C.A.E. Youth Enrollment Packet

COMMUNITY ARTS EXPERIENCE, INC.

Youth (Ages 7-17) Enrollment Packet - FY2023/2024
Community Arts Experience (C.A.E.) 501(c)(3) charitable organization is a coalition-base mentoring arts academy dedicated to empowering individuals to transform culture.

This enrollment packet is intended for youth ages 7-17.

To ensure a safe and engaging experience, guardians must complete this packet in its entirety. This packet must be completed for each child in the program and must be completed at least three business days before programming.
Instructions: Unless otherwise indicated, all requested information must be provided. If the information is not known or does not apply, “unknown” or “none” is the required response. A blank field, a line through a field or “N/A” are not acceptable responses.
Child Information
Child's Full Name*

First NameMiddle InitialLast Name
Current Grade*
Birth Date*

MonthDayYear
Date
Ethnicity*
Gender Identification*
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Are you a resident of the Mercer County Housing Authority?*
Will you need financial assistance for program tuition?*
Households with incomes within these guidelines are eligible to receive financial assistance.

Household Size Maximum Gross Monthly Income
1 $2,266
2 $3,052
3 $3,840
4 $4,626
5 $5,412
6 $6,200
7 $6,986
8 $7,772
9 $8,560
10 $9,348
Each additional member +$788
C.A.E. Site Locations & Programming

Choose an option below
Choose a C.A.E. Site Location*
Choose Your Program*
ABOUT C.A.E.'s STOMP INITIATIVE

The Students Taking Ownership Mentoring Project (S.T.O.M.P.) is a countywide initiative designed to prevent violence in all forms by employing a comprehensive trauma-informed framework to transform culture. Anticipated outcomes positively impact youth ages 7-17, their families, and the community.

Services are offered in a safe and productive environment (S.T.O.M.P. Safe HUB). Participants and their families are encouraged to be introspective, empowered to lead, and equipped to address aggressive or violent behaviors and mental, social, and economic triggers.

For more program information, please visit www.caeww.com/stomp
ABOUT C.A.E.'s 'PLANET ROCK' SCHOOL TOUR

C.A.E.’s ‘Planet Rock’ School Tour is created to boost student achievement and provide a workforce development pipeline from education to job placement by seamlessly merging arts standards with core academic curricula. Each uniquely designed workshop explicitly solves supplemental service needs for public, private, and charter schools, including organizations and churches within C.A.E. service areas.

We explore specific models inclusive of civic and community engagement projects, career and technical education programs of study, entrepreneurship, arts-infused learning, and mandated family engagement capacity-building activities. These offerings are intended to entice students organically by creating an attractive, relatable environment through combined family-friendly entertainment and inter-generational technology that is conducive and engaging to both learning and well-being.

Monetary and professional incentives are offered through our work-study programs, scholarships, internal employment opportunities, earned industry certifications, new product development, and self-serving personal achievement by completing student projects.

For more program information, please visit www.caeww.com/planetrock
Date of Admission *Administration Only

MonthDayYear
Date

1st Parent/Guardian/Authorized Representative
1st Parent/Guardian/Authorized Representative Name*

PrefixFirst NameLast Name
1st Parent Address (if different from child)

Street Address

Street Address Line 2

CityState

Zip Code
1st Parent Mobile Phone Number*
1st Parent Home Phone Number (if Different from child)
1st Parent Email Address*
example@example.com
1st Parent Employer Name & Address*
1st Parent Business Phone Number*
2nd Parent/Guardian/Authorized Representative
2nd Parent/Guardian/Authorized Representative Name

PrefixFirst NameLast Name
2nd Parent Address (if different from child)

Street Address

Street Address Line 2

CityState

Zip Code
2nd Parent Mobile Phone Number
2nd Parent Home Phone Number (if Different from child)
2nd Parent Email Address
example@example.com
2nd Parent Employer Name & Address
2nd Parent Business Phone Number

Emergency Contacts/Authorized 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
Person 1 Name*

PrefixFirst NameLast Name
Person 1 Phone Number*

Area CodePhone Number
Person 1- Address (If different from Child)

Street Address

Street Address Line 2

CityState

Zip Code
Person 1- Relationship To Child*
When To Contact Person 1 (Choose up to 2)*

Emergency ContactRelease of Child

Person 2- Name*

PrefixFirst NameLast Name
Person 2- Phone Number*
Person 2- Address (If Different from Child)

Street Address

Street Address Line 2

CityState

Zip Code
Person 2- Relationship To Child*
When To Contact Person 2 (Choose up to 2)*

Emergency ContactRelease of Child

Person 3- Name

PrefixFirst NameLast Name
Person 3- Phone Number
Person 3- Address

Street Address

Street Address Line 2

CityState

Zip Code
Person 3- Relationship To Child
When To Contact Person 3 (Choose up to 2)

Emergency ContactRelease of Child

Person 4- Name

PrefixFirst NameLast Name
Person 4- Phone Number
Person 4- Address

Street Address

Street Address Line 2

CityState

Zip Code
Person 4- Relationship To Child
When To Contact Person 4 (Choose up to 2)

Emergency ContactRelease of Child

Restricted Pick Up

The following individuals are RESTRICTED from signing out my child due to a court-issued restraining order (a certified copy of the official documentation must be kept in the child’s C.A.E. file).
Restricted Name 1

PrefixFirst NameLast Name
Restricted Name 2

PrefixFirst NameLast Name

Child's Health Statement
I, the undersigned, understand that physical activity is a regular part of the daily scheduled activities at a C.A.E. program. To the best of my knowledge, my child is in excellent physical health and has no restrictions (except what is listed in this packet under “special consideration”) from strenuous activity. If I have any questions regarding my child’s health, I understand that it is my obligation to seek professional medical advice and to inform the C.A.E. of any restrictions on my child’s activities. I understand that C.A.E. is a group-centered program with one adult teacher assigned to a group of children.
Check One

Yes, I agreeNo, I do not agree
Primary Parent/Guardian electronic signature (If student is under the age of 18)
Whether digital or encrypted, the electronic signature is intended to authenticate this document and has the same force and effect as a manual signature.

TRANSPORTATION RELEASE
FIELD TRIP/TRANSPORTATION AUTHORIZATION: My child, has my permission to be transported in C.A.E. contracted transportation service to any field trip scheduled, if applicable. I understand that a notice will be sent home in advance of any field trip. If C.A.E. is providing transportation, record of each child riding in the bus will be on site. All buses carry a first aid kit for emergencies.

Yes, I agreeNo, I do not agree
Primary Parent/Guardian electronic signature (If student is under the age of 18)
Whether digital or encrypted, the electronic signature is intended to authenticate this document and has the same force and effect as a manual signature.

Release and Waiver of Liability and Indemnity Agreement
IN CONSIDERATION for being permitted to utilize the facilities, services, and programs of C.A.E. (or for my children to so participate) for any purpose, including, but not limited to, observation or use of facilities or equipment, or participation in any off-site program affiliated with C.A.E., the undersigned, for himself or herself and such participating children and any personal representatives, heirs, and next of kin (hereinafter referred to as “the undersigned”) hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating will inspect and carefully consider such premises and facilities and/or the affiliated program. It is further warranted that such entry into C.A.E. for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgment that such premises and all facilities and equipment thereon and such affiliated program have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use or participation by the undersigned and such children. IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER C.A.E. FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO, OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY ON-SITE OR OFF-SITE PROGRAM AFFILIATED WITH C.A.E, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:

1.    THE UNDERSIGNED, ON HIS OR HER BEHALF AND BEHALF OF SUCH CHILDREN, HEREBY RELEASES, WAIVES, DISCHARGES, AND COVENANTS NOT TO SUE C.A.E., its directors, officers, employees, volunteers and agents (hereinafter referred to as "releasees") from all liability to the undersigned or such children and all personal representatives, assigns, heirs, and next of kin of the undersigned for any loss or damage, and any claim or demands on account of injury to the person or property or resulting in the death of the undersigned or such children whether caused by the negligence, active or passive, of the releasees or otherwise while the undersigned or such children is in, upon or about the premises or any facilities or equipment therein or participating in any program affiliated with the C.A.E.

2.    THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees, and each of them, from any loss, liability, damages, or costs they may incur, whether caused by the negligence, active or passive, of the releasees or otherwise while the undersigned or such children is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the C.A.E.

3.    THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR, AND RISK OF BODILY INJURY, DEATH, OR PROPERTY DAMAGE to the undersigned or such children due to negligence, active or passive, of releasees or otherwise while in, about or upon the premises of C.A.E. and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with C.A.E.

THE UNDERSIGNED further expressly agrees that the foregoing RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of Pennsylvania and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT and further agrees that no oral representations, statements, or inducement apart from the foregoing written agreement have been made.
By signing below, I acknowledge that I have read and agree to all the statements of this Release and Waiver of Liability and Indemnity Agreement:
Date*

MonthDayYear
Date
Primary Parent/Guardian electronic signature*
Whether digital or encrypted, the electronic signature is intended to authenticate this document and has the same force and effect as a manual signature.

PHOTO & VIDEO/AUDIO RECORDING RELEASE
I, the undersigned,
Student Name

First NameLast Name
am eighteen years of age or older, and if not, then my Parent/Legal Guardian has also signed below under my signature.

With regard to my participation in activities sponsored by or related to any activity in which I participate in any way sponsored by C.A.E., I hereby give my permission and consent, now and for all time (without any further compensation, claim or demand by me) to C.A.E., and to advertising agencies, agents, entities and third parties collaborating with C.A.E. and their representatives, if any, (the “Organizations”) to make, reproduce, edit, broadcast or rebroadcast any video, film, or digital footage and other soundtrack recordings, or photo reproductions of my image or voice in any form, and my narrative account of my experience with C.A.E. activities (“Materials”) for publication, display, sale or exhibition thereof in promotions, advertising and legitimate business uses without any further compensation to me. I may or may not be identified by name in such reproductions. However, I shall not be stated by name to have endorsed any particular commercial products or commercial services without my express written permission. I further agree to the following:
- Any Materials created subject to this Release shall belong to C.A.E. as its property, with full right of disposition of them without my oral or written permission.
- The Materials will not be subject to any obligation of confidentiality and may be shared with and used by the Organizations and with any third parties as the C.A.E. may elect.
- C.A.E. shall not be liable for any claim arising from the use or disclosure to a third party of any of the Materials.
- C.A.E. shall exclusively own all known or later existing rights to the Materials worldwide and shall be entitled to the unrestricted use of the Materials for any purpose without compensation to the provider of the Materials or me.
AGREEMENT AND CONSENT I have read and understood the contents of this Release. I agree that my consent to this Release is irrevocable. I hereby voluntarily release and discharge C.A.E. and the Organizations and their representatives from any and all claims arising out of or relating to or in connection with the uses and reproductions of my image and voice and my narrative account as described herein. I understand that the term “C.A.E.” in this Release specifically includes the Community Arts Experience, Inc.
Choose One:*

Yes, I AgreeNo, I do not agree
Date*

MonthDayYear
Date
Youth electronic signature*
Whether digital or encrypted, the electronic signature is intended to authenticate this document and has the same force and effect as a manual signature.
Primary Parent/Guardian electronic signature (If student is under the age of 18)
Whether digital or encrypted, the electronic signature is intended to authenticate this document and has the same force and effect as a manual signature.

Payment Information

The annual enrollment fee of $50 has been WAIVED for fiscal year 2023/2024. No payment is due until July 2024. Please provide the total number of children you will be enrolling this fiscal year.
How many additional children will you be enrolling/registering?
Please list additional child(ren) names
Note: An enrollment packet must be completed for EACH individual child
2 Children Enrolled: Enter coupon code caeww2 to receive a 10% discount!
3 Children Enrolled: Enter coupon code caeww3 to receive a 15% discount!
4+ Children Enrolled: Enter coupon code caeww4 to receive a 20% discount!
MCHA Residents Only: Enter coupon code mcha50 to receive a 50% discount!
Payments can be received at the C.A.E. Arts Academy & Sports Complex (Chavers Center), located at 211 Federal St., Farrell, PA 16121, between the hours of 3:00 PM - 5:00 PM, or call Ms. Miah Bickley, chief operations officer, at (866) 961-2239 ext. 2 to schedule an appointment.
Please select your preferred method of payment.*
Please scan the barcode below or click HERE to pay via Cash App.

*** BE SURE TO ADD YOUR CHILD'S NAME AND COUPON CODE LISTED ABOVE, IF APPLICABLE, IN THE NOTE SECTION.

If you have completed all sections, please click the submit Below. After clicking submit, your packet will be saved, and no further edits may be made.

If you are experiencing any technical difficulties, please call our offices at (866) 961-2239.
Please verify that you are human*
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COMMUNITY ARTS EXPERIENCE, INC.

Child Information

C.A.E. Site Locations & Programming

1st Parent/Guardian/Authorized Representative

2nd Parent/Guardian/Authorized Representative

Emergency Contacts/Authorized Pick Up

Restricted Pick Up

CONFIDENTIAL HEALTH HISTORY STATEMENT

Child's Health Statement

TRANSPORTATION RELEASE

Release and Waiver of Liability and Indemnity Agreement

PHOTO & VIDEO/AUDIO RECORDING RELEASE

Payment Information