Registration for Ages 17 and Under
Enter your first and last name as the parent/guardian of child being registered:
Enter your Child's First & Last Name:
Enter your contact phone numbers. These numbers must be current in case there is an emergency situation with your child.
Enter your email address:
Please provide emergency contact information for someone other than the parent/guardian:
Education - Vocational Training - Workforce Development Referred Service
Money Assistance - Referred Services
Health Assistance - Referred Services
By signing below, I agree to the fact that if participation results in any harm or injury, I release the organization Community Empowerment Center from all, costs and damages which could arise from participation in the above named activities. I agree to accept responsibility for the costs related to treatment.
I understand that the expectations for good behavior in the 2022 Youth and Young Adult Intervention Program including dress and Code of Conduct. Participants who refuse to follow these procedures will not be allowed to continue in the program. Parent(s)/Guardian(s) will be contacted if a child misbehaves. Chronic misbehavior may result in dismissal from the program.
I understand and agree to the evaluation process for participants and parents, which include surveys and interviews. Student and parent interviews are needed to determine what impact the program is having and to implement necessary changes in the program.
I have read and understand the guidelines for the 2022 Youth and Young Adult Intervention Program and by registering in this program I am guaranteeing participation and consistent attendance.
By entering my name and date below, this constitutes my signature for this online registration.
My child may be asked to participate in interviews, photos, and/or videotaping pertaining to this program. I understand that these items may be used for public relations and community awareness activities. By entering my first and last names below, I DO NOT want my child to participate in interviews, photos, and/or videotaping pertaining to this program.