2015-2016 FYC Program |Fairfax Community Center |16 Park Rd. Fairfax, CA 94930
Membership Form
The Fairfax Youth Club (FYC) is a unique program offered by the Town of Fairfax , which allows students
in the surrounding area to use as a place to where they can decompress, seek school-related assistance,
and have fun. The program acts as an extension for the transitional period between the ending of school
until parents are able to come home after their work day.
The Fairfax Youth Club Schedule is open for students on:
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Mondays, Tuesdays & Thursdays from 3:30pm – 5:30pm
Wednesdays from 2:30pm – 5:00pm
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Fridays (1 of each month only) from 7pm – 10pm
Registration & Fees: There will be an annual membership fee of $200 or $20 (5-day) Visitation cards
may be purchased instead. (Please mail checks made payable to Town of Fairfax at 142 Bolinas Rd,
Fairfax, CA 94930 Attn: Anne Mannes.).
Membership Incentives: (Annual Membership Only)
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Unlimited Access to the Fairfax Community Center (on open days)
50% discount or FREE admission to special town events or FYC workshops
FREE weekly snacks and drinks
Admissions Agreement
Behavior Agreement: Members of the Community Center must be on their best behavior while using
the facility and can waive their membership at any time if there becomes a behavioral issue that leads
others from being able to use the resources.
Personal Propery: Members are welcome to bring their MP3 players, tablets, phones and other devices
to share, though we are not held responsible if they become lost, damaged or stolen.
Electronics/Resource Agreement: The electronics/resources in the Community Center are used to
enrich the environment of the members. Any member misusing or damaging these resources will be
responsible for proper replacement. NO TE CH to be used the 1st HOUR-unless it’s for schoolwork!
Health-related Disclosure: We will have a first aid kit available for any minor injuries. If a member
becomes extremely injured or sick we will notify the parents immediately. Members will be responsible
for their own medications as we are not qualified to store and administer.
Contact Information: You can contact the Program Coordinator at: fairfaxyouthclub@gmail.com .
Program provided by Roots to Branches and Fairfax Recreation
Please retain the above copy for your records and fill-out/return the bottom portion:
Please Print Clearly
Member Name:___________________________________________________ Gender: ____________
School: ______________________________________________________
Date of Birth: _______________________
Age: __________ (Must be in Middle School or higher)
Home #:_______________________________ Cell #: ________________________________________
Email: _______________________________________________________________________________
Home Address: _______________________________________
City: _________________________
Parent Name: ____________________________________ Parent Cell#:__________________________
Parent Email: __________________________________________________________________________
By Filling out and signing below you are authorizing and acknowledging the following:
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Allowing my child to leave the facility without an adult.
Photos used by the Community Center can be used for public relations.
Both the Electronics and Behavior Agreements.
Will disclose any medical/health conditions to the on-site facilitators.
Understand that any reports of child abuse will need to be reported to CFS.
Parent Signature:____________________________ Student Signature:___________________________
*Return this form in person at Fairfax Town Hall (142 Bolinas Rd.) or by mail attn: Anne Mannes.*
Program provided by Roots to Branches and Fairfax Recreation