For Sta Only Date enrolled Date Closed CDG Code Sta Check Applicable: YAC @ Wildwood YAC

Quilts! - After School YAC Quilts! - Summer YAC Productions Other

Youth Arts Corps is a program of Family Resources, Inc. Major funding and support provided by Coordinated Child Care of Pinellas, City of St. Petersburg, City of Clearwater, City of Pinellas Park, Bank of America and the National Endowment for the Arts.

Member Application
Name

Youth Arts Corps at Wildwood & Quilts!

1000 28th St South, St. Petersburg 727-552-1825

youthartscorps.org

Youth Arts Corps Productions

Skyview Rec Center 9010 54th Way, Pinellas Park 727-528-5797

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OST Attestation For Eligibility

Coordinated Child Care, the main funder for the Youth Arts Corps after-school programs require that participants be residents of Pinellas County and their family income be within 300% of the federal poverty level to be eligible for free services.

For Staff Use Only

Orientation Date Application Status Sta Member

Reviewed

Pledge Attendance Policy Eligibility Requirements Job Training Method

Youth Participant Name

(please print)

Residency
I certify that the information regarding my and my child(ren)s residency is true and complete to the best of my knowledge. I fully understand that any omissions, falsications or misrepresentations may disqualify my child(ren) from participating in the Out of School Time (OST) Program.
Notes:

Parent/Guardian Signature OST Sta Signature

Date Date

Income
check one

$0 - $9,999

$10,000 $19,999

$20,000 $29,999

$30,000 $39,999

$40,000 $49,999

50,000 up

I certify that the information regarding my and my child(ren)s income is true and complete to the best of my knowledge. I fully understand that any omissions, falsications or misrepresentations may disqualify my child(ren) from participating in the OST Program.

Parent/Guardian Signature OST Sta Signature

Date Date

Proof of Age
Please list the name of the document you are providing to verify age of participant, (state ID, birth certicate, vaccine record, etc.)

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Youth Info
please print clearly
First Name Preferred Name Address City Youths email Youths Cell Home Phone Zip Middle Initial Last Name Male Female

Have any more questions or comments ?

Todays Date Birth date Age Social Security # / /

Household
Total # of adults in household Total # of youth in household Is anyone in your household currently a member Yes No of Youth Arts Corps? check one If yes, please list their name(s)

Do you receive? check one

Free lunch Reduced lunch Not eligible

School
Student ID #
Name of school

Grade level

G.P.A.

Are you a teen parent?

check one Yes No

Race/ethnicity check one

White Cuban Mexican American Chicano Puerto Rican Spanish/Hispanic/Latino American Indian or Alaska Native Asian Unspecied Black, African American Chinese Filipino Guamanian or Chamrro Japanese Korean Multiracial Native Hawaiian Other Asian Other Pacic Islander Samoan Vietnamese Other

Do you have any allergies or medical conditions?

check one Yes No if yes, please list:

Parent/guardian
Parent/Guardian Name[s] Parents email Parents Cell Parents Cell Does your family Own or Rent your home? check one Home Phone Work Phone Own Rent other

Emergency contacts
Thank you for your input, you have nished the application!
Name Name Phone Phone Relationship Relationship

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Youth Info (continued)

How did you nd out about the Corps? If a friend told you about us whos the friend? Are you currently in any other after-school program? Yes No If yes, please explain

Transportation Release
Family Resources Youth Arts Corps provides transportation for program participants based on the program site and availability. Please review and answer the following questions so we may best serve your youths needs. How will your youth get to and from the program? Check all that apply: I will provide transportation to and from the program. My youth will walk or ride their bike to and from the program. My youth will ride with a friend or relative to and from the program. If checked please provide names of people authorized to transport your youth:

What types of art are you interested in? List any previous arts training or classes (visual, performing or literary):

Tell us about your school experience. What subjects are you doing well in academically and what subjects would you like to improve in?

Name Name Name

Phone Phone Phone

Relationship Relationship Relationship

My youth will ride public transportation to and from the program. Does your youth need transportation to and from the program? Yes No Please note, transportation is provided as available per program site. What would you like to learn about running your own business? List three positives qualities you possess:
1. 2. 3.

Family Resources Youth Arts Corps provides transportation to and from eld trips and depending on program site and transportation availability, to and from the program. To allow your youth to be transported to the program, please read the following and sign below: I understand that Family Resources Youth Arts Corps provides transportation for youth participants and I authorize Family Resources to transport my youth via company vehicles, and contracted transportation services including TLC Transports, Lifestyle Limo and others. On occasion I understand that Family Resources employees and volunteers personal vehicles may be used to transport my youth under limited circumstances such as emergencies and special outings. I understand that transportation is provided based on availability and resources.

What do you hope to receive from your membership in the Youth Arts Corps?

Is there anything else you want to share about yourself, your interests or your talents?

Youth Participant Name Parent/Guardian Name Do you have any special needs or challenges, or require access to special equipment that we need to be aware of to help you succeed at the Youth Arts Corps? For example, language interpretation, help with reading or TTD/TTY phones? Parent/Guardian Signature Date

(please print) (please print)

Please contact me regarding volunteering to provide transportation for elds trips. I understand I will be subject to driving record & background checks to determine eligibility.

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Youth Arts Corps Pledge

Respect
Dierences People Artwork Supplies Language Ideas Environment
Being a Youth Arts Corps member is an exciting and serious commitment. Being on time and attending all your workshops is critical. Missing more than four workshops within the workshop session may result in the termination of membership. Reapplication is at the discretion of the sta. If you cannot attend your workshop, please call the sta so they may notify the artist of your absence. All work created at the Youth Arts Corps (unless specied by your instructor or produced in YAC Productions program) will be sold in the Youth Arts Corps gallery and in other settings or shown as part of an exhibition of works.

Program Requirements & Evaluation Consent Form

The Youth Arts Corps provides quality arts education experiences for youth. But the Youth Arts Corps is much more than an arts education program. The mission of the Corps is to utilize the ne arts to help youth realize their potential. We are foremost a positive youth development program that recognizes and capitalizes on the many benets the study of the arts oer youth. Such benets include opportunities for self expression, increased understanding of ones own and others culture, increased academic performance, association with positive adults and peers, opportunities to learn and practice critical job skills, appreciation for all art forms, increased understanding of self and others, development of critical thinking skills and learning teamwork. The major funder of our after-school programs, Coordinated Child Care of Pinellas (CCC), requires us to evaluate the impact our program has on youth to ensure that the programs they fund make a meaningful dierence. Additionally, the Corps is dedicated to improving our programming to help youth reach their potential and uses the following formal evaluation tools: Healthy Kids Survey (HKS), a research-based tool that evaluates our youths internal and external assets. Research shows that youth who have a high number of internal and external assets (positive adult and peer relationships, access to quality after-school activities, feelings of adequacy, parental support, and age-appropriate challenges) are much more likely to be healthy, productive, and well adjusted adults capable of realizing their potential. The survey is given at intake, annually, and when the youth leaves the program. Program Satisfaction Surveys, given twice each year.

Consequences

1. Warning 2. Conference with YAC Sta and Corps Member 3. Call Parent/Guardian 4. Suspended for Three Days 5. Lose membership

I, , hereby pledge to abide by the rules and consequences of the Youth Arts Corps Program.

Youth Participant Signature Parent/Guardian Signature

Date Date

Performance Evaluations, given halfway and at the end of each project workshop. Critiques of Artwork, given throughout the workshops. Art Knowledge Pre- and Post-Tests, given at the beginning and end of each workshop. For youth participating in Youth Arts Corps Productions, we also utilize the following tools:

Attendance Policy
I understand that I am expected to attend each workshop and to be on time. I understand that if I do not call ahead to let sta know I will be more than 15 minutes late, I may not be allowed into the workshop. I understand that I am allowed two unexcused absences and two excused absences during each 12 week period per workshop. I understand that my absence will be considered unexcused if I do not call or tell sta in advance that I will not be able to attend.

