Corning Youth Center -TREE of Dreams Registration Application

Corning Youth Center

T.R.E.E. of Dreams Teen Space

Registration Form

To best serve the community, the Laura Richardson Houghton Corning Youth Center & T.R.E.E. of Dreams Teen Space will be open during the school year 2:45 PM - 7:00 PM for youth 8-18, select half days we will be 11AM-7 PM. Summer is July & August 8 AM - 6 PM. 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. All forms must be filled out, TANF forms are a requirement by the county not by our program. We are a DROP IN CENTER which means it a youth can sign out at anytime. If you do not want your child to leave without permission please have these discussions with your youth and the staff. We have a list of rules and regulations that must be followed for safety of youth and staff.

Are you interested in youth or teen programming for your child? *

Youth (8-13)

Teen (13-18)

Select the time of year you are registering for? *

School Year

Summer

Both (School & Summer)

Child's First Name: *

Child's Last Name: *

Child's Preferred Name/Nickname: *

Race/Ethnicity *

Child's Age (only youth ages 8-18 can register for Youth Center programs) *

Child's Grade: *

Child's Date of Birth (MM/DD/YYYY): *

Child's Gender: *

Parent/Guardian Name: *

Relationship to Child: *

Phone #: *

Email:

Parent/Guardian's Work Phone:

Preferred Method of Contact: *

Phone

Text

Email

Does youth know parent/guardian's phone number?

Yes

No

Home Address: *

City *

State *

Zip *

Child's Activities and Interests *

Name of Child's School: *

Child's Emergency Contact Person (Needs to be someone other than parent/guardian): *

Emergency Contact Phone Number: *

Relationship to Child: *