2026-2027 KYCC Youth Services Participant Application
Language
  • English (US)
  • Español
  • Korean

  • 2026-2027 KYCC Youth Services Participant Application

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

  • Thank you for your interest in our KYCC Youth Services Programs! All program participants must complete the 2026-2027 KYCC Youth Services Participant Application Form. After submitting this form, your enrollment status will be pending until our KYCC Staff reach out to confirm with you. You will be required to fill out additional form(s) based on the specific program(s) you are applying for.

  • YOUTH PARTICIPANT INFORMATION

  • Birthdate:*
     / /
  • Race & Ethnicity (Select One):*
  • Preferred Language(s):*
  • Format: (000) 000-0000.

  • PARENT/GUARDIAN (PRIMARY CONTACT) INFORMATION

  • Does the Parent/Guardian (Primary Contact) live at the same address as the youth participant?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Race & Ethnicity (Select One):*
  • Preferred Language(s):*
  • How did you hear about KYCC? (select all that apply):

  • PARENT/GUARDIAN (SECONDARY CONTACT) INFORMATION

    If there is no Secondary Parent/Guardian, you may leave this section blank.
  • Does the Secondary Contact live at the same address as the youth participant?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Race & Ethnicity (Select One):
  • Preferred Language(s):

  • ADDITIONAL PICKUP/EMERGENCY CONTACT INFORMATION

  • The individuals listed below are authorized to pick up/drop off the youth participant, sign them in or out of program, and can be contacted in the event of an emergency. KYCC Staff will always attempt to contact the Parent/Guardian (Primary and Secondary Contacts listed above) before contacting Additional Authorized Person(s) when communicating program information. If no additional contacts are available, you may leave this section blank.
  • Would you like to share information for additional people who are authorized to pick up the student from program?*
  • Preferred Language(s):
  • Does Authorized Person #1 live at the same address as the youth?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred Language(s):
  • Does Authorized Person #2 live at the same address as the youth?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • 2026-2027 KYCC Emergency Medical Release Form

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

  • YOUTH PARTICIPANT MEDICAL INFORMATION

  • Allergies -- Does your child have any allergies to food, medications, insects, etc.?*
  • Does your child have an IEP/504 Plan with their school?*
  • Health Conditions -- Has your child ever been diagnosed with any health conditions?*

  • MEDICATION POLICY

  • KYCC staff do not administer medication to students, as we do not have a licensed nurse on site. If your child requires medication to be taken during program hours on a regular basis, please contact the Program Coordinator. A Medication Consent Form must be completed and approved in advance to make appropriate arrangements.
  • Does your child currently take any medication(s)?*

  • EMERGENCY RELEASE

  • 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.

  • Date:*
     / /

  • 2026-2027 KYCC Liability Acknowledgement Form

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

  • ACKNOWLEDGEMENTS

  • 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.

  • Date:*
     / /

  • MEDIA RELEASE

  • 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).
  • Permission for child to appear in media:*
  • Date:*
     / /

  • KYCC YS Sign In and Sign Out Policy Acknowledgement

    This form is required for Middle and High School participants in KYCC YS Activities. Please complete each section thoroughly, sign, and date.

  • YOUTH SERVICES SIGN IN AND SIGN OUT POLICY

  • All middle and high school students can sign themselves in and out of the program. I understand that KYCC is not liable for the health and safety of my child before signing in and after signing out of the program.
  • Parents and/or Guardians have the right to request information about their child's attendance (i.e. asking if their child attended program on certain days or asking for the time their child signed in/out). Any questions about attendance history can be addressed to the Program Lead Staff.
  • Please check below to indicate your preference:*
  • Date:
     / /

  • Submission Confirmation Page

  • Thank you for completing the 2026-2027 KYCC Youth Services Participant Application Form! After submitting this form, your enrollment status will be pending until our KYCC Staff reach out to confirm with you. You will be required to fill out additional forms based on the specific program you are applying for.

  • Please indicate what specific program the youth participant will be enrolling in:*
  • Should be Empty: