FY27 Youth Education Application

Youth Education

2027 General Application for Services
Prior Student
Student Name

First NameLast Name
Date of Birth

MonthDayYear
ASD School
School Name
If your student is not enrolled in an Anchorage School District school (ASD) please indicate where your student attends school.
Grade Enrolled for school year 2026/2027
Is student enrolled in Title VI?
Does your student receive free or reduced lunch, SNAP or TANF?

Student Health Information
Do you have a preferred doctor?
Physician Name

First NameLast Name
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you have a preferred hospital?
Hospital Name
Health or Physical Condition (This Includes Allergies/Seasonal Allergies)
Please Indicate Here
Does your child require prescription or over-the-counter medication during program hours? (Include medication that is on a "as needed" basis)
Please describe what is it and the dosage
If your child has medication needs (prescription or over the counter) please email yesdept@citci.org.
Is there anything we should know that helps your child feel comfortable and do their best when they're in a group setting, working on their own, or adjusting to new environments? (Optional)

Home Room Teacher
Is your student less than 57 inches (4 feet 9 inches) and weighs less than 65 pounds, or is between 4-8 years old?
CITC follows the guidance of Alaska safety laws. Per Alaska State Law and DMV Regulations, children between 4-8 years of age or who weights 20-65 pounds and is less than 57 inches (4 feet, 9 inches) shall be properly secured in a booster seat that is secured by a seat belt system or by another child passenger restraint system that meets or exceeds the standards of the U.S. Department of Transportation and is used in accordance with the manufacturer’s instructions.
What is your purpose in applying for participation in the Program? (Optional)
Will your student be able to walk home? If your child is not allowed to walk home, only the guardians or authorized pick-up indicated on this form will be allowed to pick up the student
Please note that elementary students who attend programs or camps at our facility will not be allowed to walk, regardless of parent permission (the ONLY exception is when the elementary program is located at the school they are attending).
The following information is necessary for various funding and reporting obligations.
Is your student Alaska Native and/or American Indian?
K-12 Education
Participant Gender
Participant Education Level

Parent /Legal Guardian Information

Please Note: Application must be completed by a parent/legal guardian.
Primary Guardian

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Preferred Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Guardian Email
example@example.com
Would you like to be able to receive SMS messages from CITC Denełchin Lab
Please Note: By submitting this form you agree to receive calls, text messages, and/or emails from CITC and affiliates at the phone number and/or email you have provided. These communications may be for informational or service-related purposes. My consent is not required to receive services from CITC. Message and data rates may apply for text messages. The frequency of messages may vary. I can revoke this consent at any time by contacting CITC at 907-793-3600 or toll-free at 877-985-5900. This consent applies to the phone number and/or mail I have provided, even if it is registered on any state or federal Do-Not-Call list. CITC may use automated technology to place calls or send text messages to me.
Is there a 2nd Parent / Legal Guardian?
Secondary
Secondary Legal Guardian

First NameLast Name
Secondary Preferred Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name (other than parent and legal guardian listed above). Please note that this contact is not authorized to pick up your student unless it is an emergency.

First NameLast Name
Emergency Contact Information
Please enter a valid phone number.Format: (000) 000-0000.
Authorized pick Contact Name (Other than parent or legal Guardian listed above)

First NameLast Name
Authorized pick Contact Information
Please enter a valid phone number.Format: (000) 000-0000.

Participant Documents
To Complete Enrollment with Cook Inlet Services – Youth Education Programs

To fully enroll your participant in Cook Inlet Tribal Council's Youth Education (YE) programs, we require the following documentation:

1.) School Verification

To confirm school enrollment, please submit one of the following:

A screen shot of demograph information provided on the homescreen of Q.
A current class schedule showing the student’s name and term.
Please use the upload button below to attach all required documents. If you have any questions or need support, feel free to reach out.
School Verification

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To Complete Enrollment with Cook Inlet Services – Youth Education Programs

To fully enroll your participant in Cook Inlet Tribal Council's Youth Education (YE) programs, we require the following documentation:

1. General Elgibility
Our programs require verification of Alaska Native/American Indian heritage. Please upload a document showing your student’s Tribal Enrollment or other eligbility documents.

2. Birth Certificate or Certiificate of Adoption
This allows us to confirm that you are the participant’s legal guardian.

