Corning Youth Center
Fall 2020 Registration Form
To best serve the community, the Laura Richardson Houghton Corning Youth Center will remain open from 8 AM -6 PM for youth 8-18. This will allow youth not in school on days they are doing online to complete necessary school work in a structured format.  We will be taking a limited number of youth and you will be contacted by the program once we have received this registration. This is being provided in effort to continue with social distancing and safety guidelines, while supporting youth's educational needs. In order for your child(ren) to be considered, you will need to complete the attached form, and each child will need their own form completed. At this time we cannot be a drop in center and for that we are truly sorry but we are hoping to support your youth in other ways during these times.  

CHILD INFORMATION

Child's Average Grades: *
Child Needs: *

PARENT/GUARDIAN/FAMILY INFORMATION

Preferred Method of Contact: *
Do you receive any public assistance? *

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

By signing below I attest that the Youth Center can communicate with my child’s school and a signed consent will be required, I attest that my child will not be sent to the Youth Center if sick, I understand that my child will be isolated if becoming ill after arrival. I understand that I may be ask to provide medical documentation to allow my child back into the program if sick.
Parent/Guardian signature (By signing below I attest that the Youth Center can communicate with my child’s school and a signed consent will be required, I attest that my child will not be sent to the Youth Center if sick, I understand that my child will be isolated if becoming ill after arrival. I understand that I may be ask to provide medical documentation to allow my child back into the program if sick). *
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Birth Certificate Access Permission Parent Form

I give my permission to Family Service Society, Inc. to access my child/children’s birth certificate copy held on file at their school district as proof of U.S. citizenship as required by the parameters of our Family
Service Society, Inc., Family Service Society Prevention Programs contract.
My child is an immigrant *
Parent/Guardian signature (I give my permission to Family Service Society, Inc. to access my child/children’s birth certificate copy held on file at their school district as proof of U.S. citizenship as required by the parameters of our Family Service Society, Inc., Family Service Society Prevention Programs contract). *
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Consent for Release of Information

This online consent for release of information form allows for information exchange between the school and the Corning Youth Center (a program of Family Service Society, Inc.), 79 Flint Ave., Corning NY 14830-2932, 607-962-3507.
INFORMATION EXCHANGE BETWEEN THE SCHOOL AND THE CORNING YOUTH CENTER:
I understand this consent for release of information form includes the disclosure of the following information: birth certificate verification, academic progress, medical issues, observations, classroom behaviors, and any COVID-related health concerns. *
I hereby authorize the periodic release of the above information to the person/organization/program identified above as often as necessary to support my child’s progress in school and at the Corning Youth Center. I understand that the information to be released is confidential and protected from disclosure. I also understand that I have the right to cancel my permission to release information at any time.

My consent to release information to the person/organization/program identified above, will expire one year from this date unless otherwise noted or I withdrawal consent in writin beforehand.
Parent/Guardian signature (I hereby authorize the periodic release of the above information to the person/organization/program identified above as often as necessary to support my child’s progress in school and at the Corning Youth Center. I understand that the information to be released is confidential and protected from disclosure. I also understand that I have the right to cancel my permission to release information at any time. My consent to release information to the person/organization/program identified above, will expire one year from this date unless otherwise noted or I withdrawal consent in writing beforehand. *
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