Parent/Guardian Information
Parent/Guardian First Name:
Parent/Guardian Last Name:
Parent/Guardian Email Address:
Parent/Guardian Phone Number:
Child Information
Child First Name:
Child Last Name:
Child Birthdate:
School:
Grade:
Select
K
1
2
3
4
5
6
7
8
9
10
11
12+
Grad
Cincinnati Public School Student ID Number:
Emergency Information
Emergency Contact Name:
Emergency Contact Phone Number:
Allergies/Partinent information
Participation Agreement
I give permission for my child named above to participate in Cincinnati Youth Collaborative (“CYC”) program(s). I understand that volunteers in the programs are not school or CYC employees, and that program related activities with my child are intended to help them graduate from high school with the knowledge, skills, attitudes, and behavior necessary to participate fully and responsibly in society.
Liability Waiver
I agree to fully release and hold harmless the CYC, its volunteers and mentors, partner schools, facilities, and their agents or employees from any and all claims arising from my child's participation or non-participation in CYC programs. I understand that the program may include various recreational activities (like basketball, football, soccer, yoga, etc.)
I also understand that I am responsible for seeing that my child gets to and from the program activities and their locations. I also understand that the CYC and its mentors, volunteers, workers at program facilities, and CYC staff are not responsible for my child before or after the program ends, and/or if my child chooses to leave a program location early or on their own. CYC programs are not daycare or babysitting. If I have any concerns about my child leaving program facilities or participating in the program, I understand that I am welcome to accompany my child to the program facility and to observe their activities in addition to participating in drop-off and pick-up.
Transportation Waiver
My child has my consent to go to program activities in a private car driven by a volunteer, in a bus, public transportation vehicle, or in a vehicle driven by a school or recreation facility employee.
Media Release
As a participant in the program, I understand and consent for my child to appear in media/recruitment materials including TV, radio, web, printed materials, newsletters, and social media. If I do not want my child photographed, I will not send him/her to this program or I will send him/her in a face mask and hat or bandana that obscures his/her appearance. I consent to my child participating in program evaluation surveys and understand I may be required to complete occasional program evaluations.
Signer's Name
I support CYC programs and will encourage my child's participation and good behavior. I understand that if my child does not adhere to the guidelines of CYC programs, my child may be removed from CYC programs.
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