YOUTH ENROLLMENT FORM

Community Arts Experience, Inc. (CAE) is a nonprofit organization that helps people and communities grow through the arts. We focus on improving mental health, supporting recovery, building job skills, and strengthening community connections.

This application is required for youth ages 7–17 and must be completed by a parent or legal guardian for each child at least three business days before programming begins. Some programs have limited capacity and may involve a waiting list. CAE will contact you if a space becomes available.

Participation in CAE’s Character & Leadership Development Course—held once a week for 1.5 hours—is required. To remain eligible for continued participation, students must attend the course regularly, and parents or guardians must complete a minimum of two volunteer hours per month.

CAE does not discriminate based on income, race, gender, religion, ethnicity, or disability.

INSTRUCTIONS: Unless otherwise indicated, all requested information must be provided. If the information is not known or does not apply, “unknown” or “N/A” is the required response. A blank field or a line through a field are not acceptable responses.

How did you hear about us? *

CAE SITE LOCATION

Choose your site location below

CHILD INFORMATION

Current Age *

Race/Ethnicity *

Gender Identity *

Primary Language *

Is your child on an Individualized Educational Plan (IEP)? *

Child's T-Shirt Size *

TUITION ASSISTANCE

A one-time, non-refundable $100 registration fee is required before the start of class. No additional costs will apply for eligible participants unless otherwise noted in advance (i.e., supplies for specific activities, field trips, etc.). Scholarships are available on a first-come, first-served basis.

Will you need financial assistance for program tuition? *

FINANCIAL INFORMATION: The information you provide will be used to determine your child’s eligibility for the USDA Child Care Food Program and CAE’s Scholarship Program. All financial details will remain confidential and used only for eligibility and reporting purposes. For more information, contact Keith Cross, Executive Director, at (866) 961-2239 ext. 3.

Total number of members residing within the home *

Please select your eligibility for a 50% discount: *

Please select your eligibility for a 20% discount: *

List the name(s) of additional children registering for CAE, if applicable

1ST PARENT/GUARDIAN AUTHORIZED REPRESENTATIVE

Primary Parent/Guardian #1 Full Name *

Relationship to Child (Individual #1) *

Phone (Individual #1) *

Email (Individual #1) *

2ND PARENT/GUARDIAN AUTHORIZED REPRESENTATIVE

Parent/Guardian #2 Full Name

Relationship to Child (Individual #2)

Phone (Individual #2)

Email ((Individual #2)

EMERGENCY CONTACT/AUTHORIZATION PICK-UP

Emergency Contact Phone *

Emergency Contact Relationship to Child *

When to Notify Authorized Contact *

For an Emergency

Release of Child (Pick-up)

Both

Emergency Contact #2

Emergency Contact Phone #2

Emergency Contact Relationship to Child #2

When to Notify Authorized Contact #2

For an Emergency

Release of Child (Pick-Up)

Both

RESTRICTED PICK-UP

Names of additional persons (not parents, legal guardian, authorized representative) who may be called in an emergency and/or who are authorized to take the child from the site. *The child will not be allowed to leave with any other person without written authorization from parent or authorized representative.

Listed below are the individual(s) prohibited from signing out my child due to a court-issued restraining order (a certified copy of the official documentation must be provided and kept in your child’s CAE file).

MEDICAL BACKGROUND AND HISTORY

All information provided will be kept confidential in compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

Physical Limitations: Does your child have any physical limitations that might present a special problem, such as any health factor requiring them to follow a limited program of activities? *

Is your child under regular/current care or supervision of a physician? *

Does your child have any disabilities, physical limitations or needed adaptations? If so, please list *

Please list any conditions such as recent surgery, recurring or infrequent occurrences of asthma, mild allergies, hay fever, emotional problems, ADHD, etc. *

Does your child have any serious illness? (i.e. severe asthma, heart disease, diabetes, depression) If so, please list *

Does your child have any serious or life-threatening allergies, including food allergies (i.e., bee stings, peanuts, dairy, allergies to medications)? If so, please list *

Please list any prescription medications your child will take while at CAE, if applicable. All medications must be in original pharmacy containers labeled with the prescribing physician’s name, medication name, dosage, and instructions. CAE will not administer medications that do not meet these requirements—no exceptions. This policy ensures participant safety and compliance with medical standards. *

Please list all over-the-counter (OTC) medications your child will take while at CAE, if applicable. NOTE: All OTC medications must be in original packaging, with your child's name on the bottle. Please do not send medicines in alternate packaging. *

We keep a supply of the over-the-counter items listed below. Please check any items you authorize CAE to provide to your child, if needed, during program hours. *

Upon check-in, all medications, except asthma inhalers, will be turned in to our on-site LPN. They will keep and distribute all medications to your child as needed.

