Community Based Program Application & Registration Form FY 2026-2027

PARTICIPANT INFORMATION

Please select your language:

IMPORTANT DISCLAIMER: This form offers automated translation powered by Google Translate, which does not guarantee 100% accuracy or reliability. In the event of any discrepancies, the English version is the official, binding document. Please contact our office if you have any questions or concerns.

For legal compliance, CYC requires a parent/legal guardian to complete and sign this application if the applicant is under 18 years of age. Please select the below:

I attest that I am over 18 years old and am legally able to complete this application form myselfI attest that my child is under 18 years old and I am their legal parent/guardian authorized to complete this application form for my child

I would like to apply and register for the below program

Participant First Name

Participant Middle Name (Optional)

Participant Last Name

Participant Email

Participant Cell Phone

Participant Date of Birth

mm/dd/yyyy

Grade in Fall 2026

If Grade Other:

School Currently Attending

Please Specify College/University or Vocational Program

Please Specify Other

Participant Street Address

Apartment / Unit / Suite / Floor Number

City

State

Zip Code

PARENT/GUARDIAN INFORMATION

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to Minor

If Relation Other

Parent/Guardian Email

Parent/Guardian Phone Number

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Email

Emergency Contact Phone Number

Emergency Contact Relationship to Minor

If Emergency Contact Relationship Other

Would you like to add another emergency contact

Another Emergency Contact First Name

Another Emergency Contact Last Name

Another Emergency Contact Email

Another Emergency Contact Phone Number

Another Emergency Contact Relationship to Minor

If Another Emergency Contact Relationship Other

END OF DAY ARRANGEMENTS FOR IN-PERSON PROGRAMS: Children must be picked up by program end time. Late pick up fee of $2 per minute if late. Please check all that apply

My child walks or takes the bus home. I give permission for my child to sign themselves outMy child will be picked-up each day and I give permission for my child to sign themselves outMy child will be picked-up each day AND ONLY PARENT/GUARDIAN may sign them out. (MUST fill out Authorized Pick-Up fields).Not ApplicableOther

If End Of Day Arrangement other:

Authorized Pickup First Name

Authorized Pickup Last name

Authorized Pickup Email

Authorized Pickup Phone Number

Authorized Pickup Relationship

If Authorized Pickup Relationship Other

Would you like to add another authorized pickup

Another Authorized Pickup First Name

Another Authorized Pickup Last Name

Another Authorized Pickup Email

Another Authorized Pickup Phone Number

Another Authorized Pickup Relationship

If Another Authorized pickup Relationship Other

PARTICIPANT DEMOGRAPHIC INFORMATION

Race/Ethnicity

Specify Race/Ethnicity

English Fluency

Primary Language

Primary Language Other

Gender

Gay / Lesbian / Bi:

Special Needs

Please Specify

Housing Status

RELEASE AND AUTHORIZATION FOR MEDICAL TREATMENT

Please provide the following

Health Insurance Company

Please Type "NONE" if you have no insurance.

Policy/Group Number

Doctor Name

Doctor Phone Number

Please list medical conditions (i.e. asthma, heart condition, allergies, seizures, diabetes, etc.) and list name, dosage, and purpose of medications currently being taken by minor:

Emergency Medical Treatment Authorization

I authorize CYC and its affiliated program staff to furnish and/or obtain emergency medical treatment which may be necessary for my child during the ProgramI DO NOT authorize CYC and its affiliated program staff to furnish and/or obtain emergency medical treatment which may be necessary for my child during the Program

Household Income Information

Household Size

Annual Household Income

$

Round to the nearest whole dollar

SFUSD Multipurpose Family Income (MFI) Form: If applicable, please complete and upload the MFI Verification Form if you would like to apply for free or sliding scale fees for any of CYC's fee based programs. You may upload other financial documents for verification or contact our office if you have any questions.
https://www.sfusd.edu/services/health-wellness/nutrition-school-meals/apply

Please upload File

PRIORITY ENROLLMENT: Please select the options below to help us determine your child’s priority enrollment status for qualifying programs. (Check all that apply)

My child meets one or more of the following criteria: Family qualifies for free/reduced price meal benefits, foster youth, homeless youth and/or English language learner.My child is currently enrolled or was in a CYC program last year.None of the above/Not applicableOther

If Other

CYC Progressive Response Policy, Waiver, and Limited Liability

CYC believes that emotional and physical safety is extremely important, and we strive to create a safe and supportive environment for children, youth, and their families. We are required to document any injuries, referrals, and crisis situations. To ensure a safe and supportive community, all program managers, directors, and coordinators are trained in restorative practices, guidelines, and procedures and use them to manage behaviors. Parents/guardians are notified of agency policies and protocols upon program acceptance and/or during program orientation and are given opportunities to comment and ask questions.

