Prep Lab 2026-2027

1
What grade is the participant currently in?
7th Grade
8th Grade
10th Grade
9th Grade
11th Grade
12th Grade
GED
Other
2
Select the day(s) you are interested in your youth attending CCC Prep Lab* This field is required.
Tuesday
Thursday
3
A maximum of 10 youth per day needing transportation will be accepted. We can only pick up, drop-offs will not be offered. Pick-up locations must be within a 4 miles radius of NAYA (Oregon only). We will do our best to accommodate transportation needs, but our services are not guaranteed. Areas/schools with the most youth will be prioritized.* This field is required.
My youth's afterschool pick up location is within 4 miles of NAYA, and I would like my youth to be transported by NAYA staff to NAYA afterschool. I will pick up my youth from NAYA.
My youth does NOT need transportation to NAYA or their pick up location is further than 4 miles from NAYA.
4
NAYA unfortunately does not have capacity to provide transportation for all youth.* This field is required.
I understand as the parent/guardian that NAYA cannot guarantee transportation support and that I am responsible for organizing transportation to and from Learning Center for my youth in the case NAYA cannot.
5
Does your youth currently have a NAYA Youth Advocate?* This field is required.
Yes
No, not interested
No, but I am interested
6
Please enter Youth Advocates nameIf you are youth's NAYA advocate enter your name. You may proceed with filling the interest form out for your youth
7
Youth Name* This field is required.
First Name
Last Name
8
Youth's Preferred Name (if different from above)
9
Date of Birth* This field is required.
Date
Year
Month
Day
10
Youth's Phone Number* This field is required.
Please enter a valid phone number.
11
Youth's Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
Youth's Gender* This field is required.
Please Select
Female
Male
Two-Spirit
Intersex
Transgender
Non-Binary/Third gender/Another gender
Decline to Answer
13
Youth's Preferred Pronouns* This field is required.
She/Her
He/Him
She/they
He/They
They/them
Other
14
Ethnicity or Ethnicities (select all that apply)* This field is required.
African
Alaska Native
First Nations (Canada)
Hispanic/Latino
Middle Eastern/Arabic
Pacific Islander
White
African American/Black
Hawaiian/Part Hawaiian
Indigenous to South America
Native American
Slavic/Eastern European
Unlisted
15
Youth's Tribal Affiliation Formal enrollment in a Tribe is not required
16
Please list any Medical Conditions/Allergies that the student may have: If yes, list all. If no, put "none."* This field is required.
Huge
Large
Normal
Small
Ok
Ok
17
What school is the youth currently attending?* This field is required.If GED, write GED.
18
Youth's Synergy ID (District ID Number, contact youth's school if you don't know)* This field is required.This is the same as the lunch ID number. Should be six digits
19
Parent/Guardian's Name * This field is required.
First Name
Last Name
20
Parent/Guardian's Name* This field is required.
example@example.com
21
Parent/Guardian's Phone Number* This field is required.
Please enter a valid phone number.
22
Emergency Contact Name (parent/guardian will be first emergency contact)* This field is required.
First Name
Last Name
23
Relation to Youth?* This field is required.
24
Emergency Contact 2 Phone Number* This field is required.
Please enter a valid phone number.
25
List the first and last names and phone numbers of anyone who has permission to pick up your youth (parents, guardians, family, friends, NAYA staff, etc.) If some one arrives to pick up your youth who is not listed here, they will NOT be able to pick them up. IDs may be required.* This field is required.If your youth is allowed to leave via Trimet please indicate this.
