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BECOME AN LCYC MEMBER!
If you are between
12-18 years old
, we would love to meet you!
Please fill out the membership application and bring it with you to the Centre.
Youth Information
Please fill in all applicable spaces to the best of your ability. You must be between the ages of 12-18 years old to attend LCYC!
Youth Name
(Required)
First
Last
Age
(Required)
Birth Date
(Required)
Year
Month
Day
Health Care #
(Required)
Address
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Gender
School Name
Grade
Youth Cell Phone (if applicable)
Are you First Nations/Metis/Inuit?
Yes
No
Please identify any special needs your youth may have including physical, emotional, and/or behavioral conditions, allergies, or food restrictions. This information helps us to better meet the needs of your youth.
(Required)
Parent/Guardian Information
Youth Lives With
(Required)
Mother
Father
Both
Guardian
Other
Parent/Guardian Name
(Required)
First
Last
Relationship to Youth
(Required)
Address (if different than youth's)
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Primary Phone
(Required)
Secondary Phone (if applicable)
2nd Guardian Full Name (if applicable)
First
Last
Relationship to Youth
Address (if different than Youth's)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Primary Phone
(Required)
Secondary Phone (if applicable)
Emergency Contact Information (other than parent/guardian)
Emergency Contact Full Name
First
Last
Relationship to Youth
Phone
Secondary Phone (if applicable)
Youth's Physician's Name
Clinic Name
Program Consent
I, the parent/guardian of the above mentioned youth acknowledge the risks associated with my child participating in any events, programs, and activities scheduled with the Lloydminster Community Youth Centre (LCYC), a program of the Spark Foundation of Lloydminster (SPARK). SPARK is legally responsible to contact Child & Family Services if there are concerns for your child's safety or well-being. This includes information that is disclosed to staff by youth.
Please check off to indicate consent on the following:
I give permission to LCYC/SPARK staff to transport youth within the 50-km service area of Lloydminster. This includes rides home, rides to off-site trips & programs, and pickups from the schools.
Yes
I give consent for my child to be in pictures and/or audio-visual productions for promotion, advertising or fundraising activities unless otherwise stated. This includes LCYC and SPARK social media.
Yes
I agree that the Spark Foundation of Lloydminster is not responsible for illness or injury of my child or any loss to my child's property.
Yes
I understand my child will have access to various mental health supports & life skills development, including educational sessions and support provided by third parties such as Saskatchewan Health Authority, Alberta Health Services, etc.
Yes
LCYC Code of Conduct: Respect For All
Please read the following LCYC Code of Conduct rules
LCYC Code of Conduct: RESPECT FOR ALL
The staff and volunteers at LCYC strive to make our space and programs inclusive, safe and fun for everyone. Our core values are INTEGRITY, RESPECT, COMPASSION and ACCOUNTABILITY. The following requirements are in place to support youth while accessing programs at LCYC.
Signing In/Signing Out
All youth must sign in when they arrive and sign out when they leave. Once youth have used their allotted sign ins, they will not be allowed back in that night.
Accessing Items from LCYC
There is a 30-minute sign out time for electronics (gaming consoles and computers). If items are not returned in original condition, youth may lose sign out privileges.
Behavior Standards:
Ø Language
All language should be respectful, inclusive and appropriate for everyone at LCYC. If youth use profanity or derogatory language, staff will implement a 3-chance system. Staff have the right to ask a a youth to leave for the evening depending the situation.
Ø Tobacco & Vapes
There is a zero tolerance for tobacco use and vapes on LCYC property. LCYC property includes the front and fenced in areas around the building, the parking lots, the grass in front of the building and the LCYC van. Youth are required to leave LCYC property if they choose to use tobacco and nicotine products.
Ø Drugs/Alcohol
Use of any alcohol or drugs is not allowed on LCYC property. If youth are in possession of drugs or alcohol OR are suspected to be under the influence, staff have the right to ask the youth to leave the property immediately.
Ø Fighting/Bullying and Aggressive Behavior
Violent, aggressive, intimidating, or threatening behavior with the intent to harm is strictly prohibited at LCYC. Youth who engage in these behaviors will be asked to leave for the evening. The severity of the youth's behavior may result in suspension. Bystanders may also be asked to leave for the evening. RCMP may also be contacted at the discretion of the staff.
Ø Consent, Boundaries and Public Display of Affection
LCYC believes in having a culture of consent. Youth must respect other's boundaries and personal space. Public displays of affection are discouraged on LCYC property. Staff will address behaviors that make others uncomfortable.
Ø Weapons
Weapons are not permitted on LCYC property. There is zero tolerance for an obvious use of or threat to use a weapon. If necessary, the RCMP will be contacted to deal with the situation.
Ø Dress Code:
Youth are encouraged to dress in a way that demonstrates self-respect and respect for others. Offensive clothing or visible undergarments are not appropriate at LCYC. Staff will provide youth with alternative clothing or ask the youth to leave the Centre and change if the clothing is considered inappropriate for LCYC.
Ø LCYC Van:
Youth are REQUIRED to always wear seat belts while in the van. The LCYC Code of Conduct and consequences apply in the van. Food and drinks are not allowed to be consumed in the van.
Chances
When the LCYC Code of Conduct is not followed and behaviors compromise the physical and/or emotional safety of others, youth will be given three chances to change their problematic behavior. After three chances are used, staff will deliver reasonable and appropriate consequences that are proportionate to the youth's behavior. Staff retain the right to ask youth to leave without 3 chances when behavior may cause harm or affect the safety or well-being of anyone.
Staff will determine an appropriate length of time for the youth to take a break from LCYC. A parent/guardian will be contacted for suspensions that are a week or more. Following a suspension of a week or more, youth will be required to meet with staff to discuss the conditions of their return. Staff may request a parent/guardian to attend the meeting if determined necessary. A letter will be provided for suspensions that are a month or longer. A one chance probationary period may be implemented following a suspension.
LCYC Code of Conduct: Respect For All
(Required)
I acknowledge the LCYC Code of Conduct and agree to uphold it to the best of my ability.
I acknowledge and understand the implications of this consent form.
(Required)
Parent/Guardian
Youth Name
Youth Signature
Parent Signature
Parent/Guardian Name
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