BLACK & GOLD 2.0 Year 3 Registration

Black & Gold 2.0 Year 3 Registration Packet
IMPORTANT - PLEASE READ BEFORE ATTENDING
This packet must be fully completed and submitted before your first workshop.
Youth who have not submitted our required forms will NOT be permitted to participate.
Section 1 – Youth Information
Legal Name

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age:
School:
Grade
Home Address:
City:
Zip Code:
Youth Phone Number (if any):
(000) 000-0000Format: (000) 000-0000.
Youth Email (if any):
example@example.com
Gender
RACE / ETHNICITY - check all that apply

Other

Section 2 – Medical Information

Please fill in all fields. Write N/A if not applicable
Does your child have any medical conditions or allergies?
If yes, please describe below, including any emergency instructions staff should follow (medications, devices, or care steps)
Does your child need medication during program hours?
If yes, please explain (medication, dosage, timing)
Does your child have any food allergies or dietary restrictions?
If yes, please describe
Section 3 - Parent / Guardian Contact
Parent / Guardian Name:
Relationship to youth:
Home Address:
Parent Email:
example@example.com
Phone Number:
Format: (000) 000-0000.
Section 4 - Emergency Contact
Emergency Contact Name:
Relationship to youth:
Email:
example@example.com
Phone Number:
Format: (000) 000-0000.

Section 5 – Transportation
Black & Gold 2.0 workshops take place at three locations. Transportations options are listed below:
- Crane Community Center (1001 Vine St, 2nd FL): Coach Cook's City Van is available for North Philly youth. SEPTA passes are also provided.
- Hanks Gathers Youth Access Center (2501 W Diamond St): SEPTA passes provided for independent travel to Crane and then additional transportation is provided to the Hanks Gather Center.
- Drexel University – Culinary Series: Transportation is provided for all youth
Please check ONE:
Section 6 – Media & Photo Release
Photos and videos may be taken during workshops for educational and promotional purposes, including on our Instagram (@blackgold20philly) and in our newsletter.
Please CHECK

Section 7 – Code of Conduct

Please read each section carefully. Youth must initial each section and sign at the bottom.
1. RESPECT FOR OTHERS
- Treat all peers, staff, and speakers with kindness and respect at all times.
- No profanity, bullying, or disrespectful language toward anyone.
- Phones are silent and away unless permitted by staff.
- Ask staff permission before using the restroom during programming.
- ZERO FIGHTING POLICY: Any physical fighting results in immediate removal from the program.
Youth Initials:
2. RESPONSIBILITY & ACCOUNTABILITY
- Take responsibility for your actions and be honest with staff.
- Treat all facilities, equipment, and materials with care.
- Clean up after yourself during and after all activities.
- ZERO THEFT POLICY: Any youth caught stealing will be immediately removed and not invited back.
- If unable to attend a workshop, notify staff in advance.
Youth Initials:
3. SAFTEY
- Follow all safety rules at every workshop location.
- Do not leave the workshop location without a staff member or adult.
- Stay home if sick with COVID, flu, or fever.
Youth Initials:
4. PARTICIPATION & ENGAGEMENT
- Arrive on time and be ready to participate.
- Engage actively and keep an open mind — growth requires stepping outside your comfort zone.
- Respect the cultures, backgrounds, and experiences of all peers.
Youth Initials:
5. DIGITAL CONDUCT
- Communicate respectfully during any online activity.
- Ask permission before recording or photographing anyone, including other youth and staff.
Youth Initials:
I understand that removal from the program may occur if I violate the Code of Conduct.
Printed Name
Date Filled

