Student Application

Please fill out the form below. All information is strictly confidential and private. Program duration includes February, March, April, and May. Must attend at least 75% of programming activities.

*Orientation is required for students and parents.

Students must be enrolled in a local high school, grades 9 through 12, or be homeschooled.

Student's Information

First Name

Last Name

Preferred Name

Birthday

Student's School Email

Student's Cell Phone

Student's Personal Email

Explain

Student's School

Home Address

Street Address

State

City

Zip code

1. Parent/Guardian Name

First

Cell Phone

Last

Work Phone

2. Parent/Guardian Name (optional)

First

Cell Phone

Last

Work Phone

How did you hear about us?

Member Benefits Include:

Access to all programming activities
Name badge
Leadership roles
Field trips fee coverage
Hands-on training
Access to special resources
Light snacks and food

To qualify for programs/events at Tyler's House KC, students must meet the criteria listed above. We reserve the right to deny services at any time based on any of the aforementioned eligibility requirements or for any other reason, including the actions/inactions of the student, parent, or guardian. These eligibility requirements are subject to change without notice.

Interests & Activities

Personal Goals

Please read each student code agreement

Respect:

I will honor Tyler's House KC and other's space and property by treating others the way I want to be treated
I will promote kindness and encourage others, rather than put them down with hurtful comments.
I will avoid horseplay and intimate contact while at Tyler's House KC
I will respect Tyler's House KC staff and volunteers by giving them my full attention when asked

Responsibility:

I will promote an alcohol, tobacco, drug, and violence free environment at Tyler's House KC activities
I will use appropriate language at all times while at Tyler's House KC
I will be responsible for my actions and attitude by being open and teachable
I will help keep Tyler's House KC clean and accessible to all

Participation:

I will attend the events I sign up for and I will let Tyler's House KC know 24 hours in advance if I cannot attend
I will remain in the immediate area of the event for the entirety of the event unless I have communicated with staff and my parent(s), and I have received permission to leave

I agree and commit to the Student Code above for Respect, Responsibility and Participation.

I commit to these Agreements and I understand attendance at Tyler's House KC is a privilege and voluntary. Tyler's House KC reserves the right to contact the student’s parent(s)/guardian and/or the authorities as appropriate for the situation.

Student Signature

Name

Sign

Thanks for completing the Student Application! Your Parent/Guardian will receive an email with permission forms they need to complete for you to attend events at Tyler's House KC.

Safe, creative spaces for students in grades 9 through 12