CYC’s progressive response process is outlined below:

Issues and behaviors are communicated with parents/guardians frequently or as needed. Referrals to the school care team will be made if necessary to provide additional support.
Restorative circles will be used, and behavior agreements will be reviewed and documented to provide further support. Parents/guardians will be asked to be present at all meetings to ensure clear communication of agreements.
If agreements are broken, or if a student is physically hurting themselves or others, discussions regarding possible suspension may take place.

It is under the discretion of the Director, Program Manager or Site Coordinator to redirect the child and family to services that may provide more support after a number of unsuccessful attempts to accommodate the child without undermining the quality of the program.

I acknowledge that I have reviewed, understand, and CONSENT to the program policies and information.I acknowledge that I have reviewed, understand, and DO NOT CONSENT to the information above. I understand that this disqualifies my child from participating in CYC programming and that I cannot continue with this application.

ONLINE PLATFORM / VIRTUAL LEARNING

I understand that I or my child may be participating in an online platform utilizing video and audio chat with instructors as well as other program participants. I understand the classes may be recorded and used for educational purposes. I understand foul images, audio, or chat will not be condoned and agree to follow community agreements and high standards of digital citizenship.

I consent for myself and/or my child to participate in virtual or in-person classes and activities offered by Community Youth Center of SFI DO NOT consent and understand that my child will NOT be able to participate in CYC programs

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION

The San Francisco Department of Children, Youth, and Their Families (DCYF) funds our agency and the services we provide. To fulfill the requirements of this funding, we share information about the participants in our services with DCYF. DCYF and the San Francisco Unified School District (SFUSD) maintain a shared, secure database to record information about services provided to San Francisco youth by DCYF’s grantees in order to facilitate outreach and enrollment and track program use and impact. As a DCYF grantee, our agency has access to the shared database to both see and report data about the youth we serve. The data that we report to DCYF is also shared with SFUSD.

By signing this form, you authorize

Our agency to share information about your child’s participation in our program (or your participation, if you are 18 years of age or older) with authorized staff at DCYF and SFUSD for the purposes described above. The information that our agency reports to DCYF includes:

Person information, such as name, date of birth, and address:
Demographic information, such as race/ethnicity and gender identity;
Education information, such as school name and grade level;
Participation in activities and services, such as dates of attendance dates and hours attended; and

Anonymous and voluntary youth experience surveys.

SFUSD to share certain information about your child (or you, if you are 18 years of age or older) with authorized staff from our program as a DCYF grantee. The information that SFUSD reports to DCYF includes:

Personal information, such as name, date of birth, and address;
Education information, such as school name and grade level; and

Dates of attendance in SFUSD or an SFUSD school.

DCYF, SFUSD, or our agency will not publicly report any information that we provide in a way that may be used to identify your child (or you, if you are 18 years of age or older).

Restrictions: All information that we provide or access that is related to an SFUSD student is protected by federal and state laws that govern the use, disclosure and re-disclosure of student education records. Parties other than DCYF, SFUSD and our agency will not have access to any personally identifiable information that is reported into the database, except to the extent that the parties have obtained prior written authorization from you or have followed SFUSD policies and procedures to obtain access to such information.

Expiration: This authorization expires on June 30, 2029 when our current funding cycle ends.

Your Rights: You may refuse to sign this form. You may cancel it at any time by information our agency in writing. If you cancel your permission allowing us to release information to DCYF and SFUSD, and SFUSD to our agency, it will go into effect immediately, unless the information has already been released. You have a right to receive a copy of this form.

I acknowledge that I have reviewed, understand, and CONSENT to the information above.I acknowledge that I have reviewed, understand, and DO NOT CONSENT to the information above. This does not disqualify my child from participating in CYC programming and I may continue with this application.

PHOTOGRAPHY AND MEDIA RELEASE

During you or your child’s attendance at CYC, she/he/they may participate in activities that are photographed or videotaped. These photographs and video recordings may be used for promotional purposes.

By not submitting an opt out form, I authorize the SFUSD, San Francisco Department of Children, Youth, and Their Families (DCYF), CYC, or any third party it has approved to photograph or videotape myself and/or my child during CYC and/or After School program activities and to edit or use any photographs or recordings at the sole discretion of the named entities as stated above. I understand that I and my child shall have no legal right or interest arising from the recording, including economic interest. I also agree to release and hold harmless the SFUSD, DCYF, CYC, or any third party it has approved from and against all claims, demands, damages, and liabilities arising out of or use of the recording.

PHOTOGRAPHY AND MEDIA RELEASE: By clicking below, I agree to the below:

I acknowledge that I have reviewed, understand, and CONSENT to the information above.I acknowledge that I have reviewed, understand, and DO NOT CONSENT to the information above. This does not disqualify my child from participating in CYC programming and I may continue with this application.

