Connected Youth Impact (CYI) Monthly Gathering Registration & Parent/Guardian Consent
Complete this form to register your child and confirm consent, emergency contacts, and sign-in/sign-out authorization for each CYI gathering.
Child Information
Child Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Grade
*
Please Select
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
Gender
Please Select
Female
Male
Non-binary
Prefer to self-describe
Prefer not to say
Other
Allergies
Dietary Restrictions
Medical Conditions: CYI staff and volunteers do not administer or dispense medication. Parents/guardians are responsible for making any necessary medication arrangements for their child.
Behavioral, Accessibility, or Special Support Needs
Additional Information Staff Should Know to Safely Support the Child
Parent/Guardian Information
Parent/Guardian Full Name
*
First Name
Middle Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Guardian
Grandparent
Aunt/Uncle
Foster Parent
Other
Home Address
*
City
*
State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other
ZIP Code
*
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact
Emergency contact must be someone other than the parent/guardian listed above.
Emergency Contact Full Name
*
First Name
Middle Name
Last Name
Relationship to Child
*
Please Select
Aunt/Uncle
Grandparent
Adult Sibling
Family Friend
Neighbor
Other
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Acknowledgments and Permissions
Acknowledgment of sign-in and sign-out procedure
*
I understand that a parent/guardian or another authorized adult must personally sign my child in and out, and that there will be no drop-off or release without following the established procedure.
Permission to participate
*
I give permission for my child to participate in the Connected Youth Impact (CYI) Monthly Gathering.
Emergency medical authorization
*
In the event of an emergency, I authorize CYI staff to seek emergency medical treatment for my child if I cannot be reached promptly.
Photo/video permission
YES
NO
Hold harmless and assumption of risk acknowledgment
*
I acknowledge and accept all risks associated with participation and agree to hold harmless the organizers, while understanding that this acknowledgment does not waive any non-waivable rights.
Parent/Guardian Certification and Source
Parent/Guardian Printed Name
*
First Name
Last Name
Electronic Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How did you hear about CYI?
*
Rivers of Life
Tributary Global Network
Social Media
Community Event
Friend/Family
Trunk or Treat
Other
Submit
Submit
Should be Empty: