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: *

Child's Gender: *

Parent/Guardian Name: *

Relationship to Child: *

Phone #: *

Email:

Parent/Guardian's Work Phone:

Preferred Method of Contact: *

Phone

Text

Does youth know parent/guardian's phone number? *

Yes

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: *

Child's Medical Provider's Name *

Child's Medical Provider's Phone Number *

Health Insurance Information *

Is your child allergic to anything? *

Yes

Does your child have health / behavioral health concerns that we should be aware of? Such as Allergies (Shellfish, Peanut, Bee Sting, Seasonal, etc) or Behavioral Health Issues (ADHD, previous Mental Health Concerns, Substance Use Concerns, Violence, Aggression, Bullying, etc). If so or if they have any other condition, 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 also understand that I will also be contacted to pick up my child if they attend after school and arrive ill. *

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Date *

IMPORTANT RULES FOR CORNING YOUTH CENTER & TREE OF DREAMS

RULES THAT I WILL GO OVER WITH MY YOUTH:
1. No Vulgarities (swearing) at each other or Staff.
2. No Disrespecting Staff or other youth in the program.
3. No Bullying
4. Youth must respect the Property at the center including but not limited to the video/board games, equipment, tv's, controllers, lego's, pool sticks, ping pong balls, outside equipment, tables, chairs, etc
5. If your youth breaks things after being asked numerous times to not do something we will request a meeting with the parent, at which time we may also ask that the parent reimburse the item.
6. If your youth has behavioral problems that are unable to be controlled in the center, it will be expected that you will come pick them up.
7. We ask that parents respect staff while also assisting staff with your youth if you are contacted when behavior issues take place, we do not want to suspend a youth but if the behavior(s) continue we will suspend as necessary.
8. We have the right to decline any registration.
9. Meal time is meal time. Which means youth will be required to sit at the tables electronic free. NOT OUTSIDE FOOD OR DRINKS ALLOWED.Please be mindful that all meal times if the youth cannot leave their phone in their pocket they will be required to put the phone in a bin.
10. Cell phones and laptops are becoming problematic at the center. Youth are not to be using TikTok, SnapChat, video calls, or anything that would break privacy of another youth and or bully's another youth. We also ask that you have conversations with your youth about electronics, we spend a lot of time developing programs for them to engage in something other than phones, tablets, or on computers.

If you and your youth have gone over the rules, please type your name below. *

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Date *