LAYTFC

Thank you for your interest in the Koreatown Youth and Community Center's (KYCC) Los Angeles Youth First Tobacco Coalition (LAYFTC)! We are excited to have you join our team and work with us to improve the lives of our youth, families and community.

The purpose of this form is to enroll youth ages 0-17 into the LAYFTC program and it must be completed by all participants. Parent signature is required to finalize submission of this form. If the participant is 18 years of age or older, please complete this form.

Should you have any questions about completing this form or encounter any issues, please don't hesitate to contact Hadrian Panaroma hpanaroma@kyccla.org.

Thank you again and we look forward to working together!

Youth Participant Information

The following questions are for contact and demographic data collection purposes only. Your personal information is confidential and will not be shared outside the agency. When completing this form press and hold CONTROL to select multiple responses.

Youth Participant First Name

Youth Participant Last Name

Gender:

Youth Participant Date of Birth

MM/DD/YYYY

Youth Participant Phone

###-###-####

Youth Participant Email

Youth Participant Race/Ethnicity

Latino/Hispanic Ethnicity Breakdown

Asian Ethnicity Breakdown

Native Hawaiian/Other Pacific Islander Ethnicity Breakdown

If you speak any languages other than English, please include them here:

Other language (please specify)

Address

City

Postal Code

Parent/Guardian Information (primary contact)

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Phone

###-###-####

Parent/Guardian Email

Parent/Guardian Address (if different from above)

City

Postal Code

Household Size

# of people living in your home (family and non-family)

Household Income

Emergency Contact (must be different than parent/guardian)

Emergency Contact First Name

Emergency Contact Last Name

Phone

###-###-####

Address (if different from above)

City

Postal Code

Media Consent

I hereby grant to KYCC the unqualified and perpetual right to use, and consents to the use of, the name and likeness of the above named child in connection with KYCC’s activities of the photographs, worldwide and in any and all media, including, by way of illustration, but not limitation, the display of still photographs, the inclusion on the World Wide Web and the preparation and dissemination of any advertising and promotional materials used to promote KYCC. As consideration for participating at the Koreatown Youth and Community Center, I hereby agree that I, and my assignees, heirs, guardians, and legal representatives, will not make a claim against or sue Koreatown Youth and Community Center or its employees, agents or contractors for injury or damage resulting from the negligence, whether active or passive, or other acts, however caused, by any of its officers, employees, agents, or contractors of Koreatown Youth and Community Center as a result of my child’s participation.

YES, I give my permissionNO, I do not give my permission for my child to appear in agency media

Acknowledgment of Handbook Receipt

I acknowledge that I have received a copy of KYCC’s Volunteer Handbook dated February 2009. I understand that the statements contained in this Handbook are guidelines concerning some of KYCC’s policies and procedures, and do not create any contractual or other legal obligations. I have read and I understand the contents of these policies, and I have been given the opportunity to ask any questions I might have about policies that I did not understand. I recognize that this Handbook cannot anticipate every situation or answer every question about my participation in the Volunteer Program by KYCC. I understand that KYCC reserves the right to change or revise all or any portion of this Handbook – without advance notice and at any time that KYCC, in its sole discretion, deems such change or revision appropriate or necessary.

Yes, I have received, read and understand the KYCC Volunteer Handbook.No, I have not received, read or do not understand the KYCC Volunteer Handbook.

MANDATED REPORTING AGREEMENT AND RELEASE FROM LIABILITY

Mandated Reporting: I understand that all KYCC staff are mandated reporters by California Law, and as long as staff have reasonable suspicion that minors under the age of 18 have been victims of physical abuse, sexual abuse, emotional abuse or neglect, they are required to report these cases to the proper authorities.

Liability:

I, the Undersigned, am the parent or guardian of the above-named child and wish to allow my minor child to participate in programs with the Koreatown Youth and Community Center (KYCC). I understand that my child will not be compensated for any time spent volunteering, nor are they entitled to benefits, including employment insurance benefits upon the termination of this agreement or as a result of this service. I am aware that my child’s participation may require periods of contact with community members and other participants, and other potential risk of injury and will require the exercise of reasonable care to avoid injury. I am voluntarily allowing my child to participate in this activity with knowledge of the hazards and potential dangers involved, and agree to accept any and all risks of personal injury to my child and property damage.

I hereby consent to the use of my child's work products, photos, videos, writing and other creative materials (e.g., volunteer-created projects and artwork) by KYCC . I also grant KYCC the right to edit, use, and reuse said products for nonprofit purposes, including but not limited to, use in print, on the internet, audiovisual presentations, promotional literature, advertising, community presentations, and all other forms of media, without financial compensation and in perpetuity. I also hereby release KYCC and its agents and employees from all claims, demands, and liabilities in connection with the above. I understand that said products may appear in electronic form on the Internet or in the public, and I agree that I will not hold KYCC responsible for any harm that may result. I am aware that any withdrawal of this consent must be submitted to KYCC staff in writing prior to any planned use.

As consideration for volunteering for Koreatown Youth and Community Center, I hereby agree that I, and my assignees, heirs, guardians, and legal representatives, will not make a claim against or sue Koreatown Youth and Community Center or its employees, agents or contractors for injury or damage resulting from the negligence, whether active or passive, or other acts, however caused, by any of its officers, employees, agents, or contractors of Koreatown Youth and Community Center as a result of my child volunteering. I HEREBY RELEASE AND DISCHARGE KOREATOWN YOUTH AND COMMUNITY CENTER AND ITS OFFICERS, EMPLOYEES, AGENTS AND CONTRACTORS FROM ALL ACTIONS, CLAIMS, OR DEMANDS THAT I, MY HEIRS, GUARDIANS, AND LEGAL REPRESENTATIVES NOW HAVE, OR MAY HAVE IN THE FUTURE, FOR INJURY OR DAMAGE RESULTING FROM MY CHILD'S PARTICIPATION IN THE PROJECT.

I UNDERSTAND THAT IF I AM INJURED IN THE COURSE OF THE PROJECT, I AM NOT COVERED BY KOREATOWN YOUTH AND COMMUNITY CENTER WORKERS’ COMPENSATION PROGRAM. I authorize Koreatown Youth and Community Center to seek emergency medical treatment on my behalf in case of injury, accident or illness to me arising from my involvement as a volunteer. I understand that I will be responsible for medical costs incurred by such accident, illness or injury.

YES, I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY, AND SIGN IT OF MY OWN FREE WILL. This release, its significance, and assumption of risk have been explained to and are understood by the minor.

Contact Information