3. School Verification

To confirm school enrollment, please submit one of the following:
- A screen shot of demograph information provided on the homescreen of Student Connect.
- A current class schedule showing the student’s name and term.
Please use the upload button below to attach all required documents. If you have any questions or need support, feel free to reach out.
File Upload

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Are you enrolled in an Anchorage School District (ASD) school?
Verification of Residency Needed:
Per Cook Inlet Tribal Council Policy all participants must reside in the Municipality of Anchorage to receive services. Accepted documents include:
- Signed rental or lease agreement
- Property deed or mortgage document
- Utility bill (including cell phone)
- Employment verification (on letterhead)
- Insurance documents (health, home, vehicle, etc.)
- Government-issued tax document
- Bank statement
- Voter registration confirmation
- Proof of resident tuition at a public Alaska institution
- Letter from shelter, nonprofit, employer, or agency confirming Alaska residency
- Alaska vehicle title or registration
- USPS change of address confirmation
- First-class mail with postmark (handwritten)
Please upload proof residency below:

Cancelof

Release of Student Records
CITC collects participant information to support grant requirements and evaluate program impact. This data is often necessary for the grants that fund Youth Education programs. Do you consent to sharing this information with CITC?
Please Note: If you select "No," CITC staff will not have access to your child's grades or attendance information. This will limit our ability to monitor their academic progress and provide support for their academic success.
Consent for Release of Education Records

AUTHORIZATION FOR USE AND/OR DISCLOSURE OF EDUCATION RECORDS
The Family Educational Rights and Privacy Act (FERPA) is a federal law that protects the privacy of student education records created or maintained by a school that receives federal funds. Completion of this document authorizes the disclosure and use of education records as described below. Completion also authorizes you to discuss this information with representatives of the organization named below entitled to receive said information.
Student Information
Student Name (ROI)

First NameLast Name
Date of Birth

MonthDayYear
Participant Identification
Current Grade
School
Use and Disclosure Information:
I, the undersigned, do hereby authorize to disclose and deliver the complete education records maintained under the above student's name.
I approve the sharing of the following educational records:
The educational records can be shared with:

Name: Youth Empowerment Services
Organization: Cook Inlet Tribal Council
Address: 3600 San Jeronimo Dr Anchorage, Alaska 99508

Purpose:

This information is to disclosed for the purpose of:
- Sharing of Educational Records
- Grants Reporting
- Longitudinal Data
- Program impact assessment
Authorization for Redisclosure:

Under federal law, the requester (Cook Inlet tribal Council) may not redisclose the information identified above to any other party without your consent. If you wish to authorize Cook Inlet Tribal Council to redisclose the information identified above please mark the box below:
I authorize the Cook Inlet Tribal Council to redisclose the education information described above and I understand that if the information is redisclosed it may not be protected by federal privileges, privacy laws or regulations.
Primary Guardian (ROI)

First NameLast Name
Relationship to Participant
Parent/Legal Guardian Signature (ROI)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Media Release
CITC use images and video to promote and share programs. Do you consent to CITC using images and/or video with your participant in it?
I grant Cook Inlet Tribal Council, Inc., Alaska Native Justice Center, Inc. (ANJC), Clare Swan Early Learning Center (CSELC), and/or Get Out the Native Vote (GOTNV), and their agents, affiliates, and assigns (collectively "CITC") permission to use my and/or my child[ren]'s likeness in images captured for use in photograph, print, film, or other digital reproduction in any and all of its publications and any media, including social media (collectively "Media"), and I fully understand and acknowledge that:
- my and my child(ren)'s participation in CITC's Media activity is strictly voluntary;
- I or my child[ren] may be photographed and/or videotaped for educational, promotional, commercial, and archival purposes. I grant CITC permission to use my and/or my child[ren]'s likeness in images captured for Media use;
- I irrevocably authorize CITC to edit, alter, copy, exhibit, publish, or distribute images of me or my child[ren)'s likeness in any Media for purposes of publicizing CITC's programs or for any other lawful purpose, including but not limited to commercial and informational and training purposes, video games, film, books, posters, cultural and language materials, and other forms of content without payment or any other consideration;
- my and/or my child[ren)'s or dependent's confidentiality as a CITC participant, if applicable, may be waived when CITC use an image in Media, and I voluntarily consent to their use, understanding that these uses may be subject to public use and/or view without my knowledge or previous consent and will not be returned; and
- I waive the right to inspect or approve the finished product, including written or electronic copy, where my or my child[ren]'s likeness appears. I also waive any right to royalties or other compensation arising from or related to the use of my or my child[ren]'s image(s) in any form and for any purpose. I hold CITC harmless and release and forever discharge CITC, its directors, officers, employees, agents and assigns from all claims, demands, and causes of action which I, and/or my child[ren]'s heirs, representatives, executors, administrators, or any other persons acting on my and/or my child[ren]'s behalf or on behalf of my and/or my child[ren)'s estate have or may have related to my or my child[ren]'s likeness or any CITC publication or media of any type.
By signing below, I confirm that I am at least eighteen (18) years old and am competent to contract in my own name. I have read this release before signing. I fully understand the contents, meaning, and impact of this Media Release.
Student Name

First NameLast Name
Parent / Guardian / Adult Student Signature

Youth Code of Conduct
This is to affirm that I agree to the following terms and conditions for participation in the CITC Youth Education Program:
- I understand any technology I bring other than a laptop for schoolwork, will be placed in a designated technology area.
- I will let staff know if I need to use my phone before retrieving it from the technology area.
- I will abide by the rules of CITC Youth Education Program and follow the instructions given by the instructors, counselors, staff, and supervisors.
- I will respect the culture and ways of others and be respectful of their words and thoughts.
- I will participate in the scheduled activities, to the best of my abilities.
- I will be accountable for my whereabouts at all times, agreeing to keep staff informed of my plans and activities.
- I will keep my hands and extensions to myself, which means I will not engage in public displays of affection or aggression.
- I will refrain from any behavior deemed inappropriate or behavior that involves risk to others, or myself (e.g., inappropriate use of CITC equipment, leaving CITC Youth Education Program without permission).
- I will give CITC equipment and facilities the highest levels of care and consideration. If I misuse equipment or materials, I may not be allowed to use them.
- CITC is a drug- and alcohol-free campus, and the use, possession, or handling of any substances is strictly prohibited.
- If I cause any danger, damage, or disruption in any manner to the Youth Education Programs’ employees, visitors, participants, grounds, facilities, and/or other programs, I fully understand that I will be subject to disciplinary actions to and including expulsion from Youth Empowerment Services Programs and may be prohibited from returning to CITC’s property.
Dress Code:

Shirts:
- Should not be revealing (no spaghetti straps).
- Should be long enough that the midriff does not show.
- Should not display messages that are disruptive to the learning environment.
- This includes inappropriate language/images, and should not promote alcohol or drugs.
Skirts/Pants/Shorts:
- Skirts and shorts should be no higher than 2 inches above the knee when measured from a kneeling position.
- The waistline of the pants may not sag below the waist of the wearer
Leggings:
- Leggings & athleisure may be worn, but cannot be see through.
Shoes:
- Participants should wear functional shoes at all times for safety (preferably sneakers). If activity occurs in Fab Lab, closed toes shoes are required.
  Weather:
Participants are responsible to dress appropriately for the weather.
I agree and consent to my child[ren]’s participation in any program within the Youth Education department and assume the CITC YE department staff is dedicated to provide a safe space for our students while understanding that no measures can be completely eradicate the risks and hazards of all activates. By enrolling a student(s) at CITC YE Department, families understand and accept the risk of injury, which may occur.
I acknowledge I have read and understand the Youth Code of Conduct. I agree to its terms and conditions and confirm that I have discussed the Youth Code of Conduct with my child(ren).
Student Name (YCC)

First NameLast Name
Parent / Guardian / Adult Student Signature

Movie Permissions

COOK INLET TRIBAL COUNCIL – YOUTH EDUCATION DEPARTMENT
General Permissions Section
Student Name (MP)

First NameLast Name
Guardian Name (MP)

First NameLast Name
Parent/ Legal Guardian must sign (MP):

CITC Participant Transportation
I authorize CITC personnel to transport my participant in CITC vehicles. I also authorize my participant to be transported by other organizations approved by CITC.
PLEASE NOTE you have indicated that you do not authorize CITC staff to transport your participant in CITC vehicles. Please be aware that the Youth Education Department offers a variety of off-campus activities as part of its programming. If you have selected "No" for transportation authorization, your participant will not be eligible to participate in off-campus activities unless transportation is arranged and provided by the parent or legal guardian.
Parent/Legal Guardian Signature: I certify that I am the participant's legal guardian and that the information provided in this application is true, accurate, and complete to the best of my knowledge.
Elementary After School Club For 3rd-5th Grade (At The Denełchin Lab)

CITC will create a welcoming environment for students to form supportive friendships and connections. Participants will have the chance to explore Alaska Native cultures and crafts while engaging in a variety of creative projects. Snacks will be provided!