26
Parent/Guardian Acknowledgement Signature* This field is required.As the Parent/Guardian of the student applicant, by providing my e-signature, I give my permission for the student to participate in the NAYA Learning Center 2026-27 field trips. By signing this agreement I acknowledge that NAYA has my permission to drive my child in NAYA owned vehicles, staff vehicles, and chartered buses and include my child in all of the NAYA Learning Center 2026-27 activities. In the case of an emergency, the signature provided does hereby consent to any and all medical and surgical treatment including anesthesia and operations which may be deemed advisable by the physician, and surgeons, to perform all examinations. I also agree that the patient, when admitted is to remain in the hospital until their physician recommends the patients discharge. NAYA will not be held liable for any injuries or accidents caused to the student if they choose not to follow NAYA staff directions or rules. Full Signature required
27
Non-Discrimination Agreement I agree* This field is required.We, the organizers, parents, guardians, participants, students, teachers, and staff of NAYA Youth and Family Center, hereby pledge to create an environment that is inclusive, respectful, and free from discrimination of any kind. We believe in the inherent dignity and worth of every individual and are committed to upholding the following principles: Equal Opportunity: We affirm that all individuals, regardless of race, color, ethnicity, nationality, religion, gender, gender identity, sexual orientation, disability, socio-economic status, or any other characteristic, have the right to equal opportunities and treatment within our program. Respect and Dignity: We will treat each other with respect, dignity, and empathy. We recognize that everyone brings unique perspectives, experiences, and talents to our community, and we value this diversity. Non-Discrimination: We will not tolerate any form of discrimination, harassment, or prejudice. This includes but is not limited to actions or language that is racist, sexist, homophobic, transphobic, ableist, or otherwise discriminatory. Zero-Tolerance for Isms and Phobias: We have a zero-tolerance policy towards all forms of isms (such as racism, sexism, ableism, etc.) and phobias (such as homophobia, transphobia, etc.). Any behavior or language promoting such ideologies will not be tolerated and will result in immediate disciplinary action. Decolonization: We acknowledge the historical and ongoing impacts of colonization on marginalized communities. We commit to challenging colonial structures, narratives, and practices within our program. This includes centering Indigenous knowledge, perspectives, and voices, as well as amplifying the experiences of marginalized groups. Inclusivity: We are committed to creating an inclusive environment where all individuals feel welcome, valued, and supported. We will strive to foster an atmosphere of openness, acceptance, and understanding. Accessibility: We will make reasonable accommodations to ensure that our program is accessible to individuals with disabilities. We will also consider the diverse needs of participants and work to address any barriers to participation. Conflict Resolution: In the event of conflicts or concerns related to discrimination or harassment, we will address them promptly and fairly. We encourage open communication and constructive dialogue to resolve issues and promote mutual understanding. By agreeing below, we affirm our commitment to these principles and pledge to uphold them throughout the duration of participating in the NAYA Learning Center 2026-27 and NAYA Youth and Family Center.
YESNO
28
Permission Media consent to photograph, video, interviews and quotations I agree * This field is required.I give consent for myself or my child to participate in NAYA Family Center marketing activities, including interviews, the use of quotes, and the taking of photographs, movies or video tapes by NAYA Family Center employees. I grant NAYA Family Center the right to edit, use, and reuse said products for non-profit marketing purposes including use in NAYA Family Center grant writing and marketing in print, on the internet, and all other forms of media. I also hereby release NAYA Family Center and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.
YESNO
29
Consent to Emergency Care and Relevant Information I agree* This field is required.In the event of an emergency, if reasonable attempts to contact persons listed are unsuccessful, I give consent to the NAYA Family Center to transport myself or my child to the doctor or to the Emergency Medical Department of the nearest hospital. If my doctor cannot be contacted, all medical treatments deemed necessary by the attending licensed physician, including examinations, anesthesia, operations, and diagnostic procedures, may be administered. I further acknowledge that I will be responsible for all fees and costs associated with the medical treatment that are not covered by my insurance.
YESNO
30
Consent for Transportation in NAYA Vehicles and NAYA Staff Vehicles I agree* This field is required.I understand that NAYA Family Center programs and activities may include local and long distance travel, and give permission to the NAYA Family Center to provide transportation. The participant understands and agrees to abide by the following rules with being transported. All participants must be responsible for wearing seatbelts at all times. All children under 80 lbs. are required to be properly placed in a child seat or booster seat. Appropriate conduct will be mandatory when being transported. Smoking is not allowed in NAYA Family Center vehicles or personal staff vehicles when being transported. A participant may be subject to suspension of transportation privileges if found in violation of any rules of transportation, or for disobeying the NAYA Family Center staff providing the transportation.
YESNO
31
NAYA Internal Information Sharing Agreement I agree* This field is required.Information sharing within NAYA services, or internal information sharing between staff, is often necessary in order to better serve the participant and family. Please indicate your agreement for NAYA staff to share your information within NAYA programs as needed to provide services. By acknowledging Yes, you understand that electronic mail (e-mail) is not confidential and can be intercepted and read by other people.
YESNO
32
Parent / Guardian Signature* This field is required.Must be youth's Parent/Guardian to provide Consent and Releases
Should be Empty: