C4K Membership Application, Spring 2027

C4K Membership Application

Spring 2027
Completing this application is a indication that the youth will be joining our next 1:1 Mentoring cohort, Spring 2027:
- Member Training, One two hour session the week of January 18th
- Mentoring Session, One one hour session per week from February 1st through May 7th.
- Three two hour community events during the session including:
  - Project Launch Night
  - Community Building
  - Project Showcase
If you are referring a youth that is interested but are not a parent / guardian, please fill out a New Member Interest Form. We will follow up with steps to complete the application.

If you have questions or concerns, please reach out C4K's Community Engagement Coordinator by calling / texting 434-214-0277 or emailing join@c4kclubhouse.org.
Member Information
First Name
Middle Name
Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Sex
Grade
If it's Summer, choose grade that member will be going into.
School
If it's Summer, choose school that member will be going into.
Other - School Name
Please type in the name of the school that is not in the list.
Ethnicity (check all that apply)
Primary language spoken at home
Other - Language
Please type in name of other language

Address
Street Address
Street Address Line 2
City
State
Zip Code
In which locality do you live?
Other - Locality
Please type in the name of the locality that is not in the list.
Is this youth in foster care?

Household Information
How many people (including member) live in the household?
What is your family's annual income (2)?
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.
What is your family's annual income (3)?
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.
What is your family's annual income (4)?
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.
What is your family's annual income (5)?
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.
What is your family's annual income (6)?
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.
What is your family's annual income (7)?
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.
What is your family's annual income (8+)?
Include ALL sources of income, such as child support, alimony, Social Security, welfare payments, dividends or interest, rental income, unemployment, retirement income, pensions, veteran payments, regular contributions from persons not living in the household, royalties, or other cash income.
Does the member qualify for free or reduced meals at school?
Have either the member's parents or legal guardians completed a four-year (bachelor's) college degree at an institution within the United States?

Contact Information
Parent/Guardian Name
Parent/Guardian Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Do you authorize C4K to text messages about program updates and events to the parent/guardian number provided?
Emergency Contact Name
Not Parent/Guardian
Emergency Contact Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email Address
example@example.com
Do you authorize C4K to text messages to the emergency contact number provided?
Youth Email Address (if applicable)
example@example.com
Youth Mobile Number (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Do you authorize C4K to text messages about program updates and events to the youth number provided?
SMS Notice and Non-sharing Disclosure

Message and data rates may apply. Reply HELP for help or STOP to opt out.

No mobile information will be shared with third parties/affiliates for marketing/promotional purposes.

Program Agreements
Please review the following documents. Printed copy is available upon request.
I have reviewed and agree to the C4K Program Agreement and schedule.
I understand that C4K is a drop-in facility and cannot prevent youth from leaving the premises. Once youth leave the Clubhouse, they are not allowed to return that day.
Parent / Guardian Signature
Should be Empty:

C4K Membership Application

Member Information

Address

Household Information

Contact Information

Program Agreements