Instructors Will:
- Ease the transition to school by advocating on the youth and family’s behalf.
- Provide enriching experiences in cultural exploration and hands-on fabrication, fostering creativity, critical thinking, and cross-disciplinary learning.
Elementary School After School Club Hours: Monday - Friday 2:15 pm to 5:00 pm. Transportation will be provided at student release at College Gate and Susitna Elementary.

Attendance Policy:
To best support our students and ensure that opportunities are available to those who can commit consistently, we have the following expectations:
- Communication of Absences- We kindly ask that you notify us in advance, whenever possible, if your student will be absent.
- Attendance Requirement- Students are expected to attend Fab Lab club if they are present at school that day. If a student does not attend school, they may not attend afterschool Fab Lab club.
- Unexcused Absences- Three (3) unexcused absences within a month will result in the student being moved to the waitlist. If this happens, we will reach out to inform you and let you know if a spot becomes available again
Thank you for helping us maintain a consistent and supportive environment for all students!

Location: Denełchin Lab (7710 Grass Creek Rd, Anchorage, Ak 99504)

Transportation:

CITC will provide transportation from the following schools:

Elementary Schools

College Gate Elementary School
Susitna Elementary School

Please Note: Transportation will be available for students enrolled at College Gate and Susitna. Parents will be responsible for pick-up at the Denełchin Lab.

The After-School Club for elementary is only open to participants that attend College Gate or Susitna Elementary school.
Before Middle School Programming (At The Denełchin Lab)

CITC will offer a safe space for building supportive friendships and provide quiet areas for reading, homework, and organization. Students will have the opportunity to learn about Alaska Native cultures and crafts.

Youth Advocates will:
- Monitor student educational plans weekly of accomplishments and barriers.
- Provide leadership relating to CITC services, social services within the Native Community
- Follow-up on educational referrals and advising parents of students’ status.
- Respect parent & youth values providing relevant resources, school information and community updates to keep families informed.
- Provide value-driven mentorship (Including if student gets suspened)
- Ease the transition to school by advocating on the youth and family’s behalf
Drop Off Times: 7:30 am - 8:15 am (Monday to Friday)

Attendance Policy:
To best support our students and ensure that opportunities are available to those who can commit consistently, we have the following expectations:
- No call no shows - we will reach out to you.If you know you will be out, just let us know and we won’t penalize you.
- 3 days in a row for absentees and if we don’t hear from you, the student will move to the waitlist.
- Student may still attend programming if suspended from ASD schools (parent must communicate and plan transportation)
- Please reach out to email: yesdept@citci.org text/call: (907)-793-3265
Parents/ Guardian will be responsible for pick-up/drop off at their school or must indicate on this form if their student is allowed to walk home.
Please note: Students may walk home from this program under the following circumstances:
- Attending home school program
- Parent Request
- Student suspended from school
Please Note: Student enrolled at Begich Middle school will be expected to walk with program staff to school regardless of weather conditions.
Please note: For students not enrolled at Wendler, Clark, Romig, or Central, parents will be responsible for transporting their students to school after the morning program concludes.
High School After School Club (At The Denełchin Lab)

CITC will create a welcoming environment for students to form supportive friendships and connections. Participants will have the chance to explore Alaska Native cultures and crafts while engaging in a variety of creative projects, hands-on learning experiences that support academic growth, career exploration, and future readiness. Through skill-building activities, real-world connections, and occasional educational field trips, participants will explore career pathways, discover their interests, and develop skills that prepare them for future success. Snacks will be provided.

Instructors will:
- Monitor student educational plans daily of accomplishments and barriers.
- Follow-up on educational referrals and advising parents of students’ status.
- Respect parent & youth values providing relevant resources, school information and community updates to keep families informed.
- Ease the transition to school by advocating on the youth and family’s behalf.
- Offer culture and fabrication enrichment.
High School After School Club Hours: Monday-Thursday 3:15 pm to 5:00 pm. No Afterschool Club on Fridays. Transportation will be provided at student release at Bartlett and East high school.

Location: Deneļchin Lab (7710 Grass Creek Rd, Anchorage, AK 99504)

Transportation:

CITC will provide transportation from the following schools:
- Bartlett High School
- East High School
High Schools: Students are expected to arrive at the designated pick-up location within 10 minutes of school dismissal. Attendance is optional; it is the student’s responsibility to arrive on time. Staff will not escort or require students to attend the program.

Please Note: Students who actively participate in the program for a total of 120 hours will earn 0.5 elective credit. Credit is awarded based on consistent engagement, participation in program activities, and successful completion of required experiences. Transportation will be available for students enrolled at Bartlett and East High School. The After-School club is open to all high school participants, but those not enrolled at Bartlett or East will need to arrange their own transportation or walk. End of day transportation will not be provided. Parents will be responsible for pick-up at the Denełchin Lab.
Please note: For students not enrolled at Bartlett or East high school, students will be responsible to provide their own transportation to program.
Do you give permission for your child to use their own email address to sign up for learning websites and apps used in this program?
Elementary After School Club - 3rd-5th Grade (At The School)

CITC will create a welcoming environment for students to form supportive friendships and connections. Participants will have the chance to explore Alaska Native cultures and crafts while engaging in a variety of creative projects. Snacks will be provided!

Instructors Will:
- Ease the transition to school by advocating on the youth and family’s behalf.
- Provide enriching experiences in cultural exploration and hands-on fabrication, fostering creativity, critical thinking, and cross-disciplinary learning.
Elementary School After School Club Hours: Two days a week 2:30 pm to 5:00 pm (Exception to this is the Alaska Native Charter School).

Attendance Policy:
To best support our students and ensure that opportunities are available to those who can commit consistently, we have the following expectations:
- Communication of Absences- We kindly ask that you notify us in advance, whenever possible, if your student will be absent.
- Attendance Requirement- Students are expected to attend Fab Lab club if they are present at school that day. If a student does not attend school, they may not attend afterschool Fab Lab club.
- Unexcused Absences- Three (3) unexcused absences within a month will result in the student being moved to the waitlist. If this happens, we will reach out to inform you and let you know if a spot becomes available again
Thank you for helping us maintain a consistent and supportive environment for all students!

Parents/ Guardian will be responsible for pick-up at their school or must indicate on this form if their student is allowed to walk home.
Airport Heights

Start Date
- (TBD)
Days of the week
- (TBD)
Eligible to Attend
- Airport Heights students and ASD homeschool students in the area
ANCCS (3rd - 5th Grade)

Start Date
- Wednesday, September 23, 2026
Days of the week
- Wednesday & Thursday
Club hours
- 3:30 - 5:00 pm
Eligible to Attend
- ANCCS students and ASD homeschool students in the area
Chinook

Start Date
- Wednesday, September 2, 2026
Days of the week
- Wednesday & Thursday
Eligible to Attend
- Chinook students and ASD homeschool students in the area
Gladyswood

Start Date
- (TBD)
Days of the week
- (TBD)
Eligible to Attend
- Gladyswood students and ASD homeschool students in the area
Taku

Start Date
- Monday, August 31, 2026
Days of the week
- Monday and Tuesday
Eligible to Attend
- Taku students and ASD homeschool students in the area
Willow Crest

Start Date
- Thursday, September 24, 2026
Days of the week
- Thursday and Friday
Eligible to Attend
- Willow Crest students and ASD homeschool students in the area
ANCCS (6th - 8th Grade)

Start Date
- Monday, August 24, 2026
Days of the week
- Monday - Friday
Club Hours
- 4:00 - 5:00 pm
Eligible to Attend
- ANCCS Students
MEARS

Start Date
- Tuesday, September 15, 2026
Days of the week
- Monday - Thursday
Club Hours
- 4:00 - 4:45 pm
Eligible to Attend
- MEARS Students
Do you anticipate any transportation challenges getting your child to and from programming?
Please Explain
Would you be interested in having your student attend the program shown above
Should be Empty:

Youth Education

Student Health Information

Parent /Legal Guardian Information

Secondary

Participant Documents

Release of Student Records

Consent for Release of Education Records

Student Information

Use and Disclosure Information:

Media Release

Youth Code of Conduct

Movie Permissions

CITC Participant Transportation