EDCC Youth Registration Form

Child's Information

Child Name

Age of child

Grade of child

Child's Cell Phone (If Applicable)

Gender of child

Female

Male

Does this child receive free or reduced lunch?

Yes

Birthday

Month

Day

Year

Child's School

School Name if not in list above.

Parent's Information

Parent/Guardian First name

Parent/Guardian Last name

Parent/Guardian Street Address

City, State, Zip

Parent/Guardian Phone

Parent/Guardian Email

Emergency Contact Person

Emergency Contact Phone

Emergency Contact Email

Race & Ethnicity - Please Select one

Programs and activities of Interest

Health Insurance Information

Does your child have Health Insurance?

Yes

If yes, please select one.

Medicaid

Child Health Plus

Private

Do all family members have health insurance?

Yes

If yes, please select.

Medicaid

Child Health Plus

Private

Medical Condition(s) & Allergies

Does your child have any medical conditions or disabilities that we should be aware of?

Yes

Please list condition(s)

Please list allergies

Please list any medications that your child is taking that we should be aware of.

I grant permission for my child to receive first aid and professional medical treatment in an Emergency while in the care of the EOP Staff

Yes

Please list instructions to be taken in the event of an emergency or an allergic reaction

Preferred Hospital

Child's Physician

Physician's location

Physician's Phone

Permission & Consent of Release

I give permission to photograph or interview my child for program activities, newspaper articles, radio & television releases and educational & promotional publications.

Yes

Additional form may be required for specific event(s).

I give permission for my child to attend field trips with EOP Staff.

Yes

Additional form may be required for specific events.

I give my permission to EOP to exchange information with my child's school and teacher to provide a coordinated effort for my child's academic enrichment.

Yes

Additional form required from school district.

Teacher's name (for information exchange above)

Household Information

Siblings' names & school attending

EDCC Registration and Income Verification Policy: All students participating in programs at the Ernie Davis Community Center (EDCC) must have a completed registration form on file. Registration forms and proof-of-income documentation must be updated annually. To comply with local and state funding requirements, families must provide one of the following forms of income verification: current pay stub, W-2 form, federal income tax return, verification from the Social Security Administration (SSA), verification from the Department of Social Services (DSS), or verification from New York State Unemployment Insurance. All personal and financial information is kept strictly confidential, stored in locked files, and securely shredded annually. Reports provided to funders include only combined participation totals and never identify individual youth or families. No youth will be denied services because of their family's income level. However, certain funded programs require complete income-verification documentation. If the required documentation is not provided, a student may be unable to participate in those specific programs until the documentation is received. EDCC/EOP staff reserve the right to request updated income verification at any time when required for program eligibility or funding compliance.

Please bring one form of income verification to the Ernie Davis Community Center, 350 East Fifth Street, Elmira. Please do not email financial documents.

Student Form: EDCC Principles & Guidelines

EDCC PRINCIPLES

A - Always listen, follow guidelines, and speak the truth

B - Be a good sport

C - Commit to clean, clear, and positive language

D - Demonstrate respect of people and property

E - Educate others by not tolerating violence or intimidation

F - Free to speak openly and honestly to staff

GUIDELINES

Respect for Property: The destruction of facility property will not be tolerated. Depending on the nature of the offense, law enforcement may be contacted, and an extended suspension from the facility may be enforced.
Stealing: Stealing of any kind will result in immediate suspension. This includes items within the Bistro or any other part of the facility.
Language & Behavior: The use of vulgar, profane, aggressive, or disrespectful behavior/language will not be tolerated. Everyone is expected to show respect at all times.
Respect for Self and Others: All students and adults must act respectfully toward themselves and others.
Registration Requirement: All students and adults must be registered at the Ernie Davis Community Center. Anyone not registered will not be allowed in the facility.
Following Directions: Students are expected to listen to staff and follow all directions.
Designated Areas: Students must remain in designated areas of the building(s). Moving through undesignated areas may result in suspension, at the discretion of staff.

EDCC IS YOUR PLACE - YOUR PROPERTY TO BE SAFE, EXCEL AND BE CREATIVE. Respect others - most important, respect yourself! LEAD BY EXAMPLE AND MAKE GOOD CHOICES.

Student: I understand and agree to follow the Code of Conduct and Guidelines for the Ernie Davis Community Center.

Student signature (or initials)

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Parent / Guardian Signature

Parent/Guardian printed name

Parent/Guardian signature