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Home > Programs & Events > Youth Registration Form

Youth Registration Form
 
  • Program Information

    Which Program are you applying?

    After School Program

    Summer Program

    Entry Date?


    Who were you referred by?


    School's Name

    School Phone

    Child's Age

    Grade

  • Child Information

    Child's Last Name

    Child's First Name

    Date of Birth

    Child Lives With...

    Mother Father Both Other:

    Boy or Girl?

    Male Female
  • Parent Information

    Parent/Guardian's Name

    Phone Number


    Cell Number

    Other Number

    Work Number

    Street Address

    City

    Zip

    State

    Mailing Address

    City

    Zip

    State

    Names of Siblings in CYM Program

  • Emergency Contact Info

    Contact's Name

    Relation to Child?

    Emergency Numbers

    Does your child have any Allergies?

    Doctor's Name

    Doctor's Phone


    Give permission to CityYouth Staff
    to administer medication(s) to my children?

    Yes No

    Any Medications?

    No Yes listed here:

    Does your child have Insurance?

    Yes No

    Insurance Plan?

    Medicaid ARKkids Other Insurance

    Policy Number

    Physical Limitations, Disabilities, or other Health Issues?

  • Personal Information

    Ethnicity?

    White Asian
    Black/African American Native American
    Hispanic Please specify below:

    Total Persons in Household?

    Total Adults? (Over 18)

    Total Children in Household?


    Total Income of all persons living in household

    $0-$10,000 $10,001-$20,000 $20,001-$30,000 $30,001-$40,000
    $40,001-$50,000 $50,001-$60,000 Over $60,000
  • Transportation/School | Records/Discipline

    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 PM

    9. I expect my child home by PM

  • Parent's Section Only
    (Parents Complete This Next Section According To What Specific Things You Would Like For CityYouth Ministries To Concentrate On With Your Child. I.E.. —Learn How To Get Alone Well With Others; Better Reading Skills; Learn More About God, Etc.)

    Goals for my child at CityYouth.

    Does your child attend church?

    Yes No
    If yes, name of church/temple:

    How Often? Weekly Monthly

    Does your child have a mental health case manager?

    Yes No
    If yes, name of 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.