Community Evening Resource Center (CERC)-Registration form 
This form is for youth ages 10-17
The purpose of the CERC is to provide a safe space for teens to gather 7 days a week, during evening hours to reduce curfew violation & for safety concerns due to the surge in youth violence. We are open from 6PM-2AM for, but not limited to walk-ins and curfew violation drop offs (police transports), We provide full evening programming, family supports, nightly meals, snacks and transportation home.  

*Pleas complete this registration form and one of our CERC staff will make outreach
Email *
Name of the person completing the registration form *
Phone number of the person completing the registration form
Email of the person completing the registration form
Relationship to child *
Name of youth being registered *
Are you interested in transportation for youth being registered? If yes, answer the next 2 questions *
Please select preferred drop off time (this is the default time and can only be changed if a parent gives permission)* drop off times are the time the youth will leave the program.  We can not determine an exact arrival time. *
Please use this section to add important information (allergies, behavior concerns, probation status (if applicable), etc...
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy