Community Youth Development (CYD) Program Application

Community Youth Development (CYD) Program Application

Complete this multi-page application for the youth and their parent/primary caregiver to apply for free CYD services in Montgomery County.
Youth Information
Youth Full Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex
Current Grade
Youth Phone
Please enter a valid phone number.Format: (000) 000-0000.
School Name
School District
Youth Home Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
County Where Youth Lives
Conditional Notice
Parent / Primary Caregiver Information
Parent / Primary Caregiver Full Name

First NameMiddle NameLast Name
Relationship to Youth
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Best Way / Time to Reach You
Preferred Language
Same Address as Youth?
Caregiver Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Household & Family Members
Total people in household
Number of adults (18+) in household
Other children/youth in the home
Eligibility Screening
Is the youth joining CYD voluntarily, by the family's own choice?
Is the youth currently on juvenile probation?
Has the youth been on probation in the past?
Did probation end at least 12 months ago?
Date probation ended (if known)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Eligibility notice
Program Interests & Emergency Information
Program Interests
Other Activities of Interest
Availability
Transportation Help Needed
T-Shirt Size
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Other Approved Pickup Contacts
Allergies, Medications, or Health Needs Staff Should Know About
Accommodations That Would Help the Youth Participate
Emergency Contact Alternate Phone
Consent & Signatures
Consent paragraph
Consent and authorization
Additional permissions
Parent / Primary Caregiver signature
Parent / Primary Caregiver date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Youth agreement
Youth signature
Youth date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Community Youth Development (CYD) Program Application

Youth Information

Parent / Primary Caregiver Information

Household & Family Members

Eligibility Screening

Program Interests & Emergency Information

Consent & Signatures