Youth and Family Assessment, a meeting between the youth, their parent(s)/guardian(s), and a sta member who will recommend program components and help link families to area resources as needed. To participate in the Youth Arts Corps, youth and when applicable, parents/guardian(s) must agree to participate in the programs evaluation requirements. By signing below, you acknowledge the evaluation requirements and give consent to participate in the evaluation of the program and individual progress.

Youth Participant Signature I understand that I have to speak with sta directly or leave a message on the sta or program voice mail to report my absence or tardy. Leaving a message with another youth member to relay to sta is not acceptable. Youth Participant Signature Parent/Guardian Signature Date Date Parent/Guardian Signature

Date Date

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Consent Form (Parental/Guardian)

I, the Parent / Guardian of understand that the Youth Arts Corps, a program of Family Resources, Inc. provides skill development in the ne arts and job training. I give full consent for my child to participate in artistic workshops, job training, eld trips, community service, projects performance and other events / activities as a part of the Youth Arts Corps. I understand that Family Resources, the City of St. Petersburg, Coordinated Child Care of Pinellas, City of Pinellas Park, and other program funders, their agents, employees and volunteers will not be liable for loss, damages or injury to person or property whether caused by negligent acts or otherwise while the person for whom this application has been submitted is participant or parent/guardian. The Youth Arts Corps reserved the right to dismiss any participant for just cause. Furthermore, I understand that Youth Arts Corps can be subject to publicity in order to promote and enhance the program. I hereby authorize my youths involvement in the making of photographs, videotapes, or news stories used to educate and inform the public about the mission of the Youth Arts Corps. I hereby release from liability Family Resources, the City of St. Petersburg, Coordinated Child Care of Pinellas, City of Pinellas Park and sta and agents of all such entities for their acts of inclusion or omission regarding the making of photographs, videotapes, or written material and I understand that there is no monetary compensation for reproduction of these photos, videotapes or written materials. I hereby authorize Family Resources, Inc., or any of its agents, to publish print, display (through television or any other media) or otherwise publicly use my name, photograph, portrait, or other likeness of me in which I may be included in whole or in part, with or without my own name or a ctitious name for the purposes of trade or any commercial or advertising purpose, including but not limited to publicity and/or education. I also authorize Family Resources, Inc., or any of its agents, to publish print, display (through television or any other media) or otherwise publicly use interviews or statements that I make, whether in their entirety or in parts, for the purpose of trade or any commercial or advertising purpose, including but not limited to publicity and/or education. I hereby expressly waive my Common Law or Statutory Right of Privacy and Right of Publicity, and I expressly waive any right that I may have in the nished product, or any rights to inspect or approve the nished product, the advertising or any other copy of reproduction that may be used in connection with my name, photograph, portrait, or other likeness of me, or any interview or statement that I make, whether in whole or in part or the use to which it may be applied I hereby release from any and all liability, of every nature , Family Resources, Inc., its sta and agents all such entities for their acts or omissions performed in connection with the making, dissemination and or use of my name, photograph, portrait, or other likeness of me, or any interview or statement that I make, whether in whole or in part, for any trade, commercial or advertising purpose. Youth Participant Name Parent/Guardian Name
Address (please print) (please print)

Household Arrangement
The purpose of collecting household arrangement information is to establish the closest denition in comparison with census data.

Dual Parent: Married example: Mother & Father, or Parent & one Step parent Other-Relative/Kinship Care: Married example: Grandmother & Grandfather, or Aunt & Uncle Single Parent: Female Head of Household example: Mom & Children Single Parent: Male Head of Household example: Dad & Children Dual Parent / Non-Married: Female Head of Household example: Mom, Children & Signicant Other in Moms house Dual Parent: Non-Married - Male Head of Household example: Dad, Children & Signicant Other in Dads house Other / Relative / Kinship Care: Female Head of Household example: Aunt & Nieces / Nephews Grandma & Grandchildren Other / Relative / Kinship Care- Male Head of Household example: Uncle & Nieces/Nephews or Grandpa & Grandchildren Other: Non Relative example: Youth living with unrelated adults such as friends parents Foster Care example: Child living in Foster Care

Thank you for providing us with this information.

City State Zip

Parent/Guardian Signature

Date Parent/Guardian Signature Date

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