Apply for YouthQuest at Flint Community Schools

in partnership with

2021-22 School Year Program Application

Programs are for Flint Community Schools’ students only. PLEASE NOTE: Limited spots are available. A completed registration/application form does not ensure acceptance into the program. A YouthQuest staff member will contact you regarding your child’s application status within three (3) business days.

Please contact the YouthQuest Main Office at (810) 600-1422 with any questions.

Student Information

Please complete a different form for each individual student

Student Last Name *

Student First Name *

Student Middle Initial

Student Date of Birth (MM/DD/YYYY) *

Student Age (Years)

Address *

Country

City

State

Zip code

Student Gender

Eligible for Free/Reduced Lunch *

Yes

Student Shirt Size *

YouthQuest Program Preference (select one) *

Students will be able to switch between Fall, Winter and Spring sessions

Traditional YouthQuest (Monday-Thursday)

YQ Clubhouse (Allows for selecting specific interest clubs Monday-Friday, such as Kettering robotics, CrimFit Sports Program and other partner activities)

Grade *

School Attending *

Homeroom Teacher Name *

Parent/Legal Guardian Contact Information

Parent/Guardian Name *

Student(s) Lives with *

Yes

Relationship to Student *

Primary Phone Number *

Secondary Phone Number

Sign me up for the monthly YouthQuest eNewsletter - Afterschool Download

Yes

Parent/Guardian Name

Student(s) Lives with

Yes

Relationship to Student

Primary Phone Number

Secondary Phone Number

Sign me up for the monthly YouthQuest eNewsletter - Afterschool Download

Yes

Additional Emergency Contacts

(allowed to pick up child)

1 - Additional Emergency Contact Name

Primary Phone

Alternate Phone

Relationship to Student

2 - Additional Emergency Contact Name

Primary Phone

Alternate Phone

Relationship to Student

Additional Information

My child may NOT be released to the following individual(s)

Name(s) of Sibling(s) Registered for YouthQuest

Please explain any concerns from the above list:

Medical Concerns, Allergies, Medications, Dietary or Other Special Needs:

Please list and explain any information that will assist our staff in working with your child (Allergies; Asthma; Medication List – please note , staff will not be authorized to administer medication; Social concerns; Dietary concerns; Other)

Consent & Waiver

Parent/Legal Guardian Consent *

	Yes	No
Does your child have emergency medication at the school? If yes, please list medication(s) above.
May staff administer emergency medication it if necessary?
Are there activities your child should NOT participate in? If yes, please list below.
May the staff perform general first aid if necessary?
May the staff photograph, videotape, and /or interview your child for promotion with the understanding that this may be used in various media outlets?
Do you allow bug spray?
Do you allow sun screen?
Do you give permission for your child to attend virtual field trips (if applicable)? (Permission Slip for all Trips)
Do you give permission for your child to attend field trips via bus transportation? (Permission slip for all trips)
Is your child’s medical form updated and on file with the school?
Do you give the program permission to access your child’s student records?
My child is in good health and free from communicable disease.
My child is up to date on their immunizations and a copy of their immunization record is on file with the school.
I am aware there is a licensing notebook available for me to see at the school.

Activities student should NOT participate in

Waiver and Release of Liability

I hereby certify that by completing and signing this form, I give my approval and permission for the child/children listed below to participate in Flint Community Education Initiative activities provided by the Crim Fitness Foundation, Flint Community Schools, YouthQuest, whose Programs are administered by the Flint and Genesee Chamber of Commerce, as well as by other community partners as convened by the Crim Fitness Foundation (the Programs). I understand my child’s/children’s participation in the Programs is voluntary and subjects him/her to the possibility of physical injury (which could be minimal, serious, and/or result in death) and loss of or damage to my property (Risks). Accordingly, I do hereby waive, release, absolve, indemnify and agree to defend and hold harmless Crim Fitness Foundation, the Flint Community Schools, YouthQuest, the Flint and Genesee Chamber of Commerce and their partners, officers, directors, employees, agents, volunteers, organizers, sponsors, and contractors other participants, including any other persons or entities transporting myself or my child or children (the Releasees) from any claim, demand, loss, liability, damages, including attorney fees and costs whatsoever arising from, related to, or resulting from these Risks, including those caused by the negligent acts or omissions of any or all of the Releasees occasioned by their participation in Community Education activities.

I attest and certify that my child or children is/are physically fit to compete safely, and I have not been advised otherwise by a health care professional. As between each of the Releasees and me, I will be solely responsible for any and all medical and related bills that my child/children may incur because of any injury, as well as costs related to loss or damage to my property, that my child/children may sustain as a result of his/her participation in any Flint Community Education Initiative Program, including those sustained on the premises where any Flint Community Education Program is conducted and while he/she is traveling to and from such premises, regardless of the location or mode of transportation. This agreement shall be binding on my estate, heirs, executors, administrators, successors, and assigns, as well as any other party asserting a claim on my behalf or on behalf of my estate.

I understand that the Programs may use ethnic background and data supplied on the Flint School District meal application for their records, that my child’s teachers may share attendance and grade information, that Program employees, agents and volunteers may gather information about my child/children and that all this information may be shared with non-Program entities for evaluation purposes. Health information on file with the school may be released as needed in order to secure emergency medical treatment.

Behavior Expectations

It is the goal of Flint Community Education Initiative, YouthQuest, Crim Fitness Foundation and their partners to provide both a physically and emotionally safe environment for all program participants. With this in mind, each Program participant is required to follow the Flint Community Schools’ Code for Student Conduct as distributed to all Flint Community School students as well as provided on the www.flintschools.org webpage and on file at each school in order to ensure that all Program participants strive to meet behavior expectations.

I will attend parent/family events and communicate with staff as necessary to address my child’s needs.

All out of school time programs are provided in partnership with The Flint Board of Education. The Flint Community Schools’ Code for Student Conduct (Code) has been prepared as a service to all students, parents, and faculty of the Flint Community Schools. The Flint Board of Education has authorized these policies and procedures to provide the standards and structure necessary to foster that safe educational environment in which students can learn as they mature mentally, physically, emotionally and socially in the Flint Community Schools. All policies, regulations, definitions, and procedures have been prepared to comply with the laws of the State of Michigan and of the United States to the best of our understanding, regarding the disciplining of general education/special education students. All parents, students, and faculty are expected to become familiar with the contents of this Code. I understand that if I do not follow the rules of conduct I may be asked to leave or not allowed back for Programs.

The Flint Community Education Initiative will use the information on this form the entirety of 2021-2022 School Year. If any information on this form changes, it is the responsibility of the parent or legal guardian to notify the Crim Fitness Foundation, Community Education Staff.

STUDENTS MUST BE PICKED UP ON TIME. FAILURE TO PICK UP YOUR CHILD ON TIME MAY RESULT IN YOUR CHILD BEING EXCLUDED FROM PROGRAMS.

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

Student Name *

Phone *

Digital Signature of Parent or Legal Guardian *

Reset Signature

Signature is required.

To learn more about the Community Education Activities please contact the Crim Fitness Foundation at (810) 201-5620 or visit www.flintcommunityed.org

YouthQuest is a no-cost after school initiative operated by Flint & Genesee Education & Talent through the generous support of the Charles Stewart Mott Foundation and others.