives.
Date Signed

MonthDayYear
Date
Parent/Guardian Signature

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CORNERSTONE YOUTH CENTRE
904 19 Street NE, Calgary, AB, T2E 4X7
programs@cyccalgary.com - www.cornerstoneyouthcentre.com
Should be Empty:

Mentorship Matter

Youth Personal Information

Parent/Guardian Details

Emergency Contact Details

Off Campus Consent

Respectful Behaviour Policy

Phone Policy

Questionaire

Acknowledgment, Authorization, and Photo Consent