CYC LIABILITY RELEASE AND WAIVER AGREEMENT

In consideration for permission to participate in Community Youth Center of San Francisco (CYC) programs and activities, each person signing below hereby stipulates and agrees:

1. ASSUMPTION OF RISK
I represent that I am physically sound and have medical approval to participate in CYC programs and related activities. I have recently sought and received a medical examination that determined that it is safe for me to participate. I shall promptly notify CYC in writing of any changes in my health that might call into question the appropriateness of me continuing to participate. I VOLUNTARILY AND FREELY CHOOSE TO ASSUME ALL RISKS AND DANGERS, including the risk of injury or death that may be associated with, or result from, my participation
2. RELEASE FROM LIABILITY
I agree, for myself and my heirs, to fully and forever discharge and release CYC, their officers, directors, agents and employees from any and all liabilities, claims, demands, actions and causes of action whatsoever whether known or unknown based upon any injuries, costs, loss of services, expenses, actions and causes of action, whether caused by their NEGLIGENCE or for any other reason, on the account of, or in any way resulting from, personal injuries, conscious suffering, death or property damage to myself or to any other person or property, in any way connected with my preparation or practice for, or participation in, the activities. I agree that this Liability Release and Waiver Agreement shall include my participation in any and all sports activities sponsored by the Releasees including, but not limited to, practice sessions, instructional sessions, activities directed by a coach or a team representative and/or promotion activities.. 3. COVENANT NOT TO SUE I agree, for myself and all my heirs, not to sue Releasees, not to initiate to assist the prosecution of any claim for damages or case of action which I or my heirs may have by reason of personal injury or death to participation or destruction to participant’s property arising from Releasees’ activities. 4. INDEMNITY AGREEMENT I agree, for myself and my heirs, to indemnify and hold harmless the Releasees from any loss, claims, action, causes of action, or proceedings of any kind which may be initiated by me or by any other person, entity or organization, including demands, judgments, costs, loss of services, expenses, or reimbursement of counsel fees incurred by participant or by the Releasees from activities contemplated by this agreement. I give permission to Releases to obtain on my behalf any emergency medical treatment. In case of sickness, accident or injury, Releasees have my express permission to secure, at my expense, such medical treatment as is deemed necessary in the sole discretion of Releasees. 5. CONTINUATION OF OBLIGATIONS I agree, for myself and my heirs, that the above provisions, including ASSUMPTION OF RISK, RELEASE FROM LIABILITY, COVENANT NOT TO SUE & INDEMNITY AGREEMENT shall continue in full force and effect now and at all future times when participant is involved in the activities. In the event of any dispute or controversy arising with respect to this Release and Liability Agreement, its interpretation, application and/or extinction, said dispute or controversy will be resolved by binding arbitration proceedings conducted by the American Arbitration Association (“AAA”) in San Francisco, California, pursuant to the commercial arbitration AAA rules then in effect. 6. CYC MEDIA RELEASE CYC may from time to time, capture photographs and video of our participants at all related sponsor CYC activities in action. Therefore, we request that you agree with the terms of our media release. I hereby grant Community Youth Center of San Francisco the unrestricted right and permission to copyright and use, re-use, publish, and republish photographic portraits, pictures, videos or audio recordings of me or in which I may be includes intact or in part, composite or distorted in character or form, without restriction as to changes or transformations in conjunction with my own or a fictitious name, or reproduction hereof in color or otherwise, made through any and all media now or hereafter known for illustration, art, promotion, advertising, trade, or any other purpose whatsoever, as well as any publication thereof.. I HEREBY ACKNOWLEDGE THAT I HAVE FULLY READ EACH OF THE ABOVE PROVISIONS AND FULLY UNDERSTAND AND AGREE WITH EACH PROVISION. I HAVE HAD THE OPPORTUNITY TO HAVE COUNSEL OF MY CHOICE REVIEW IT WITH ME. I HAVE READ AND FULLY UNDERSTAND AND ACCEPT EACH OF THE PROVISIONS OF THIS AGREEMENT. I HEREBY EXPRESSLY WAIVE THE PROVISIONS OF CALIFORNIA CIVIL CODE SECTION 1542 WHICH PROVIDES AS FOLLOWS: CERTAIN CLAIMS NOT AFFECTED BY GENERAL RELEASE. A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF KNOWN BY HIM, MUST HAVE MATERIALLY AFFECTED HIS SETTLEMENT WITH THE DEBTOR.

I HEREIN UNDERSTAND AND AGREE that all rights under Section 1542 of the California Civil Code are expressly waived and that this Release releases all injuries, damages, or losses to the person and property, real or personal, whether known or unknown, foreseeable, unforeseeable, patent or latent, which she/he may have against another party or parties herein released. I hereby declare that I am over the age of 18, unless my guardian has signed.

I acknowledge that I have reviewed, understand, and CONSENT to the program policies and information.I acknowledge that I have reviewed, understand, and DO NOT CONSENT to the information above. I understand that this disqualifies my child from participating in CYC programming and that I cannot continue with this application.

PLEASE SIGN BELOW:

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This section requires consent/permission for participation. Please contact our office if you do not agree or have questions.