Online Registration

* Participant Information:

2022-2023 Site Registration Location*

Enrollment Location

* Participant Information (Please complete all applicable fields):

Youth's Name*

Date of birth*

Preferred Pronouns*

She/Her
He/Him
They/Them

Email (if applicable)

YouthPlaces may communicate events, program launches, and/or other relevant resources

Address*

Race*

American Indian / Native American
Asian
Black or African American
White
Pacific Islander
Bi or Multi-Racial
Do not wish to disclose

Ethnicity*

Hispanic
Non-Hispanic

ESL (English as Second Language)*

Yes
No

ACADEMICS

School Disctrict*

School*

Grade Level*

Grades 6-12

Eligible to receive free/reduced lunches?*

Yes
No

Student ID# (if known):

Please list any important health information you would like our staff to be aware of, including:

MEDICAL INFORMATION

* Please list any important health information you would like our staff to be aware of, including:

Allergies:*

Please enter any known allergies. If none, please list N/A

Medications:*

Please list any daily medications. If none, please list N/A

Diet Restrictions:

If none, please list N/A

Other:

Please provide any other conditions or concerns you would like our staff to be aware of.

FAMILY INFORMATION

* Parent/Guardian Information:

*Parent/Guardian Information

Parent/Guardian Name*

Relation to Youth (mother, father, etc.):*

Parent/Guardian Date of Birth:*

Phone 1:*

Phone 2:

Email Address*

Emergency Contact (other than parent referenced above)

MUST PROVIDE AT LEAST ONE

* Emergency Contact Information (must be at least one additional person other than the parent/guardian referenced above).

Name 1:*

Relation to Youth:*

Phone*

Name 2:

Relation to Youth:

Phone

*Household Information (required for grant purposes only – this information this information is kept anonymous)

Household Annual Income Level*

$0 - $20,147
$20,148 - $27,214
$27,215 - $34,281
$34,282 - $41,348
$41,349 - $48,415
$48,416 - $55,482
$55,483 - $62,549
$62,550 or higher

Number of people in household*

Single parent household?*

Yes
No

Highest education level:*

High School Diploma/GED
2 Year Degree
4 year Degree
Master's or Doctorate

Pittsburgh Public School Academic Release Statement

As an approved partner with Pittsburgh Public Schools for the 2022-2023 school year, academic data will be shared and YOUTHPLACES is authorized to receive personal identifiable student educational data that includes: grades, PSSA and other assessment scores, attendance and discipline data, Promise eligibility, credit count, and graduation rates. IF YOU DO NOT WANT THIS INFORMATION SHARED WITH YOUTHPLACES, please contact Tylor Hart, Program Assistant, Out-of-School Time for Pittsburgh Public Schools at thart2@pghboe.net or 412-529-3537 and your child’s name will be placed on an opt-out list and no student data will be shared

The Family Educational Rights and Privacy Act (FERPA) protects you and your child’s right to privacy and confidentiality of educational records. Pittsburgh Public Schools provides you with a detailed written notification of these rights annually and you may always access this notice via the Department of Education link here: http://www.ed.gov/policy/gen/guid/fpco/ferpa/index.html. FERPA requires prior consent to share personally identifiable information. Therefore, the District has developed this Release and Authorization form for its Community-Based and Faith-Based After-School Partners.

***PLEASE COMPLETE RELEASE AND DISCLAIMER INFORMATION ON THE REVERSE SIDE*** (must provide signature or initials in all places requested to finalize your child’s enrollment)

Academic Information Release

I authorize my Child’s School District to provide information and educational records of my child to YouthPlaces. The following information may be released: student ID numbers, attendance, discipline, grades, test scores, citizenship marks, credit count (high school only), Pittsburgh Promise eligibility, and graduation attainment. This Authorization and Release shall remain in effect for one calendar year from the date of my signature.

Parent Signature*

Date:*

Please complete section below to acknowledge parent review and authorization.

Photo Release*

I authorize the use of my child’s likeness in media or print YouthPlaces staff documents activities through various mediums such as photographs and videos. Please indicate if images of your daughter/son can be used to promote YouthPlaces’ mission on our website and social media spaces.

Yes
No

Medical Release*

In case of an emergency, I authorize a representative of YouthPlaces to seek and agree to medical treatment for my child on my behalf.

Yes
No

Transportation*

I give permission for YouthPlaces to transport my child in an authorized YP van or bus for following reasons: field trips (with permission slips), transportation to and from program site and partner program sites, emergency purposes, and any reasons deemed necessary by program.

Yes
No

Behavior Policies and Procedures*

I acknowledge that I have received and read the YouthPlaces’ behavior policies and procedures for attending the program. All youth enrolled are expected to follow YouthPlaces rules, expectations and consequences attached to this form. Rules and expectations can also be found on our website at www.youthplaces.org.

Yes
No

YP Activities*

I acknowledge I have received and read the YouthPlaces’ activities description and service plan.

Yes
No

Parental Consent Data Agreement*

Yes
No

I authorize YouthPlaces to share data information about my child with the Department of Human Services (DHS) to satisfy necessary reporting requirements.

***Parent/Guardian Signature Required***

I hereby release, forever discharge, and hold harmless YouthPlaces (YP) and its officers, agents, volunteers and employees, from and against any and all claims, demands, or causes of action of any type whatsoever, including property damage, personal injury, or death, arising out of or in any way related to me or my child’s participation in, or affiliation with, YP.

I agree that my child and I will not hold YP or any of its affiliates responsible for any injury to me, my child, or my property as a result of attending or traveling to and from such programs and activities.

I understand that YP does not carry or maintain health, medical, or disability insurance coverage for any volunteer or participant. By signing this document, I acknowledge my understanding of the terms and provisions of this waiver. I also understand that all parties acknowledge and agree that my signature shall be considered legally binding. I agree that this waiver is intended to be as broad and inclusive as permitted by the governing laws, and that this waiver shall be governed by and interpreted in accordance with the laws of Allegheny County, PA. I also agree that in the event that any section of this waiver shall be held to be invalid by any court or competent jurisdiction, the invalidity of that section shall not affect the remaining sections of this waiver.

Signature*

By inputting your name, you are attesting to the fact that all information in this registration is true.

DATE*

2022-23 Academic Year Enrollment is now open!

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