City on a Hill Youth Registration Form 1

Youth Details:

Full Name*

First NameMiddle InitialLast Name

Birth Date*

MonthDayYear

Address*

Street Address

Apartment #

CityState / Province

Postal / Zip Code

Gender*

Lives with:*

Both ParentsMotherFatherOther

Ethnicity:*

Hispanic*

Youth Cell Phone Number

Join our "Remind" Group Using our Code: COAHMKE to receive updates on events and closures*

Add my number for meShow me how to add myselfI'll download the app and add myselfNo thank you

What school does the youth attend?*

What grade is the youth?*

How will the youth get home from City on a Hill*

WalkCity BusPicked up by familyOther

Anyone who cannot pickup the youth?

Primary Language*

EnglishSpanishI need an interpreterOther

Guests with Disability - “Disability” with respect to an individual, means: A physical or mental impairment that substantially limits one or more of the major life activities; or a record of such an impairment; or being regarded as having such impairment.*

YesNo

Youth Allergies*

Food related, bees, etc.

Initials* 1. Youth will NOT be allowed entry into the program until a completed/signed registration form is returned by a parent/guardian.

Initials*2. Zero Tolerance Policy: Violating the Zero Tolerance Policy will result in immediate dismissal from the program and possible criminal charges. Parents will need to provide immediate transportation from the program in the event of dismissal.
A. The possession of or threat of use of weapons.
B. Bullying, fighting, and overtly aggressive behavior.
C. The use of tobacco products, alcohol, drugs, or fireworks on the property.
D. Theft or intentional destruction of property.

Initials*3. Spring Weekly Youth Center program hours are Mondays through Thursdays from 3:00 pm - 6:00 pm. Wednesdays and Thursdays are for teens only. Parents picking up children must pick them up no later than 5:55 p.m. at 940 N. 23^rdSt.

Initials*4. To ensure the health and safety of the children, if a youth is sick or has any symptoms that indicate a certain illness, he or she may not attend City on a Hill youth programs and will be sent home immediately.

Youth/Child's Signature: Signature*

Date*

Date

Parent/Guardian(s) Full Name(s) (1)*

First NameLast Name

Parent/Guardian (1) Phone Number*

Please enter a valid phone number.

Parent/Guardian(s) Full Name(s) (2)

First NameLast Name

Parent/Guardian (2) Phone Number

Please enter a valid phone number.

City on a Hill Youth Registration

Youth Program Guidelines:

Parent/Guardian Information