Youth Program Enrollment & Consent Form

Youth Program Enrollment & Consent Form

Provide youth, parent/guardian, program, support, media, conduct, and emergency details, then review and sign.
Youth Information
Youth Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Grade
School
Student Email
example@example.com
Parent/Guardian Information
Parent/Guardian Name

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact(s)
Program Selection
Program Selection

Other
Days of Participation
Academic Support
IEP / 504 Documentation & Participation Notice
Does the youth have a learning support plan (IEP/504)?

Other
If my child has an IEP or 504 Plan, I understand that I am required to provide a copy of the current plan to Project Impact 180 to support appropriate planning and communication.
Inclusion & Program Capacity Statement
Project Impact 180 is committed to creating an inclusive, supportive environment for all youth.
Having an IEP or 504 Plan does not disqualify a child from participation in our programs.

I acknowledge and understand that:
• Project Impact 180 is a community-based afterschool and youth development program and does not provide special education or therapeutic services
• Program staffing, resources, and facilities may limit the level of accommodations or specialized support available
• In some cases, Project Impact 180 may recommend or refer a youth to additional or alternative programs better equipped to meet specific needs
These determinations are made to support the safety, success, and well-being of the youth and the program community.
Section 6: Youth Participation Agreement (All Programs)
Youth participants agree to:
• Attend scheduled program days consistently and on time
Follow all program rules, staff instructions, and safety expectations Treat peers, staff, and property with respect Actively participate in academic, enrichment, and leadership activities Maintain appropriate behavior at all times

Failure to follow program expectations may result in disciplinary action, including suspension or removal from the program.
Academic support needs
Accommodations needed
Participation Incentive Policy
Project Impact 180 offers incentives to encourage attendance, engagement, and positive.

Incentive Eligibility

To be eligible for monthly incentives, youth must:
- Maintain at least 80% attendance each month
- Demonstrate positive participation and behavior
- Complete required weekly or monthly challenges Incentive Guidelines
- Incentives may include gift cards, educational materials, or program-based rewards.
- Incentives are not wages or compensation.
- Incentives are not guaranteed and are subject to funding and compliance guidelines.
Acknowledgement & Signatures
Media Release
• Program documentation
• Community education
Grant reporting
• Program promotion
I understand:
No compensation will be provided
Permission remains in effect unless revoked in writing.
Medical Needs or Conditions
Computer & Technology Use Agreement
Project Impact 180 provides computers and technology to support learning and program activities.
Youth agree to:
- Access only staff-approved websites and platforms
- Follow all staff instructions regarding technology useKeep food and drinks away from devices
- Return all equipment at the end of each session
  The following are prohibited:
- Accessing inappropriate or unsafe websites
- Downloading unauthorized software or games
- Bypassing security or internet filters
- Removing technology from the premises
  Liability
  Youth and families may be held financially responsible for intentional damage, theft, or repeated misuse of technology.
Youth Signature
CODE OF CONDUCT (REQUIRED - Youth & Parent Signatures)
- Youth are expected to:
- Respect themselves and Project Impact 180 staff
- Play fairly and be honest
- Avoid inappropriate language Eat and drink only in designated areas
- Follow instructions at all timesResolve conflicts peacefully
  Run only in designated areas
- Respect property and facilities
- Refrain from tobacco, drugs, alcohol, and weapons
- Clean up after themselves
Youth Signature
Parent Signature
Youth Printed Name

First NameLast Name
BULLYING / HARASSMENT / FIGHTING POLICY REQUIRED - Youth & Parent Signatures)

Bullying, harassment, or fighting will not be tolorated.

Guiding Principles
- Project Impact 180 maintains a zero-tolerance stance on bullying, harassment, and Intimidation
- Discipline is designed to be corrective, restorative when possible, and safety-focused
- All incidents are documented and reviewed by leadership
- Safety of all youth and staff is the top priority Bullying behavior includes, but is not limited to:
- Physical aggression (hitting, pushing, unwanted touching)
- Verbal harassment (name-calling, threats, racial slurs, insults)
- Social bullying (exclusion, rumors, intimidation)
- Cyberbullying (texts, social media, online harassment)
  Sexual harassment (verbal or physical)
- Repeated behaviors that cause fear, harm, or disruption Discipline Framework (Progressive but Firm)
Level 1: Minor or First-Time Incident

Examples.
• Disrespectful language
• Name-calling
• Teasing that continues after being told to stop

Response:
• Immediate staff intervention
• Verbal warning and clear explanation of why behavior is unacceptable
• Separation of involved youth (if needed)
• Incident documented
Parent/guardian notified (same day when possible.

Level 2: Repeated or Escalated Behavior

Examples:
• Repeated harassment
Threatening language
Intimidation
Targeted teasing
Parent Signature
Youth Signature
Emergency/Medical Information
Allergies
Current Medications
Emergency Care Authorization
Acknowledgment & Signatures
Youth Signature
Youth Signature Date

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

First NameLast Name
Parent/Guardian Signature
Parent/Guardian Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
My Products
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AFTER SCHOOL REGISTRATION
Registration includes program entry , a Project Impact T-shirt , and a swag bag!

$35.00 Quantity

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Youth Program Enrollment & Consent Form

Youth Information

Parent/Guardian Information

Program Selection

Academic Support

Media Release

Emergency/Medical Information

Acknowledgment & Signatures

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Payment Methods

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