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NAME _____________________________________________ BIRTH DATE_____/_____/_______ AGE____ GENDER____
ADDRESS___________________________________________ PARENT NAME___________________________________
CITY_______________________________ ZIP_____________ BEST#_____-_____-_______ TEXT#_____-_____-_______
PRIMARY EMAIL _____________________________________ ALT. EMAIL______________________________________
SCHOOL____________________________________________ GRADE___ STUDENT ID/LUNCH#___ ___ ___ ___ ___ ___
Asian/Pacific Islander
Black/African American
Caucasian/White
Hispanic
Native American
Other
Parent or Legal Guardian must read and sign below for child to participate in YouthCity
Release & Indemnification: I hereby recognize and acknowledge that my
child’s participation in activities may involve bodily injury and/or emotional injury
to myself and/or child. In consideration of my child being permitted to participate
in such events, I for myself, my child, my heirs, my executors and
administrators, hereby voluntarily and knowingly release negligence based on
any injury except that caused solely by the willful misconduct of YouthCity staff,
that may result from my child’s participation.
Refunds: YouthCity may withhold 25% of the refund (program registration fee)
for administrative costs. All refunds may be requested in person, accompanied
with a written refund request. No refunds shall be given after the first day of the
program.
Collections: I agree to pay Salt Lake City Attorney’s Office for collection. I
understand that any account delinquent 30 days or more will be turned over to
the Salt Lake City Attorney’s Office for collection.
Emergency Treatment: I hereby authorize Salt Lake City program staff to act
on my behalf in accordance with their best judgment in case of an emergency
involving my child, and agree to assume full responsibility for all expenses,
medical or otherwise, that may arise there from. I understand that I or my
insurance company will be billed for such emergency treatment.
Transportation Permission: I hereby give my permission for YouthCity
personnel to transport my child or ward for field trips.
I hereby agree and voluntarily assume all risk, which may be associated with or
result from my child’s or ward’s transportation to the YouthCity Program. I
further agree to release the Salt Lake City School District, YouthCity, Salt Lake
City Corporation and Salt Lake County, its agencies, departments, officers,
employees’ agents and all sponsors and/or officials and staff of any said entity
or person, their representatives, agents’ affiliates, directors, servants, volunteers
and employees from any and all liability, claims, demands, actions and causes
of actions whatsoever for any loss, claim, damage, injury, illness, attorney’s
fees, or harm of any kind or nature to me or my child or ward arising out of any
and all activity associated with the aforementioned activities. I have carefully
read and understand the contents of this form concerning the
transportation of my child or ward.
Photo Permission: I give permission for photographs and videotape recordings
of my son/daughter’s participation in activities with Salt Lake City to be used in
promotional materials for this and other partner programs. I understand that
these photos and/or videos may be used in brochures, edited video programs,
online and other promotional items for informing interested parties about Salt
Lake City activities.
Equal Opportunity: Salt Lake Corporation YouthCity provides equal
opportunity to participants regardless of race, creed, gender or ability to pay,
and will upon request, provide reasonable accommodations to individuals with
disabilities.
Nondiscrimination Statement: In accordance with Federal civil rights law and
U.S. Department of Agriculture (USDA) civil rights regulations and policies, the
USDA, its Agencies, offices, and employees, and institutions participating in or
administering USDA programs are prohibited from discriminating based on race,
color, national origin, sex, religious creed, disability, age, political beliefs, or
reprisal or retaliation for prior civil rights activity in any program or activity
conducted or funded by USDA. Persons with disabilities who require alternative
means of communication for program information (e.g. Braille, large print,
audiotape, American Sign Language, etc.), should contact the Agency (State or
local) where they applied for benefits. Individuals who are deaf, hard of hearing
or have speech disabilities may contact USDA through the Federal Relay
Service at (800) 877-8339. Additionally, program information may be made
available in languages other than English. To file a program complaint of
discrimination, complete the USDA Program Discrimination Complaint Form,
(AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html,
and at any USDA office, or write a letter addressed to USDA and provide in the
letter all of the information requested in the form. To request a copy of the
complaint form, call (866) 632-9992. Submit your completed form or letter to
USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant
Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C.
