Online Registration – YouthPlaces

* Participant Information:

2020-2021 Site Registration Location*

Enrollment Location

Youth's Name*

Date of birth*

Gender*

Male
Female

Email (if applicable)

Address*

Race*

Ethnicity*

Hispanic
Non-Hispanic

ESL*

Yes
No

School Disctrict*

School*

Grade Level*

Grades 6-12

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:

Other:

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

*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

Name 1:*

Relation to Youth:*

Phone*

Name 2:

Relation to Youth:

Phone

Pittsburgh Public School Academic Release Statement

As an approved partner with Pittsburgh Public Schools for the 2020-2021 school year, YOUTHPLACES is authorized to receive personally identifiable student educational data, including 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.

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

Preferred Medical Facility (if any):

If medical attention had to be rendered which hospital would you prefer like the youth to go to.

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

COVID 19 Disclaimers*

I understand that my child is to wear a mask at all times.
I understand that my child will be required to take a temperature at the beginning, middle and end of each day.
I attest that my child has not been diagnosed with COVID-19 in the past fourteen days.
I attest that my child has not been in contact with anyone whom has tested positive for COVID-19 in the past fourteen days.
I attest that my child has not traveled out of the country and has not traveled to any of the destinations deemed as hot spots by the state of PA in the past 14 days from the submission of this form.
I attest that if my child is sick or experiencing COVID-19 symptoms, he/she will be kept home so the symptoms can be monitored and evaluated.

YP will keep doing our part to prevent the spread of illness by taking everyday preventive actions such as staying home when sick, covering coughs, washing hands often with soap and water, and routinely cleaning frequently-touched surfaces and objects. Please select all acknowledgments above, to qualify your student for summer camp at YP.

***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*

Name

This field is for validation purposes and should be left unchanged.