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Youth Signature

Section 8 – Culinary Consent

The Culinary Series takes place at Drexel University's professional kitchen facilities (11:00 AM - 2:00PM). Transportation to Drexel is provided for all youth. This section is required to participate in any Culinary Series workshop.
KITCHEN SAFETY — YOUTH INITIAL BELOW
- Follow all instructions from staff, chefs, and supervisors at all times.
- Use knives, stoves, ovens, and kitchen equipment only as directed.
- Wear the apron provided. Closed-toe shoes required. Long hair must be tied back.
- Wash hands frequently and follow proper food safety and hygiene practices.
- Notify staff immediately if experiencing vomiting, diarrhea, or fever over 101°F.
Youth Initials:
CULINARY ALLERGIES & DIETARY INFORMATION
Do you have any food allergies or dietary restrictions?
Food Allergies:
Dietary Restrictions:
ACKNOWLEDGMENT OF RISK & RELEASE OF LIABILITY
I understand that participation in the Culinary Series involves inherent risks including: hot surfaces, sharp tools, slips, burns, cuts, exposure to raw food, allergens, and risks associated with transportation. I voluntarily accept these risks and agree to release PCDC, AITF, Drexel University, and all associated staff and volunteers from any claims arising from participation, except in cases of gross negligence or willful misconduct.
CULINARY SERIES MEDIA RELEASE – Please CHECK:
Parent/Guardian Printed Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Signature
Youth Printed Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Youth Signature

Section 9 - Parental Consent & Liability Waiver
A parent or guardian must complete this section. This form covers all educational, recreational, and social events for the full 2026-2027 program year. If any of your information changes during the year, notify program staff in writing.
Youth's Full Name:
I, Full Name* ,the parent / guardian of the youth named above, give permission for my child to participate in the Black & Gold Year 3 Youth Program for the 2026 - 2027 school year.

I understand that personal injury can and may occur to my child. I authorize program staff from Philadelphia Chinatown Development Corporation (PCDC) and All in the Family Group (AITF), or another appointed program staff member, to seek and consent to emergency medical attention for my child as needed. I agree to be responsible for any costs incurred.

I hereby release PCDC, All in the Family Group, their employees, agents, and volunteers from any and all liability, claims, demands, or causes of action arising out of or related to any loss, damage, or injury (including death) that may be sustained by my child while participating in or traveling to and from Black & Gold 2.0 events and activities.

Equipment & Property Damage: I agree to accept full responsibility for any damage my child may cause to any facility, property, or vehicle used in connection with the program.

By signing below, I confirm that all medical, allergy, and medication information provided in this packet is complete and accurate, and that I have read and agree to all terms above.
Printed Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent / Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Section 10 - Peer Leader Interest (optional)
Become a Black & Gold 2.0 Peer Leader (Year 3)

As a Peer Leader, you're more than just a participant — you're a role model, a leader, and a key part of what makes Black & Gold 2.0 work. You'll help create a welcoming, positive environment for your peers while building real leadership, communication, and event-planning skills along the way.
What you'll do:
- Serve as a role model and help welcome new participants at workshops, field trips, and events
- Co-facilitate or lead at least one activity during a workshop of your choice. Capture photos and videos, and help run our Instagram (@blackgold20philly)
- Support workshop setup, teardown, and materials distribution
- Help plan one element of the End of Year Celebration
- Attend a short monthly peer leader check-in (virtual or in-person)
- Show up to workshops and events to the best of your ability (75% attendance minimum)
Who can apply:
- Ages 16–18
- Registered as a B&G 2.0 participant for Year 3 (2026–2027)
What you get:
- A stipend at the End of Year Celebration (for completing at least 75% of your responsibilities)
- Leadership experience you can put on a résumé or college application
- A voice in shaping the program and a closer community with staff and peers
What's expected: Respect, confidentiality, professionalism, and open communication. Peer Leaders represent B&G 2.0 at every workshop and on social media, so we're looking for people who want to show up, lead with kindness, and help others feel included.
Next step: If this sounds like you, you'll complete a short 15–20 minute interview with PCDC program staff to share why you want to be a Peer Leader and what you hope to contribute.
Would you like to become a Black & Gold 2.0 Year 3 Peer Leader?
Should be Empty:

Black & Gold 2.0 Year 3 Registration Packet

Section 1 – Youth Information

Section 2 – Medical Information

Section 3 - Parent / Guardian Contact

Section 4 - Emergency Contact

Section 5 – Transportation

Section 6 – Media & Photo Release

Section 7 – Code of Conduct

Section 8 – Culinary Consent

CULINARY ALLERGIES & DIETARY INFORMATION

ACKNOWLEDGMENT OF RISK & RELEASE OF LIABILITY

Section 9 - Parental Consent & Liability Waiver

Section 10 - Peer Leader Interest (optional)