ELIGIBILITY SCREENING FORM

COMPLETE BELOW

A representative from Sacramento Youth Center will reach out to within 2 days of

completing this form (Mon-Fri) and let you know if you are eligible to participate.

PROGRAM DETAILS:

STARTS January 22th runs weekly at 1901 Del Paso Blvd. Sacramento CA. 95815
The program is on Monday's and Wednesday's night from 3:30-5:30
Dates that are mandatory: all class dates,
A calendar with all the dates will be provided during the first session
40 hours total of instruction and service projects
$500 Stipend upon successful completion of hours and learning projects
50$ gift card
Free SYC Camp Trip
Must live in the city limits
Must be 14-19 years old

SPACE IS LIMITED | In-Person Program

Eligibility Requirements:

Ages 14 - 19 years old on the first day of programing

Youth must reside within Sacramento CITY limits OR attend a public high school located within city limits.

CHECK YOUR ADDRESS HERE: https://www.cityofsacramento.org/Mayor-Council/Find-Your-District

QUESTIONS? email: [email protected]

Eligibility Form

Name

Date of Birth

Age (on January 23th)

Student's Ethnicity

Language spoken

Race/Ethnicity

Gender

School Name

Youth Phone Numbery

Yes, it's okay to send me text messages including confirmations, changes, and updates. Message frequency varies. Message and data rates may apply. View our terms of service & privacy policy.

Student Email

Address

Parents Name

Parent Phone Number

Yes, it's okay to send me text messages including confirmations, changes, and updates. Message frequency varies. Message and data rates may apply. View our terms of service & privacy policy.

Parents Email

Parental/Guardian Permission and Liability Release

I/we, the undersigned, individual and as parent(s) and or legal guardian(s) of the student listed above, a
minor, give permission to participate in #SacYouthWorks: Futures. In consideration of this participation,
I/we do hereby agree to release, discharge, and hold harmless Partner Organization, PRO Youth &
Families, the City of Sacramento, and the California Board of State and Community Corrections,
its trustees, officers, agents, and employees of and from all causes, liabilities, damages, claims, or
demands whatsoever on account of any injury or accident involving the said minor arising out of my child’s
participation in the program/project activitiesI understand that participation in this program does NOT guarantee a stipend and this is not a paid position.
BY SIGNING BELOW I AM CONSENTING TO STATEMENTS ABOVE.

I, the undersigned, agree to the terms above.

Media Release

I grant permission to Partner Organization , PRO Youth & Families, the
City of Sacramento, and the California Board of State and Community Corrections, and/or its agents or
employees to use photographs and/or video taken of my child during this program for use in promotional
and educational materials and to use such photographs/video in electronic versions of the same
publications or on organization sites or other electronic forms of media, and to offer them for use or
distribution in other media outlets, electronic or otherwise, without notifying me. I hereby agree to release,
defend, and hold harmless and its agents or employees, including any firm publishing and/or distributing
the finished product in whole or in part, whether on paper, via electronic media, or on Web sites, from and
against any claims, damages, or liability arising from or related to the use of the photographs/video.BY SIGNING BELOW I AM CONSENTING TO STATEMENTS ABOVE.

I, the undersigned, agree to the terms above.

Youth Program Code of Conduct

The primary purpose of the Youth Program Code of Conduct is to ensure the safety and well-being of all participants in the program. As a participant in this program, youth will be asked to abide by the following guidelines:

Conduct themselves in a courteous manner and treat members, parents, volunteers, staff, and others with respect. Appropriate language and behavior are expected at all times.

Respect and adhere to the rules and guidelines of the program including all those specific to this project.

Uphold an individual’s right to dignity by supporting an environment of inclusion which welcomes involvement of participants from all backgrounds.

Obey local, state, and federal laws.

Participants who fail to adhere to the Youth Program Code of Conduct are subject to dismissal from the program.

I/we understand the code of conduct that will be expected of all program participants.

I, the undersigned, agree to the terms above.

Parent Signature for minors OR Youth Signature if OVER 18 years old

I have read and checked the terms listed above:
- Parental/Guardian Permission and Liability Release
- Media Release
- Program Evaluation & Confidentiality
- COVID-19 Terms
- Youth Program Code of Conduct

I, the undersigned, agree to the terms above.

Almost done. Where should we send the confirmation?

Mobile Phone Number

Yes, it's okay to send me text messages including confirmations, changes, and updates. Message frequency varies. Message and data rates may apply. View our terms of service & privacy policy.

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