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JU4Y Program Packet
Just Us 4 Youth is a 501(c)3 nonprofit organization. Our mission is to mentor at-promise youth to be better students, better people, and better leaders. By filling out this packet, I give my child permission to participate in Just Us 4 Youth programs and activities. Throughout the programs, data will be collected in an effort to evaluate and continue improving the Just Us 4 Youth programs. Your child's name will never appear on the data given to outside partners or agencies. Signing this form also permits Just Us 4 Youth to use pictures of your student for promotional purposes. Please feel free to check out our website for more information: or contact us at

I do desire for my child to participate in Just Us 4 Youth programs and I agree to allow access to their academic progress. I understand that anonymous statistical data will be collected to assist in evaluating the program. *
Parent's or Legal Guardian's Name *
By typing your full name below you are digitally signing this agreement with all statements above.
 Parent's or Legal Guardian's Email Address *
 Parent's or Legal Guardian's Phone Number *
Relationship to Child *
Participant's Name *
By typing your full name below you are digitally signing in agreement with all statements above.
Participant's Date of Birth *
School Participant Attends *
Today's Date *
Group Contract
I will attend all group sessions unless a teacher has requested that I remain in the classroom, or I am absent from school with parental permission.

I will keep all electronic devices such as cell phones, chrome books, air pods in my backpack at all times, unless stated otherwise.

I understand that trust will be built in one another slowly.

I will guard things shared by leaving group discussions in the group and will not discuss others’ words outside of the group session.

I pledge to deal with broken commitments in the group and not outside of the group. If someone does break this contract, I will tell a mentor and wait for instructions from the mentor before discussing it with others in the group.

I pledge to be honest with others in the group.

I pledge to keep a judgement free environment.

I pledge to participate in the group by being an active listener.

I pledge to be respectful when others are speaking.

I will keep my hands to myself and respect the personal space of others.

I pledge to learn and grow while in the group. I will tell the mentor if I am having difficulty avoiding risky behaviors and keeping this commitment so that they can assist me.

I will tell my mentor if thinking about topics discussed during group begins to cause me great pain emotionally.

I understand it is a privilege to be in this group and therefore pledge to show leadership in my school by respecting parents/guardians, teachers, admin, and students.

All group members are entitled to their own opinions and beliefs. As a member, I will respect the rights of those who believe differently than I do.
Participant's Name *
By typing your full name below you are digitally signing in agreement with all statements above.
Parent or Legal Guardian Name *
By typing your full name below you are digitally signing in agreement with all statements above.
This is the participant code of conduct contract for Just Us 4 Youth Programs. During JU4Y events, JU4Y is committed to providing a positive environment that is highly relational, diverse, and focused on mentoring and building community. Our core values include respect, integrity, responsibility, accountability, and open-mindedness. Being a part of this program has many benefits and privileges. Participants are expected to adhere to the culture established by JU4Y. At the same time, JU4Y staff, volunteers, and parents are expected to fulfill certain responsibilities and obligations including complying with state law, maintaining a safe environment, and keeping the roads of communication open with respect and kindness.
Participants are valued at JU4Y. Each person is expected to behave appropriately in any setting, both private and public. Participants are to listen, respect and obey the guidelines and expectations. Looking out for the safety of others and having good judgment should always prevail. Students are expected to respect property, others, and themselves. If the code of conduct is not followed, appropriate action or consequences will be determined based upon the severity and/or consistency of the infraction. This may include restorative practices and/or up to removal from the program.
● Respect yourself and others

● Respect the property associated with all JU4Y event locations

● Keep words discussed within group settings confidential and do not spread sensitive information

● Understand that all group attendees may have different opinions and beliefs than you do. As a member, you are to respect the rights of others that believe differently than you do

● Keep your hands to yourself and respect the personal space of others

● Pledge to learn and grow while at JU4Y events

● Do not use drugs (including tobacco) or alcohol and do not participate in gang-related activities. Tell the group leaders if you are having difficulty avoiding risky behaviors and keeping this commitment so that they can assist you

● Do not show up to JU4Y events drunk or high. If there is probable cause you may be searched and asked to leave. You may be asked not to return that night or future JU4Y events. The student may be given an opportunity to restoratively mend what was broken

● Do not bring weapons to JU4Y events

● Students are expected to engage and participate in the event’s agenda and not opt out. Never walk away during or after an activity or event without communicating with JU4Y staff

● During JU4Y events, do not show public displays of affection with anyone. This includes, but is not limited too, holding hands, hugging, and closeness (like sitting next to each other in small spaces). Generally, keep your hands to yourself and respect personal space. JU4Y events is not the place to hook up, making out, or meeting up with someone for the sole reason to flirt or to be inappropriate. The JU4Y events environment and culture are designed for individual/community learning, growing, serving, and engaging

● Make every effort to sign up correctly, indicate if a ride is needed or not, and be punctual

● Notify a mentor or supervisor if you cannot attend an event after signing up

● In the case that an event fills up do not assume you are allowed to show up/participate at JU4Y events. Always communicate with the Program Supervisor and accommodations may be possible.

● Theft or vandalism will not be tolerated

● Avoid any abusive action or conduct, or language in relation to other students, volunteers, parents, or staff -- demonstrate good character at all times

● Avoid any activities or jokes that may endanger the safety of others

● Do not leave designated areas during retreats, camps, events, or outings unless previous arrangements are made and are approved by a supervisor

● Observe the regulations and curfews established by your mentor or supervisor
The simple rules of thumb when posting information on Social Media is to be respectful of others. We want people to have a positive experience while at JU4Y events. JU4Y prides on uplifting and bringing the community together. Anything that supports this goal is encouraged, provided it complies with the following terms of reference:

● You recognize that the public may view all online submissions

● Keep all comments clean

● Do not defame, abuse, harass, stalk, threaten or violate the privacy of others.

● Do not impersonate any other person or misrepresent who you are or your affiliation

● Do not violate the law or encourage illegal activities in connection with JU4Y

JU4Y reserves the right to suspend your ability to attend any JU4Y events if guidelines are not followed.
● Maintain distances required per social distancing protocols

● Wear face coverings where required

● Wash your hands and refrain from touching others

● Some events may require temperature checks

● If you are sick or have a fever stay home
Procedures for dealing with minor infractions shall be informal and determined by JU4Y. The student being disciplined must be told the nature of the infraction and must have an opportunity to provide information concerning the incident. Discipline could include temporary suspension to restorative justice acts (righting wrongs) (i.e. responsibility for actions, meeting with others involved, community projects and anything else determined by JU4Y).

● A single incident of disrespectful, offensive, abusive, racist or sexist comments or behavior directed towards others
● A single incident of unruly conduct such as angry outbursts or arguing
● A single incident of falsely signing up for an event and then being absent from events or activities at which attendance is required without reason
● A single incident of any violation of the code of conduct section indicated above
Disciplinary actions for major infractions are determined by the supervisors of JU4Y, with input from the staff. Written documentation of the infraction and subsequent recommended disciplinary action must be supplied to the JU4Y Mentor Supervisor and the offending student. The student has the opportunity to provide written information concerning the incident to the Mentor Supervisor. Discipline could include significant suspension to the permanent removal of the student from JU4Y programs.

Examples of Major Infractions
● Repeated incidents of disrespectful, offensive, abusive, racist, or sexist comments or behavior directed towards others
● Repeated unruly conduct such as angry outbursts or arguing.
● Repeated incidents of being absent from events or activities, falsely indicating attendance, at which attendance is required.
● Repeated curfew and safety violations (such as leaving event sites without communication)
● Activities or behaviors which interfere with the event or with partners of JU4Y or other student’s participation
● Pranks, jokes, fighting, or other activities that endanger the safety of others
● Consumption of alcohol, illicit drugs, or use of narcotics.
● Any acts of vandalism or theft
● Repeated acknowledgement of carrying weapons
I understand that it is a privilege to be a participant in JU4Y programs. I agree with the code of conduct and will do my best to follow the code. I understand that by breaking the code, there will be consequences that may include dismissal from the program. I agree to take full responsibility for my actions. *
Participant's Name *
By typing your full name below you are digitally signing in agreement with all statements above.
Parent's or Legal Guardian's Name *
By typing your full name below you are digitally signing in agreement with all statements above.
Today's Date *
Just Us 4 Youth will provide transportation to participants who are in need of transportation to JU4Y sponsored events by licensed, insured, and background checked staff and volunteers.

