Which Program are you applying?
Summer Program
Entry Date?
Who were you referred by?
School's Name
School Phone
Child's Age
Grade
Child's Last Name
Child's First Name
Date of Birth
Child Lives With...
Boy or Girl?
Parent/Guardian's Name
Phone Number
Cell Number
Other Number
Work Number
Street Address
City
Zip
State
Mailing Address
Names of Siblings in CYM Program
Contact's Name
Relation to Child?
Emergency Numbers
Does your child have any Allergies?
Doctor's Name
Doctor's Phone
Give permission to CityYouth Staffto administer medication(s) to my children?
Any Medications?
Does your child have Insurance?
Insurance Plan?
Policy Number
Physical Limitations, Disabilities, or other Health Issues?
Ethnicity?
Total Persons in Household?
Total Adults? (Over 18)
Total Children in Household?
Total Income of all persons living in household
1. My child may be picked up from CityYouth by:
Relationship
2. My child may be picked up from school by CityYouth Ministries: Yes No
3. My child may walk home/leave the CityYouth Facility without my being present: Yes No
4. I Give My Permission for CityYouth to Obtain the School Records for my Child: Yes No
5. I give CityYouth Ministries' Staff the authority to discipline my child: Yes No
6. I am willing to attend one(1) hour parent support group: Yes No
7. I am willing to volunteer one(1) hour each month at CityYouth Ministries: Yes No
8. I expect my child to stay at CityYouth until Please Choose ... 1 2 3 4 5 6 7 8 9 PM
9. I expect my child home by Please Choose ... 1 2 3 4 5 6 7 8 9 10 PM
Goals for my child at CityYouth.
Does your child attend church?
How Often? Weekly Monthly
Does your child have a mental health case manager?
List three(3) of your child's strengths
List three(3) of your child's weakness
I agree to comply with the above statement.
City Youth Ministries Info
Youth Info
Adult Info
Physical Address 118 Burke Ave. Jonesboro, AR 72401 Phone (870) 932-9398 + Fax(870) 932-7342
We have programs for students beginning with 1st Grade through Senior High. For more information about transportation, please call (870) 932-9398.
CityYouth Ministries is committed to providing unparalleled help for the children of the community, and we can do this with volunteers like you.