Corning Youth Center

FALL 2021

Registration Form

To best serve the community, the Laura Richardson Houghton Corning Youth Center will be open during the school year 2:30pm-7:00pm for youth 8-18. We will take a limited number of youth and you will be contacted by program, this is in effort to continue with social distancing and safety guidelines, while supporting youth 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.

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

Youth (8-13)

Teen (14-18)

Child's First Name: *

Child's Last Name: *

Child's Preferred Name/Nickname: *

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

Child's Date of Birth: *

Child's Gender: *

Parent/Guardian Name: *

Relationship to Child: *

Phone #:

Email:

Parent/Guardian's Work Phone:

Preferred Method of Contact: *

Phone

Text

Home Address: *

City *

State *

Zip *

Name of Child's School: *

Child's Activities and Interests *

Health Insurance Information *

Child's Emergency Contact Person: *

Emergency Contact Phone Number: *

Relationship to Child: *

Child's Medical Provider's Name *

Child's Medical Provider's Phone Number *

VERY IMPORTANT - We require masks. All youth must have them and bring them* Can you provide a face mask for your child? *

Yes

Is your child allergic to anything? *

Yes

Does your child have health concerns, such as allergies or pre-existing conditions, that staff should be made aware of? If so, please describe below:

Parent/Guardian signature (By signing below 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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Date *

IMPORTANT RULES FOR COVID

I agree I will not send my youth to the youth center if they are ill
I understand and agree to temp and questionnaire in regards to Covid protocol for DOH.
I understand that any youth with a fever will be sent home, they will not be able to return until either they test negative (with proof) or 10 days has past.
I acknowledge that my youth attends the youth center and if a case comes through, (close contact) my youth will be added to the list provided to the Department of Health.
I agree to send my youth with a Mask every day.
Masks must be worn at all times, I will have a conversation about appropriate mask wearing including having it over their nose and mouth while at the youth center.
I also understand if my youth refuses and or does not follow masking rules they will be sent home. If problems persist they may be asked not to return youth until mask rules have been lifted within our agency.
I am also aware that Youth Center Staff will not tolerate disrespect in any form in regards to Covid or any other rules from either myself or my youth, if problems arise the youth center staff will communicate with me. If problems become a continuous the youth will be suspended until youth center staff deem appropriate.

By signing below shows that I have read, understand, and agree to follow all rules and regulations set forth by either Family Service Society, Corning Youth Center, DOH, and CDC. I also agree that my youth has been made aware of the regulations as well and we agree that they will be followed.

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Date *