DCY~Opp Journalism & Broadcast Media Application

DCY~Opp Journalism & Broadcast Media Application

A Platform for the Voice & Inspiration of Our Youth
Youth Information

Please tell us about the applicant
Name

First NameLast Name
Gender

Other
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Youth Email, if none write N/A.
example@example.com
Parent Email, if none, write N/A.
example@example.com
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
School
Current Grade
GPA
What are your personal hobbies?
Please describe your skills, talents and/or experience in writing, speaking, art, photography or blogging. Please include any current leadership skills here.
Please submit a sample of your writing, artwork, or photography here

Browse Files
This must be an original article, essay, paper, poetry, artwork, or photograph done by the child applying. Cancelof
Please provide a link to any video, podcast or productions the applicant has authored or produced. If none, write N/A.
Please provide the name and phone number & title of a person (who is not related, i.e. teacher, principal, counselor, or coach) who we may contact as a character reference
Parent or Guardian

First NameLast Name
Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Detroit City Youth Magazine Policy on Conduct
The following rules and guidelines are equally binding on adult leaders/chaperones and youth.

Non-Negotiable Rules

Any participant failing to abide by these rules will no longer be a member of Detroit City Youth Opportunities (DCY~Opp/Teens in the D).

• No use of illicit drugs or alcohol

• Presence at and full participation in all group activities

• No sexual misconduct (defined as exposure, touching, or inappropriate reference to body areas normally covered by undergarments)

• Smoking and the use of tobacco products are not allowed to, from, or during any trip or while in the custody of DCY~Opp staff.

• Will not break any American laws in the United States or any other country.

• MUTUAL RESPECT IS A MUST. Participants will avoid the use of foul language, cursing, or any speech (including “humor”), which puts down, makes fun of, or stereotypes other persons or groups.

· NO member is allowed to use DCY~Opp’s name to influence, defame, bully, threaten an individual, organization, a company, or group, including, but not limited to libel or misrepresenting DCY~Opp staff, administrations or any affiliates publicly, privately, on social media or elsewhere. Whenever a member is representing DCY~Opp in apparel, badges or on assignment, they must act with integrity obeying the rules outlined above.

Medical Information

Please provide all medical information required for emergencies or self-administered medications. Please note DCY~Opp staff & volunteers do NOT administer medication even in emergencies.
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
If no answer, Call

Area CodePhone Number
Physician's Name

First NameLast Name
Physician's Phone Number

Area CodePhone Number
Date of last tetanus shot

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurance Card Information
Name of Insurance Company that covers this youth
Insurance Company Phone Number

Area CodePhone Number
Policy Group #
Policy ID #
Policy Holder's Name
Name of the Insured as it appears on the card
Upload a copy of the insurance card (Front & Back)

Browse Files
If you cannot upload the copy, please make sure your youth brings a copy to the next meeting. Cancelof
MEDICATION: List all medications(and dosage) the youth will take during any DCY~Opp trips, retreats, or events. This includes any prescription, non-prescription medications, herbal supplements and vitamins. We assume NO RESPONSIBILITY for any participant under the age of 18 in possession of their own MEDICATION. We will not assume any responsibility for dispensing ANY medication.
Over-the-Counter Medication Permission: Do you give permission for your child/youth to take over-the-counter medication as needed and as directed on the label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomach ache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while at a DCY~Opp event or meeting? Please list medication and amount.

Other
Medical Conditions:

Please answer in detail if applicable or write N/A. You cannot leave any of the questions unanswered.
List any medical conditions the youth has (asthma, diabetes, epilepsy, etc.) If none, write N/A.
List any allergies to food, medication or environmental and the severity/type of reaction. If none, write N/A.
Please explain any other pertinent information about the participant (i.e. physical, behavioral, or emotional) that would be important for the adult leaders to know. If none, write N/A.
Please tell us the best time to speak with you and your parents:
Parent Signature (Name as it appears on drivers license)
I certify that I am the legal guardian or custodial parent of the above youth, and understand that typing my full name above I grant my permission for her/him to join the Academy.By inserting my name above and by clicking the button labeled "Submit" below, you agree to the terms and conditions of this Agreement and acknowledge that you have read and understand the disclosures provided above.
DCY~Opp Photo/Video/Original Work Release for Youth
I hereby give consent for my child to be photographed, and/or recorded on audio and video during their affiliation with DCY~Opp and their affiliates. I understand the photos/videos/recordings/articles will be published on the website, social media, fliers, brochures, newspaper and magazines. Students will be credited for their work, but identities will be protected on promotional materials. I understand the articles may be used for advertising. I do not expect compensation. I accept that articles/video/photos/recordings/articles written expressly for DCY~Opp are the property of DCY~Opp and its affiliates in perpetuity. Students maintain rights to their original materials. I agree that no articles submitted by my child have been plagiarized.

I have read the foregoing. I fully understand its contents, understand that this agreement does not expire, and confirm my agreement by signing below. I am over the age of 21 and have legal capacity to sign the release.
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DCY~Opp Journalism & Broadcast Media Application

Youth Information

Detroit City Youth Magazine Policy on Conduct

Medical Information

DCY~Opp Photo/Video/Original Work Release for Youth