Apply for YouthQuest at Flint Cultural Center Academy

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in partnership with

Partners of YouthQuest at Flint Cultural Center Academy

2022-23 School Year Wait List Application

Programs are for Flint Cultural Center Academy students only. PLEASE NOTE: All YouthQuest spots at FCCA are currently full. Completing this application will add your student to the wait list. 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 if spots become available.

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

Student Information

Please complete a different form for each individual student

Parent/Legal Guardian Contact Information

Additional Emergency Contacts

The emergency contact name and phone number CANNOT be the same as the parent/guardian(s) listed above. These contacts are also allowed to pick up child.

Additional Information

Please explain in box below
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

(Permission Slip for all Trips)
(Permission Slip for all Trips)

Public Information/Image and Media Release

I authorize YouthQuest, Flint & Genesee Education & Talent and those acting under its permission or on its authority, to use the picture and/or voice video image of my student(s) for use in its publications and products. I understand these materials will be used to promote the program and its participants.

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 Cultural Center Academy, YouthQuest, whose Programs are administered by Flint & Genesee Education & Talent, a division of Flint & Genesee Group, 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, Flint Cultural Center Academy, YouthQuest, Flint & Genesee Education & Talent/Flint & Genesee Group 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 Cultural Center Academy 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 Cultural Center Academy’s Code for Student Conduct as distributed to all Flint Cultural Center Academy students as well as provided on the fccacademy.org webpage and on file at the 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 FCCA Board of Education. The Flint Cultural Center Academy Code for Student Conduct (Code) has been prepared as a service to all students, parents, and faculty of the Flint Cultural Center Academy. The Flint Cultural Center Academy 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 Cultural Center Academy. 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 Cultural Center Academy Initiative will use the information on this form the entirety of 2022-2023 School Year. If any information on this form changes, it is the responsibility of the parent or legal guardian to notify the YouthQuest, Crim Fitness Foundation, and 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.

Signature is required.
For security verification, please enter any random two digit number. For example: 48

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.