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  • KYCC YOUTH PARTICIPANT APPLICATION

    2025-2026
  • Image field 537

  • This form is required for participation in KYCC center activities. Please complete each section thoroughly, sign and date.

     

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  • Youth Participant Information

    Youth Participant Information

    This form is required for participation in KYCC center activities. Please complete each section thoroughly, sign and date.

  • Youth Participant

  • Birth Date*
     / /
  • Race & Ethnicity (check one):*
  • Format: (000) 000-0000.
  • Phone Type

  • PARENT/GUARDIAN (PRIMARY CONTACT)

  • Is your home address the same as the YOUTH PARTICIPANT?*
  • Format: (000) 000-0000.
  • Primary Phone Type
  • Format: (000) 000-0000.
  • Alternate Phone Type
  • Race & Ethnicity (check one):*

  • PARENT/GUARDIAN (SECONDARY CONTACT)

  • Is your home address the same as the PRIMARY PARENT/GUARDIAN?
  • Format: (000) 000-0000.
  • Primary Phone Type
  • Format: (000) 000-0000.
  • Alternate Phone Type
  • Race & Ethnicity (check one):

  • ADDITIONAL PICK UP/EMERGENCY CONTACT INFORMATION

  • Is your home address the same as the PRIMARY PARENT/GUARDIAN?*
  • Format: (000) 000-0000.
  • Primary Phone Type
  • Designate this person as (select all that apply):*

  • Authorized Person #2

  • Is your home address the same as the PRIMARY PARENT/GUARDIAN?
  • Format: (000) 000-0000.
  • Primary Phone Type
  • Designate this person as (select all that apply):

  • Acknowledgements

    This form is required for participation in KYCC center activities. Please complete each section thoroughly, sign and date.

  • Mandated Reporting - I understand that all KYCC staff are mandated reporters by California Law, and must report suspected child abuse or neglect of a child under the age of 18 to the Department of Child and Family Services using the resources that we were taught in our trainings. The types of reportable suspected child abuse are physical abuse, sexual abuse, emotional abuse, or neglect. By law, KYCC staff are not allowed to investigate or make any kind of judgement about the particular family. Any reports made are kept confidential and only shared with members of the Supervisor team.

    Liability - I hereby grant permission for my child to use all of the program equipment and participate in all activities of the center, and grant permission for my child to leave the premises under the supervision of a KYCC staff member. I do hereby, for my child/children, myself, my heirs, executors and administrators, release and hold harmless KYCC, and all officers, directors, employees, agents and volunteers of the organization, acting officially or otherwise, from any claims, demands, actions or causes of action which in any way arise related to my child's participation in KYCC programs.

    By signing below, I certify that I am the parent and/or legal guardian of the child named in this application. I acknowledge that I have carefully read this document and understand the information therein. I agree to each of the terms and acknowledgments above, and agree to permit my child to participate in KYCC activities.

  • Date*
     - -

  • Media Release

  • Occasionally, KYCC program activities may be photographed, videotaped, or audio taped for educational, publicity or fundraising purposes. Please indicate if you give permission for your child and/or their project work to appear in videos, photos or audio recordings without compensation (e.g., as part of brochures, slide shows or program websites).

  • Do you give permission to the statement above?*
  • Date*
     - -

  • KYCC EMERGENCY MEDICAL RELEASE

    This form is required for participation in KYCC center activities. Please complete each section thoroughly, sign and date.

  • Youth Participant Medical Information

  • Format: (000) 000-0000.
  • Does your child have an IEP/504 plan at their school?
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  • Allergies

  • Health Conditions

  • Rows

  • EMERGENCY RELEASE

  • If, in the judgment of the staff of KYCC the child named above needs immediate care and treatment as a result of any injury or sickness, I do hereby authorize and consent to any x-ray examination, anesthetic, medical, or surgical or dental diagnosis or treatment and hospital care are considered necessary in the best judgment of the attending physician, surgeon or dentist and performed by or under the supervision of the medical staff of the hospital or facility furnishing medical or dental services.

    I do hereby agree to indemnify and hold harmless KYCC (including its officers, directors, members and/or volunteers) from any claim by any person whomsoever on account of such care and treatment of said child. It is understood that a good faith attempt shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. Further, it is understood that the undersigned will assume full responsibility for any such action, including payment of costs.

  • Date*
     - -

  • KYCC SIGN-IN AND SIGN OUT POLICY ACKNOWLEDGEMENT

    This form is required for participation in KYCC center activities. Please complete each section thoroughly, sign and date.

  • SIGN IN AND SIGN OUT POLICY

    Here is a brief overview of our sign-in and sign-out policy:

    • All middle and high school students can sign themselves in and out of the program. I understand thatKYCC is not liable for the health and safety of my child before signing in and after signing out of theprogram.
    • Parents and/or Guardians have the right to request information about their child’s attendance (i.e.asking if their child attended program on certain days or asking for the time their child signedin/out). Any questions about attendance history can be addressed to the Program Lead Staff.
  • Date*
     / /
  • OPT OUT – Please check below to indicate that your child is NOT allowed to sign themselves in and/or out of the program. Select ONE option (if applicable):
  • Should be Empty: