Cape Assist's IMPACT Program

Cape Assist's IMPACT Program

Participant Information
Participant Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date (must be 10 years or older to participate in the IMPACT program)
Participant Race*
For demographic reporting purposes
Participant Email*
example@example.com (student must have access to this email during class date)
Participant Address*

Street Address

Street Address Line 2

CityState

Zip Code
Legal Parent/Guardian Name*

First NameLast Name
Legal Parent/Guardian Email*
example@example.com
Legal Parent/Guardian Phone (Cell)*
Legal Parent/Guardian Phone (Home)*
Does participant require special accommodations for academic, physical, or behavioral needs?*
Special accommodations for academic, physical, or behavioral needs
Town in which offense occurred*
Date of Offense*

MonthDayYear
Date
Age at time of offense*
Nature of offense*
Referring Source*
Enter referring police department or school
Have you ever completed a diversion program?*
Date Completed

MonthDayYear
Date
Length
Enter total hours of program
City, State of Program

Street Address

Street Address Line 2

CityState

Zip Code
Are you currently in school?*
Name of School
Grade
City, State of School

Street Address

Street Address Line 2

CityState

Zip Code

Cape Assist's IMPACT Program

Parent Consent Form
Participant Name*

First NameLast Name
Emergency Contact (on day of program)*

First NameLast Name
Emergency Contact Phone*
I hereby request and consent that my child or ward, {participantName4}, be permitted to participate in Cape Assist’s in-class or virtual IMPACT Program.

I consent that my child is permitted to participate in all activities including the survey, pre/post-test, discussions, and program evaluation. I understand and consent to the following:

I agree that no official or employee associated with the program will be held responsible for any injuries or damages occurring while my child is participating in the program. I do hereby hold harmless the sponsoring agencies, their officials, divisions, and agents against any and all liability, damage, loss, claims, or demands which arise out of or are in any way connected with my child or ward’s participation in the program.

I agree that Cape Assist can disclose attendance and participant information to the referring agency (i.e. police department, school, Prosecutor’s Office, and/or Family Court).

I agree that any discussions within the program are completely confidential unless a child expresses safety concerns such as hurting someone else or themselves at which point, Cape Assist reserves the right to break confidentiality and report the occurrence to the proper agency(ies).

I agree that if my child is asked to attend the virtual IMPACT program, they will be required to use video conferencing, phone, email, and any other form of communication that Cape Assist deems necessary to complete the program.
Legal Parent/Guardian*

First NameLast Name
Legal Parent/Guardian Signature*

Clear
Today's Date*

MonthDayYear
Date

Cape Assist's IMPACT Program

Participant Contract
CONTRACT BETWEEN

Cape Assist and {participantName4}

By signing this contract to register for the program, I agree to follow the rules:
- To participate in all activities of the program.
- To behave in a manner that is not disruptive or destructive in any way.
- To follow group rules.
- To be present at designated class time (participants will not be permitted into the class if they are more than 15 minutes late).
- Keep what is discussed in class confidential.
Failure to follow these rules will result in participants being dismissed from the class. As a result, Cape Assist reserves the right to report to the referring agency(ies) of such actions.

Participant payment (if applicable) will not be refunded for being dismissed or failed to appear on the scheduled class date. A new payment will be required for the rescheduled class.

Cape Assist agrees to:
- Present the designated program and supply all materials.
- Treat each participant with respect.
- Keep confidential what is said in class (unless a safety concern such as harming others or self-harm is reported), and notify the referral source only of attendance and further recommendations, if any.
- Issue a certificate to each participant upon completion of the program.
Participant Name*

First NameLast Name
Participant Signature*

Clear
Legal Parent/Guardian*

First NameLast Name
Legal Parent/Guardian Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty: