Fillable Liability Waiver / Cyss Youth Program Registration & Sponsor Consent (Page 2 of 3) in pdf

CYSS Youth Program Registration & Sponsor Consent

Middle and High School Teens: It’s so easy to enjoy CYSS activities now! Just fill out this form (don’t forget the back

side), get your parent to sign it and then return it (scan, fax, email or deliver) to your local Youth Program (YP) or Parent

Central Services (formerly known as CER). CYSS staff will verify your registration telephonically with your parent or

guardian within 5 working days of receipt of form. Here’s a look at some opportunities CYSS offers: dances, trips,

classes, volunteer opportunities; homework assistance; up-to-date technology and internet access; place to meet friends;

summer camps and more!

DATA REQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY: Title 10, United States Code, Section 3012. PRINCIPAL PURPOSE(S): To provide child and family program eligibility, background

information and sponsor consent for access to emergency medical care. ROUTINE USES: Information is furnished to the attending physician when it is

necessary for an individual to be taken to a medical facility by someone other than the parent. DISCLOSURE: Disclosure of requested information is

voluntary, however, if information is not provided, individual(s) may not be allowed to participate in the CYS Program.

DECLARATION OF NONDISCRIMINATION

Services will be made available to all youth in attendance, without regard to race, religion, national origin, ancestry, or sex, within the limits of AR 608-10.

YOUTH: Last Name ____________________________ First Name________ _________________ Nickname__________________

Gender: M_____ F_____

Grade_______ School______________________________ DOB________________ Age _________

E-mail Address:_________________________________

I authorize YP to email me information and announcements about programs and events:

Yes________ No_______

SPONSOR: Last Name________________________________________ First Name______________________________________

Status: Act Duty / Guard / Reserve / DOD Civ / Other___________

(If Mil: Rank________

Branch: AR / AF / NA / MA / CG )

Unit/Employer ______________________ Unit/Emp Address______________________________ APO AE____________________

Kaserne/Post____________________________ Work Phone_________________________ Cell Phone_______________________

PSC 701, Box

96555

Mailing Address________________________________________________________ APO AE_______________________________

Home Phone___________________ On-Post? Y or N

Sponsor Email Address_________________________________________

SPOUSE: Last Name______________________________

First Name_____________________________________________

Status: Act Duty / Guard / Reserve / DOD Civ / Other Employed Civ / Student / Retired / Unemployed / Other_______________

(If Mil: Rank__________

Branch: AR / AF / NA / MA / CG )

Spouse Email Address___________________________________

Unit/Employer ______________________ Unit/Emp Address______________________________ City______________________

Zip____________ Bldg #/Kaserne_________________ Work Phone____________________ Cell Phone_____________________

Must be from 2

different households

EMERGENCY/RELEASE CONTACTS (Local adults, not parents, authorized to respond in an emergency):

1. Last Name _________________________ First Name ___________________ Work Ph_____________ Cell________________

Home Phone___________________

Is this person authorized to pick-up youth? Yes______________ No_______________

2. Last Name _________________________ First Name ___________________ Work Ph_____________ Cell________________

Home Phone___________________

Is this person authorized to pick-up youth? Yes______________ No_______________

Please continue on back side

F:\Admin\Teen Center Registration Packets\TEEN CENTER WAIVER & REGISTRATION FORMS

Liability Waiver / Cyss Youth Program Registration & Sponsor Consent Page 2

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