“BYA helps youth and their families address issues and problems via Prevention—reaching youth before their problems become crises, and Intervention—providing support services to youth who are entangled in the juvenile justice system. BYA helps build capacity within individuals to reach their innate potential.”
BYA 
Berkeley Youth Alternatives
1255 Allston Way
Berkeley, CA. 94702
www.byaonline.org
510-845-9010
An Independent, Private Non-Profit Organization
Begin
 
Hi, Parent/Guardian or Individual 18 and over.
What's your name? *

(Please provide your FIRST and LAST name)
 
{{answer_25270156}}, what's your phone number? *

 
Please fill out fields A - I, as they're required from all of our participants.

We'll be asking the Participant's: Name and ID#,  DOB, Street Address, Telephone, and (3) Emergency Contact's Info.
 
Hi, what's your First name? *

 
...{{answer_25270173}}'s Last name?

 
Date of Birth of  {{answer_25270173}}: *

 
Drivers/School/State ID#:

 
{{answer_25270173}}'s Street Address (ex. 1255 Allston Way): *

 
City: *

 
Zip Code: *

 
{{answer_25270173}}'s Telephone number? *

(If it should differ from the one {{answer_25270156}} provided earlier; this can be a cell phone or an alternative house phone.)
 
Please provide THREE Emergency Contacts: *

NAME
RELATIONSHIP
DAYTIME PH. and CELL PH. Number
 
Who is AUTHORIZED to pick up {{answer_25270173}} ? *

Please choose from the provide Emergency Contact list.
 Or List all of New Contact's information (Name, Relationship, Phone Number(s))
 
Please fill out fields A - F, as they're required from all of our participants.

 
Are You and/or Your Child enrolled in Medi-Cal? *


 
{{answer_25270173}}'s Gender: *


 
{{answer_25270173}}'s Ethnicity: *


 
Check all that apply: *

*BYA must obtain verification or self-certification.

 
{{answer_25270173}} School (Under age 18 only): *

 
{{answer_25270173}} Grade (under age 18 only) *

 
PROGRAM INTEREST *


 
ATTENDANCE and REPORT CARDS (Under age 18 only)
In order for BYA to track our participant’s attendance and academic progress in school, we request attendance records and report cards from school. The information remains confidential within BYA and is only used to improve participant attendance and to develop individual academic plans. Please sign below to indicate that you give permission for BYA to obtain the participant’s attendance records as well as report cards, and to communicate with school staff about attendance and/or academic related issues.
*

I, (Parent/Guardian) {{answer_25270156}} hereby give my permission for (Participant’s school) {{answer_25270175}} to release the attendance records and report cards of (Participant’s name) {{answer_25270173}}{{answer_26257649}} to BYA.
     
 
Photo Release Authorization

I authorize BYA to publish photos, of my child or myself, participating in BYA program activities in BYA promotional or informational materials such as the newsletter, Annual Report, brochures, invitations, and the official BYA website.   Further, I do hereby for myself and for my heirs and assigns, on behalf of my child or ward or myself release and agree to indemnify and hold harmless BYA, its officers, agents, and employees from any liability, loss, claim, demand, action, or cause of action which arises or may arise or be occasioned in any way by such photos. *

I, {{answer_25270156}},  acknowledge that I have read this document and understand and accept its terms.
     
 
Waiver & Release

I, the undersigned, hereby authorize my child, ward, or myself, to participate in activities coordinated by BYA. I do hereby for myself and for my heirs and assigns, on behalf of my child, ward, or myself for his, her, or my heirs and assigns, release and agree to indemnify and hold harmless BYA and the City of Berkeley, their officers, agents, and employees from any liability, loss, claim, demand, action, or cause of action which arises or may arise or be occasioned in any way by such participation *

I, {{answer_25270156}},  acknowledge that I have read this document and understand and accept its terms.
     
 
Code of Conduct Agreement
By this application, you agree to abide by the Code of Conduct Agreement below.

-Each parent or guardian must SIGN OUT the participant with appropriate BYA staff.
-Absolutely no profanity, no fighting, nor disruptive behavior is permitted at BYA.
-Fighting will not be tolerated at BYA and will result in automatic suspension.
-Vandalizing or stealing BYA property or the property of others will result in AUTOMATIC DISMISSAL.
-No riding bicycles, skateboards, or skates inside the BYA facility.
-Running or yelling inside the BYA facility will not be tolerated.
-It is against BYA rules for any participant to leave the BYA facility once the participant has signed into BYA.
-BYA is not responsible for participants who leave designated areas of supervision without authorization.
-Participants should not bring anything of value to the BYA facility including but not limited to: basketballs, footballs, walkmen, watches, video games. BYA will not be responsible for the loss of these items or similar items.
-Participants are prohibited from using the Computer Lab without supervision.
-Participants are prohibited from going to the MySpace.Com website and will be barred from computer use if they access the site.
-Participants understand that if they are caught with alcohol or drugs that they will be automatically suspended from BYA. *

I, {{answer_25270156}},  acknowledge that I have read this document and understand and accept its terms.
     
 
Would you like a copy of this Program Application? *

A copy of this Program Application made be requested by the participant’s parent or guardian and by participants age 18 and over for record purposes.
     
Thank you,
You'll hear from us shortly and we look forward to meeting you soon!
-BYA
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