● COVID Update: Each participant and their designated guardian will be required to fill out and sign the COVID-19 form. The maximum capacity of the vehicle will be determined on the number of seatbelts minus two (2). Example: If a car has 5 working seatbelts, max occupancy will be 3. Seating arrangements will be spaced out in accordance with social distancing guidelines. Passengers are responsible for sanitizing their seat with the provided disinfectants prior to getting in and before leaving the vehicle. Temperature checks will be implemented in addition to wearing masks as a mandatory precaution.

● Events: Outside of the first student being picked up and the last to be dropped off, it is JU4Y’s best practice to always have more than one student in the vehicle with one staff member or volunteer. Best practices are two adults per one minor in the vehicle, or having more than one student per one adult driver. The driver should plan pickup and drop off routes based upon achieving this ratio rather than convenience.

● Cross Gender-Mentoring: At no time should a mentor pick up a mentee unless more than one adult or student is present. The mentor must meet in public.

● In the case where a staff or a volunteer is alone with a student upon first pick up or last drop off, the adult must communicate this to another adult staff via text or SLACK and is considered to be only in an emergency or in extreme measures.

● Any vehicle transporting youth, must have enough functioning seat belts for everyone in the vehicle and everyone, including the adults and youth must wear a seatbelt.

● No driver can be sleep deprived, consume any alcohol or drug of any kind that can affect their physical or mental performance (even if prescribed by doctor) during or before carrying out their duties as a driver.

● Only students that have a signed permission slip AND a program packet on file may be transported by a JU4Y staff and/or its volunteers.

● Transportation will be provided by a JU4Y vehicle only to events and to no other location on the way. Students must be dropped off at home or an approved place (such as a relatives home or school site). Under no circumstances may a student be dropped off in a non-approved location that can be deemed as an unsafe environment.

● No electronic devices may be utilized by the driver while driving the vehicle, unless in the case of an emergency.
Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to [Just Us 4 Youth] and its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet). This consent includes, but is not limited to: (a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice; (b) Permission to use my name; and (c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines, and other print media, on television, radio and electronic media (including the Internet), social media, in theatrical media and/or in mailings for educational and awareness. This consent is given in perpetuity, and does not require prior approval by me.

Instagram: @justus4youth
Facebook: Just Us 4 Youth
Twitter: @Just_Us_4_Youth
Participant's Name *
By typing your full name below you are digitally signing in agreement with all statements above.
Parent's or Legal Guardian's Name *
The below signed parent or legal guardian of the above-named minor child hereby consents to and gives permission to the above on behalf of such minor child. By typing your full name below you are digitally signing in agreement.
Today's Date *
I give permission for my child to attend JU4Y events and special outings. I give permission for my child to be transported by JU4Y staff and/or volunteers via JU4Y vehicles and agree to the rules and regulations as laid out by the JU4Y Transportation Policy. By signing this, I understand that all trips are separate from my child's school district.

In consideration of my signature on this permission slip for field trips/activities, I hereby for my child, their representatives, guardians, heirs, executors, and administrators, waive and release forever any and all rights, claims and damages, they may accrue against Just Us 4 Youth representatives while participating in field trips, activities on and off site events. I give permission to authorize emergency medical treatment for my child.
Participant's Name *
By typing your full name below you are digitally signing in agreement with all statements above.
Parent's or Legal Guardian's Name *
By typing your full name below you are digitally signing in agreement with all statements above.
Does your child have any food allergies/dietary restrictions? *
If yes, please list:
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