PARENT/GUARDIAN BLANKET RELEASE AND CONSENT

As part of this application, parents or legal guardians must review and respond to the following releases regarding their child’s participation in CAE programs. Completion of this section is required for enrollment. Your responses provide essential authorizations to ensure your child’s safety, access to services, and full participation.

Please read each statement carefully and select your response using the dropdown options provided.

1. PROGRAM PARTICIPATION RELEASE: I authorize my child to participate fully in CAE programming, including workshops, instruction, performances, and group activities conducted on-site or at approved off-site locations. *

I Authorize

Do Not Authorize

2. TRANSPORTATION RELEASE: I authorize CAE and its authorized representatives to transport my child to and from program-related activities, events, or field trips, using properly insured vehicles and licensed drivers. *

I Authorize

Do Not Authorize

3. MEDIA AND PUBLICITY RELEASE: I grant permission for CAE to photograph, videotape, or otherwise record my child during program activities. I understand that these images and recordings may be used in CAE’s publications, website, social media, and promotional materials without compensation. *

I Authorize

Do Not Authorize

4. EMERGENCY MEDICAL TREATMENT RELEASE: In the event of a medical emergency and when I cannot be reached, I authorize CAE staff to seek emergency care and make necessary decisions regarding treatment on my child’s behalf. I accept financial responsibility for any resulting medical costs. *

I Authorize

Do Not Authorize

5. FIELD TRIP AND OFF-SITE ACTIVITY RELEASE: I authorize my child to participate in field trips and enrichment activities conducted off CAE’s main site. I understand I will be notified in advance of scheduled off-site events. *

I Authorize

Do Not Authorize

6. TECHNOLOGY AND INTERNET USE RELEASE: I authorize my child to use CAE-approved computers, tablets, and internet-based educational tools under adult supervision. *

I Authorize

Do Not Authorize

7. DATA AND ASSESSMENT CONSENT: I consent to the collection of non-identifying data related to my child’s academic, social, behavioral, and emotional development for the purpose of program evaluation and reporting. This information will be handled in accordance with CAE’s privacy policy. *

I Authorize

Do Not Authorize

8. MENTORSHIP, COUNSELING, AND CASE SUPPORT RELEASE: I authorize my child to participate in mentorship sessions, group discussions, and, when appropriate, trauma-informed case management or behavioral health services facilitated by CAE or its licensed partners. *

I Authorize

Do Not Authorize

9. RELIGIOUS INSTRUCTION OPT-IN RELEASE: I authorize my child to participate in optional character and values instruction that references Bible-based principles. I understand this instruction does not promote any specific doctrine and participation is voluntary. I may withdraw this consent at any time with written notice. *

I Authorize

Do Not Authorize

10. GENERAL RELEASE OF LIABILITY AND HOLD HARMLESS AGREEMENT: By submitting this application, I acknowledge and agree to release, indemnify, and hold harmless Community Arts Experience, Inc. (CAE), its officers, directors, staff, mentors, volunteers, contractors, and affiliated partners from any and all claims, liabilities, damages, or losses arising from or related to my child’s participation in CAE programs. This release includes, but is not limited to, claims of personal injury, property damage, illness, or loss, except where caused by gross negligence or willful misconduct. I understand this waiver is binding for the duration of my child’s participation. *

I Authorize

Do Not Authorize

SIGNATURE ATTESTATION

By signing electronically below, I confirm that all information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that my electronic signature is legally equivalent to a handwritten signature and serves as my consent to the authorizations and releases selected. I further certify that I am the parent or legal guardian of the child named in this application.

Primary Parent/Guardian Signature *

Clear

By checking this box, Community Arts Experience, Inc. would like your consent to send text message communications from 1 (866) 223-9910, 1 (833) 977-7897, 1 (888) 515-3824, and 1 (855) 480-1718 to your mobile number listed above regarding program notifications, participant support, scheduling, service coordination, organizational updates, and marketing communications. Consent is not a condition of purchase. Message frequency varies. Message and data rates may apply. Reply “STOP” to unsubscribe at any time. Reply “HELP” for assistance or more information.

By checking this box, I do not consent to receive any text messages from Community Arts Experience, Inc.

Community Arts Experience, Inc. does not share your mobile opt-in information with third parties. Please see our Privacy Policy for information on how we collect, use, and protect your data.