Charlottesville, VA

Applicant Information

The Community Attention Youth Internship Program (CAYIP) Application
Section 1 of 3
Please note:
A completed CAYIP application packet consists of three parts: the CAYIP Application, the CAYIP Agreement to Participate, and the Youth/Guardian Expectation Form. This is section 1 of 3.
If you have any questions during the process, please feel free to reach out to us at CAYIPInquiries@Charlottesville.org.
Name of Applicant*
Physical Address*
City
State
Zip*
Mailing Address (if different than above).
City
State
Zip Code
Resident of: *
1. Charlottesville
2. Albemarle County
3. Other
Current School: *
Youth Phone Number
Youth Email Address
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Parent/Guardian Contact Information

Parent/Guardian Name(s): *
Email Address
Parent Phone Number *
Parent Phone Number
Alternate number
Emergency Contact Name*
Someone other than parent/guardian who can respond in an emergency.
Relationship to Youth
Emergency Contact Phone Number*
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Applicant Demographic Information

Applicant Section

Applicant Interest Survey

Parent Section

12. Does Your Child Require Any Special Services Or Benefit From Additional Supports? *
1. Yes
2. No
This can include behavioral, emotional, physical or health needs. If your child has an IEP or benefits from other modifications and supports, please specify.
12a. If Yes, Please Provide Additional Information So We Know How to Help Set Your Child Up For Success.
13. Does Your Child Have Any Allergies, Medical Conditions, Or Limitations On Activities? *
1. Yes
2. No
13a. If Yes, Please List
14. Does Your Child Carry A Rescue Medication Such As An Epi-pen Or Inhaler? *
1. Yes
2. No
14a. If So, Please List:
15. Does Your Child Take Any Medication? *
1. Yes
2. No
15a. If So, Please List
16. Preferred Emergency Room:
17. Permission for Emergency Treatment : The parent or guardian of the forenamed participant authorizes the staff of Community Attention to obtain immediate medical or dental care and consents to the hospitalization of, the performance of diagnostic tests upon, the use of surgery on, and/or the administration of drugs to his/her child or ward if an emergency occurs when he/she cannot be contacted immediately. This covers only true emergencies, and every effort will be made to contact parent/custodian immediately. I have been informed and understand that I will be involved in decisions regarding my medical care. Any refusal of medical care must be made in writing. Finally, my signature on this form acknowledges that I was given a copy of this consent for my own records.
Parent/Guardan Signature And Date*
Youth Signature And Date*
18. I Read The Youth and Guardian Expectation Form And Understand These Expectations
Parent/Guardian Initials*
Youth Initials*
19. I Certify That The Information On This Application is Accurate And Complete
Parent/Guardian Signature And Date*
Youth Signature And Date*

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1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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