BTO Participant Registration
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Do you agree to follow the rules listed below? *

Our rules center on RESPECT - respect for yourself, respect for ALL others, respect for the space. 

Our center uses a three warning system to help you follow the rules.  

  • Warning 1:  You’ll be reminded of the rule and asked to stop.
  • Warning 2: You’ll be reminded that this is your second warning and that next warning is your last.
  • Warning 3: You’ll be reminded that this is your last warning and that it's to leave for the night and cannot return until the next day

.Behaviors that warrant a warning:

  • Horseplay
  • Bullying
  • Disrespect of anyone in the space (language, behavior, etc.)    
  • Throwing supplies around the space
  • Destructive Behavior
  • Excessive PDA (sitting on each other, making out) 
  • Entering spaces that are off limits
  • Not allowing others to participate 
  • Repeatedly going in and out of the building - if you are outside, it is for programming only

Behaviors that will get you kicked out of BTO IMMEDIATELY:

  • Three warnings
  • Possessing drugs of any kind
  • Physical altercations
  • Smoking or vaping
  • Bringing weapons into the space

First Name *
Last Name *
Street Address *
City *
State *
Zipcode *
Your phone number *
Your email *
Your Birth Date *
MM
/
DD
/
YYYY
Gender Identity *
If you selected "prefer to self-describe", please share that information here.
Preferred Pronouns *
Ethnicity - select all that apply *
Required
Ethnicity continued - if you answered mixed ethnicity/other above, please describe.
Do you attend a Pittsburgh Public School? *
Name of the school you're attending this year *
Grade your currently in *
Are you a part of the free lunch program at your school? *
Parent/Guardian #1 First Name *
Parent/Guardian #1 Last Name *
Is this person your emergency contact? *
Is the person the head of your household? *
Where do you live? *
Number of children under 18 living in home *
Relationship *
Cell Phone *
Home Phone *
Email
Parent/Guardian #2 First Name
Parent/Guardian #2 Last Name
Relationship #2
Clear selection
Cell Phone #2
Home Phone #2
Email #2
Additional Emergency Contact NAME (if different from above)
Additional Emergency Contact PHONE NUMBER (if different from above)
Are there any people that are not permitted to pick you up?
Are you permitted to walk home? *
Do you have any of the following health conditions? (Check all that apply) *
Required
Are you taking any medications? *
If you answered yes, please list the medications you currently take.
Please list any medication allergies that you have.  If you don't have any, write none. *
Please list any food allergies that you have.  If you don't have any, write none. *
Please list any general allergies that you have.  If you don't have any, write none. *
Do you like to participate in physical activities? *
Do you have any of the following? *
Required
Do you currently receive counseling services here or anywhere else? *
Are you interested in receiving counseling services? *
Do you permit BTO staff/interns/volunteer to take your photo?  Most photos do not include your face or other identifiable traits unless you and your parents have signed written consent. *
Can we use these image in social media posts and on our website? Again, We make every effort to not include your face or other identifiable traits for your safety. *
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