Corning Youth Center
Re-Opening Registration Form
To best serve the community, the Laura Richardson Houghton Corning Youth Center will be re-opening. However, in order to continue with social distancing and safety guidelines, registration will be limited and based on need.

CHILD INFORMATION

Child/Family's Preferred Method of Contact: *
Do your child need full or half-day support? *
Child's Average Grades: *
Child/Family Needs: *

PARENT/GUARDIAN INFORMATION

Parent/Guardian working remotely from home? *

EMERGENCY CONTACT INFORMATION

HEALTH RELATED INFORMATION

Can you provide a face mask for your child? *
Is your child at high-risk for contracting COVID-19? *
Do you consent for your child to have their temperature tested before entering the Youth Center? *

PARENT/GUARDIAN SIGNATURE

Parent/Guardian signature *
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