Corning Youth Center

2022-2023

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. Summer is July and August 8AM-6PM. 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)

Select the time of year you are registering for? *

School Year

Summer

Other Other

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 are not requiring masks at this time. However, if we need to request a youth to wear one as requested by DOH, CDC, Agency Regulations, etc. Can you provide a face mask for your child? *

Yes

No

Is your child allergic to anything? *

Yes

No

Does your child have health / behavioral health concerns that we should be aware of, 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 protocols.
I acknowledge that my youth attends the youth center and if a case comes through, (close contact) my youth, I will be notified and have to mask daily for 10 days.
I also understand if my youth refuses and or does not follow masking requests they will be sent home.
I am also aware that Youth Center Staff will not tolerate disrespect in any form from youth or parent. Continuous problems will result in calls home, suspension, and or prevention counseling/youth empowerment services. If the behaviors continue parents will have to meet one on one with staff, youth, and director of the program. These appointment times will be scheduled for 2:00 - 2:30 PM prior to youth arriving at the center.
In regards to Covid related issues the Corning Youth Center will not tolerate disrespect from youth or parents and may be asked to keep youth home for a period of days.

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 *