ADULT 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.

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

PARTICIPANT INFORMATION

Race/Ethnicity *

Primary Language *

Gender Identity *

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? *

Total number of members residing within the home *

Please select your eligibility for a 50% discount: *

Enter Recovery Hub code to receive a 15% discount.

FINANCIAL INFORMATION: The information you provide will be used to determine your eligibility for the USDA 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.

EMERGENCY CONTACT

Emergency Contact Phone *

Emergency Contact Relationship *

Emergency Contact #2

Emergency Contact Phone #2

Emergency Contact Relationship #2

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: Do you have any physical limitations that might present a special problem, such as any health factor requiring you to follow a limited program of activities? *

Do you 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. *

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

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

BLANKET RELEASE AND CONSENT

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

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

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

I Authorize

Do Not Authorize

2. MEDIA AND PUBLICITY RELEASE: I grant permission for CAE to photograph, videotape, or otherwise record me 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

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

I Authorize

Do Not Authorize

4. DATA AND ASSESSMENT CONSENT: I consent to the collection of non-identifying data related to my 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

5. 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 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 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.

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.