Youth Intake Form
Program child is registering for

Applicant Information

Contact Information

Preferred Method of Contact

In case of Emergency Contact(s). Please note all youth MUST have two.

Demographic Information

This information is REQUIRED to be filled out COMPLETELY for PCC to receive funding for our programs. Information will be kept confidential.

Free or Reduced Lunch
Single Female Head of Houshold
Single Male Head of Household
Please note that a certain percentage of our youth must income qualify.
Which of the following best describes your racial identity? (check all that apply)

Health Information

General Consent to Participate

I give permission for my child to participate in Youth Programs offered by the Portage Community Center. I have completed and reviewed the application and hereby certify that the facts set forth are true and complete to the best of my knowledge.

Transportation Agreement of Minor

To be completed by the parent or guardian of the child.

In order to ensure the safety of youth volunteers PCC requires a detailed approval of transportation limits or requirements for your child. Please note if you wish to put NO transportation restrictions on your child, please check “any” on the list below to release PCC of responsibility of ensuring only approved transportation.

Any changes to the approved methods of transportation will need to occur at minimum verbally directly to staff (not left in a voicemail) in emergency situations only or in writing prior to the date of needed change.

I certify that my child is able to get home in the following ways (check all that apply):

Please list all individuals that are approved to take your child home.

Please note that emergency contacts listed in the application and parents and guardians are automatically qualified to transport a child, individuals to list in this section may include siblings, aunts, uncles, grandparents, family friend, etc.

Please list all individuals that are NOT approved to take your child home.

Private Logic Assessment Parent/Guardian Report

The information collected below is to help us to better get to know your student’s personality and their individual strengths and needs.

Directions: Think about this child and complete the top half of the assessment using adjectives to describe the way youbelieve the child views themselves, others, and the world. Then answer the questions listed in the bottom half of the assessment.

Private Logic Assessment Youth Self-Report

To be filled out by the student.

Use at least two words to describe:

Universal Needs Assessment Parent/Guardian Report

Directions: Mark each box that describes this child. You may mark multiple boxes in each section.

Adapted from L. Brendro, M. Brokenleg and S. VanBockert. 1990, Reclaiming Youth At Risk: Our Hope for the Future.

Belonging 1
Belonging 2
Belonging 3
Mastery 1
Mastery 2
Mastery 3
Independence 1
Independence 2
Independence 3
Generosity 1
Generosity 2
Generosity 3

Code of Conduct for PCC Youth

The goal of the PCC’s Youth Program is to provide youth the opportunity to become engaged in positive activities that help develop social and interpersonal skills, increase their sense of responsibility within the community and foster self-esteem. The staff and volunteers of PCC will make every effort to assist individual youth in achieving his or her goals.

To protect each youth’s right to a safe and orderly environment, policies governing youth conduct have been developed. The following is a list of unacceptable youth behaviors and the consequences that will result for any youth, regardless of age, who is participating in a PCC program who participates in any of these listed behaviors. This list is offered as an example of misbehaviors and is not intended to be all-inclusive.

The following behaviors will result in dismissal from a PCC program as well as a referral to Police.

  1. Arson
  2. Possession of a weapon
  3. Transferring and/or sale of alcohol and/or illegal substances

The following behaviors will result in consequences, which may include but are not limited to, temporary suspension from a PCC program, referral to Police, and/or restitution meeting with parents:

  1. Use or possession of alcohol, tobacco and/or illegal substances
  2. Assault or fighting
  3. Theft
  4. Profanity of any kind, written, spoken, graphics, and/or actions of vulgarity
  5. Vandalism
  6. Insubordination, persistent disobedience and/or disorderly conduct
  7. Intimidation or Harassment
  8. Ethnic intimidation or harassment
  9. Unauthorized leaving of the premises or group activity off premises
  10. Improper bus behavior

Staff has the final decision on what behavior is acceptable or inappropriate. Repeated inappropriate offenses will NOT be tolerated and is grounds for dismissal. No student will be dismissed from a PCC program until the parent/guardian has been reached and transportation arranged.


Agreement, Assumption of Risk, Consent and Permission, Liability Release

In consideration of my child, being permitted to participate in the programs or activities of the Portage Community Center (PCC), I understand and agree as follows:

I understand that my child may be involved in various activities with other children, students, and adults, and that it is foreseeable that accidents, incidents or injuries may occur and/or that property of my child may get lost or damaged. To the fullest extent permitted by law, I assume full responsibility, including financial responsibility, for any and all losses involved in a PCC program or activity.

If any emergency medical procedures are required while my child is in the care of PCC, I consent to PCC employees, representatives, or agents taking, arranging for, or consenting to the procedures or treatment in his/her discretion, and acknowledge and agree this does not create a duty for them to do so. I also give my consent to any medical facility to administer emergency treatment it deems necessary for my child. In case my child needs to be transported for a medical emergency, I understand that the Portage Community Center staff will contact 911 for emergency medical assistance. I understand there may be a charge and I agree to pay for this service. I understand that PCC staff will make every attempt to contact me or my listed "Emergency Contacts" should my child require medical attention.

I, for my child, heirs, spouse (if any), administrators, or personal representative assign, release, waive, discharge and further agree to the fullest extent permitted by law, to indemnify, hold harmless, release, and/or reimburse PCC and its board, officers, employees, agents, representatives, insurers, and others action on their behalf, for/from all claims, demands, suits, losses, cost of expense, or damage to property, personal injury or bodily injury including death, sustained or claimed, and actions which, I or any other parent or guardian, any sibling, the child, or any other person or legal entity may have or claim to have, known or unknown, directly or indirectly, arising out of, during or is in any way connected with my child’s participation in, at or with the PCC and/or the rendering of emergency or other medical procedures or treatment, if any.

I give my permission for my child to participate in the Program/s noted on the attached Youth Intake Form. I understand some activities, depending upon the Program, will be off-site and that my child will be transported by PCC.

I also give my permission to PCC to take and use any photographs of or videos taken during activities to be used in any PCC publication or other informational or advocacy media formats.