20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov.
This institution is an equal opportunity provider.
By signing this document, I acknowledge that I have read its contents and disclosure, and that I agree to its terms.
PARENT SIGNATURE______________________________________________
DATE______/________/____________
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AFTERSCHOOL 2019-20
R E G I S T R A T I O N F O R M
PARTICIPANT
RACE
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LOCATION (Check one) Central City Fairmont Park Liberty Park Ottinger Hall Sorenson Unity Center
COST: Fees range from $11 to $228 per student, per month for Salt Lake City residents, based on family size and income.
Should your child qualify for free lunch status you may request a fee waiver. Refugee scholarships are available
Family Size Family Total Gross (before deductions) Annual Income $
A - Our family's total annual income is more than what is listed below.
We qualify for a fee of: $228
Family Size
2
4
5
6
7
8
Income
$66,187.50
$82,687.50
$89,312.50
$95,937.50
$102,562.50
$109,187.50
B - Our family's total annual income is less than or equal to what is listed below.
We qualify for a fee of: $171
Family Size
2
3
4
5
6
7
8
Income
$66,187.50
$74,437.50
$82,687.50
$89,312.50
$95,937.50
$102,562.50
$109,187.50
C - Our family's total annual income is less than or equal to what is listed below.
We qualify for a fee of: $143
Family Size
2
3
4
5
6
7
8
Income
$52,950
$59,550
$66,150
$74,450
$76,750
$82,050
$87,350
D - Our family's total annual income is less than or equal to what is listed below.
We qualify for a fee of: $86
Family Size
2
3
4
5
6
7
8
Income
$37,720
$44,700
$49,620
$53,640
$57,600
$61,560
$65,520
E - Our family's total annual income is less than or equal to what is listed below.
We qualify for a fee of: $40
Family Size
2
3
4
5
6
7
8
Income
$27,798.75
$31,263.75
$34,728.75,
$37,511.25
$40,293.75
$43,076.25
$45,858.75
F - Our family's total annual income is less than $10,000 (any family size), we qualify for a fee of $11 per month.
G - My child qualifies for free lunch status and I am therefore requesting a fee waiver. Please contact a Community
Programs manager for a fee waiver form.
H - My child came to the United States as a refugee. I am requesting a full scholarship.
Payment Method: Fees can be paid online with a credit or debit card or in person with a check or money order.
I will make future payments online I will make payments by check or money order Not applicable
I certify (promise) that all information on this application is true and that all income is reported. I understand that city
officials may verify (check) the information. I understand that if I purposely give false information, I may be
prosecuted.
CHILD NAME_________________________________________ PARENT NAME_________________________________
SIGNATURE__________________________________________ DATE______/________/_________
FOR OFFICE USE ONLY
Verified___________
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PARTICIPANT____________________________ DEPARTURE & EMERGENCY CONTACT INFORMATION-SUMMER 2019
#1 PARENT/GUARDIAN_______________________________ RELATIONSHIP____________ BEST#_____-_____-_______
EMAIL___________________________________ SEND PROGRAM UPDATES YES NO VIA: E-MAIL TEXT
#2 PARENT/GUARDIAN_______________________________ RELATIONSHIP____________ BEST#_____-_____-_______
EMAIL___________________________________ SEND PROGRAM UPDATES YES NO VIA: E-MAIL TEXT
ALT. PARENT/GUARDIAN_____________________________ RELATIONSHIP____________ BEST#_____-_____-_______
EMAIL___________________________________ SEND PROGRAM UPDATES YES NO VIA: E-MAIL TEXT
DEPARTURE OPTIONS (Please check all that apply)
Parent/Guardian will pick up child (by 6:00pm) Child can sign themselves out and walk home alone
Child can sign themselves out and walk home with an older brother or sister
SIBLING NAME_______________________________ PHONE#_____-_____-_______
SIBLING NAME_______________________________ PHONE#_____-_____-_______
Other adult(s) can pick up child
NAME___________________________________ RELATIONSHIP____________________ PHONE#_____-_____-_______
NAME___________________________________ RELATIONSHIP____________________ PHONE#_____-_____-_______
MY CHILD HAS ALLERGIES YES NO Please list_______________________________________________
MY CHILD HAS SPECIAL NEEDS YES NO Please list_______________________________________________
SWIMMING INFO My child can swim My child doesn’t know how to swim
IN CASE OF EMERGENCY: (Please list at least two people to contact)
NAME_________________________________ RELATIONSHIP____________ BEST#_____-_____-_______
NAME_________________________________ RELATIONSHIP____________ BEST#_____-_____-_______
NAME_________________________________ RELATIONSHIP____________ BEST#_____-_____-_______
In case of injury sustained to my child, I give permission to have my child treated at any legitimate medical facility by
qualified medical personnel.
PARENT SIGNATURE_______________________________________________
DATE______/________/____________
mm dd yyyy
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YOUTHCITY PROGRAM RULES AND BEHAVIOR MANAGEMENT PLAN
We believe participants have the most fun when they respect themselves, respect others and respect the YouthCity
spaces. In order to facilitate a safe and enriching learning environment we have three simple rules:
1. RESPECT YOURSELF
Participate in YouthCity classes
and programs
Use good manners and be polite
Speak and act appropriate at all
times–this means no profanity
(cursing) written or spoken
Come prepared for activities and
classes so you can fully participate
Talk to an adult immediately if you
feel bullied
2. RESPECT OTHERS
Follow directions the FIRST time they
are giventhe staff are there to help
you be safe and have fun
Keep your hands, feet, and all objects
to yourself. YouthCity has ZERO
tolerance for violence.
Stay in the YouthCity section of the
building at all times
Stick together remain within the
sight of a YouthCity staff member at
all times
Follow the golden rule–treat others
how you want to be treated
Say I’m sorrywhen needed
Offer to help others
Refrain from bringing money and
purchasing items from food vendors
and vending machines
Talk to an adult immediately if you
see bullying
3. RESPECT THE SPACE
Take care of all YouthCity property,
supplies, and computers
Put things away as you gomake
sure each space is cleaner than you
found it
Walk quietly when inside buildings
Be respectful when riding in a
YouthCity van or bus:
o Seat belts must be worn at all times
o Keep your hands to yourself
o Keep your voice down
o Remain in your seat
o Only enjoy food or drink when given
permission by YouthCity staff
Leave toys/games/electronics at
home as they can distract from our
programs and classes
THREE STRIKES
1st Time participant breaks a rule:
A warning is issued and participant is
encouraged to review the choices
they have made and consider the
YouthCity rules
2nd Time participant breaks a rule:
Participant is invited to sit out for
some time and cool off. Length of
cool down is negotiated by both
participant and staff member
3rd Time participant breaks a rule:
Excused from activity and sent to the
Community Program Manager’s office
where parents could be notified and
participant completes behavior journal
PHYSICAL VIOLENCE - ZERO TOLERANCE
It is our responsibility to keep all children and staff safe. To help ensure safety, any child engaging in an aggressive
physical altercation will be suspended.
SUSPENSION
If negative behavior persists, the participant could be suspended and/or dropped from the program. Before a suspended
child is eligible to return to YouthCity, the program participant, parent/guardian and Community Program Manager must
attend a meeting to discuss future behavior expectations & the possible return to full participation in YouthCity
Programs.
PARTICIPANT SIGNATURE___________________________________________
PARENT SIGNATURE_______________________________________________
DATE______/________/____________
DATE
______/________/____________
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