Community Evening Resource Center (CERC)-Registration form

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This form is for youth ages 10-17

The purpose of the CERC is to provide a safe space for teens to gather 7 days a week, during evening hours to reduce curfew violation & for safety concerns due to the surge in youth violence. We are open from 6PM-2AM for, but not limited to walk-ins and curfew violation drop offs (police transports), We provide full evening programming, family supports, nightly meals, snacks and transportation home.

*Pleas complete this registration form and one of our CERC staff will make outreach

Email *

Record my email address with my response

Name of the person completing the registration form *

Phone number of the person completing the registration form

Email of the person completing the registration form
*

Relationship to child *

Staff

Parent/Guardian

Other

Name of youth being registered *

DOB *

YYYY

Are you interested in transportation for youth being registered? If yes, answer the next 2 questions *

yes

My child has permission to use other means of transportation: Uber, Lyft, bus, train, etc...

Required

Please select preferred drop off time (this is the default time and can only be changed if a parent gives permission)* drop off times are the time the youth will leave the program. We can not determine an exact arrival time. *

8:00-8:30PM

9:30PM

Required

Please use this section to add important information (allergies, behavior concerns, probation status (if applicable), etc...

Submit

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