Parent/Guardian Intake Form
The following form is for Parents/Guardians of youth attending programs at OUTright Youth of Catawba Valley's primary location in Hickory, North Carolina or our satellite location now located in Caldwell County, North Carolina. This includes basic information--names/birthdays, how best to contact parents/guardians, emergency contact information, any relevant medical/allergy information about the youth, and questions regarding photography/video wavers and permissions to add members to our private Discord server. Please read and fill out these forms carefully.

If the center is ever closed or a program is canceled, the listed contact will be notified using the information below. If there is an emergency on the premises, we will use the emergency contact information provided here.

If you have any questions or concerns, please email our Executive Director, Kim Bost at director@outrightyouthcv.org

Filling out this form indicates that you have read and agreed to the following rules for the OUTright Youth Center:


OUTright Youth Rules/Norms (For Youth and Adults)

  1. Respect the space and each other.

    1. No throwing things at each other.

    2. No running/horseplay.

    3. No defacing property (artwork, stickers, paint, etc.)

    4. Be courteous and attentive with our guests. They are professionals who volunteer their time and talents to come share with us.

    5. Remain in our center during group and exit only through front doors (do not access back doors or alarm will go off.)

  2. Keep discussions PG rated. We have a wide range of age groups present at most times, and need things to be appropriate for ALL ears.

  3. No outing, ever. What happens at ORY stays at ORY and is private.

  4. Speak for yourself - use “I” statements whenever possible in discussions. Everyone is different and deserves to have their opinion and experiences heard and understood.

  5. No social media connections between staff/volunteers and youth, except in group format for our private Discord server. No personal "friending" on Discord between staff/volunteers and youth. See staff to join our Discord server or learn more, with parents’ permission.

  6. Adult supervision is required at all times except for using the restroom, and ONLY ONE PERSON IN THE RESTROOM AT A TIME. No exceptions. 

    1. During a private discussion with an adult, another adult should be present as a witness.

    2. During group, youth must remain in line of sight to at least 1 adult at all times (except when using the restroom.)

  7. Quiet Room: 1 person per quiet room, no exceptions. If an adult is needed in the quiet room, 2 adults must be present with the youth.

  8. No PDA. This is a youth center for community, not a place for dating. Please respect each other and each person’s personal space.

  9. Cleanup: ALL staff, volunteers, and youth should participate in cleanup at the end of each group:

    1. Recyclable plastic, glass, and cans should all go in the sink to be rinsed and dried. If you are unsure what is recyclable, ask an adult. Cardboard and paper should go directly in the recycling bins.

    2. Trash Sweep: Everyone is responsible for the space. When cleanup time is announced, please do a sweep for trash/recyclables in your immediate area (within 10 foot radius). 

    3. Put away whatever you have gotten out. If you are using craft supplies for a group activity, help the staff/volunteers put away the supplies. 

    4. Cleaning surfaces: please wipe down tables and countertops that have been used during group with antibacterial wipes.

  10. Vacuuming: One adult should vacuum the floors after each group.

  11. If you need help with anything, including understanding these rules, ask an adult, particularly the Executive Director.

  12. Failure to follow these rules for a youth will result in a call for parent/guardian to immediately pick you up and you will be restricted from attending the following week. Continued failures to follow the rules will result in being uninvited to the group for the foreseeable future.

    Failure to follow the rules as staff/volunteer will be dealt with immediately by the Executive Director.

HAVE FUN, BE YOURSELF, SPREAD JOY.  😊

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Email *
Youth Full Name *
Youth Birthdate *
MM
/
DD
/
YYYY
Parent/Guardian #1 Full Name *
Parent/Guardian #1 Email Address *
Parent/Guardian #1 Phone Number *
Parent/Guardian #1 Mailing Address (Please include city/town) *
Parent/Guardian #1 Physical Address (If different from above) *
Do we have permission to contact Parent/Guardian #1 via the following? (Check all that apply) *
Required
What is the best way to communicate with Parent/Guardian #1? *
Parent/Guardian #2 Full Name
Parent/Guardian #2 Email
Parent/Guardian #2 Phone Number
Parent/Guardian #2 Mailing Address (If different from above)
Parent/Guardian #2 Physical Address (If different from above)
Do we have permission to contact Parent/Guardian #2 via the following? (Check all that apply)
What is the best way to communicate with Parent/Guardian #2?
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Does your child have any allergies or medical conditions that may affect their time at ORY? If so, please list them here. *
Do the above allergies/medical conditions require medication or special attention? If so, please list any medications or aid they may need access to here.
Name of Emergency contact for youth while at ORY *
Emergency Contact Phone Number *
Do you consent to your child being photographed or recorded while at the ORY center, exclusively for use by ORY? These might be shared on our website, social media, and other outlets for promotional or grant proposal purposes. *
Do you agree to your child joining the ORY private Discord server? Only youth and staff have access to it, there is no private messaging except to staff, and posts include what we are doing for programs every week, as well as community resources from other groups. Our server is highly monitored by staff and any violation of the rules will be met by being banned from the server. *
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