C.A.E. Youth Enrollment Packet

COMMUNITY ARTS EXPERIENCE, INC.
Youth (Ages 7-17) Enrollment Packet - FY2022/2023
Community Arts Experience (C.A.E.) 501(c)(3) charitable organization is 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 is a requirement to have 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 Name Middle Initial Last Name
Current Grade*
Birth Date*

MonthDay Year
Date
Ethnicity*
Gender Identification*
Home Address*

Street Address
Street Address Line 2
City State
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 faith-based 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

MonthDay Year
Date

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

Prefix First Name Last Name
1st Parent Address (if different from child)

Street Address
Street Address Line 2
City State
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

Prefix First Name Last Name
2nd Parent Address (if different from child)

Street Address
Street Address Line 2
City State
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

3rd Parent/Guardian/Authorized Representative
3rd Parent/Guardian/Authorized Representative Name

Prefix First Name Last Name
3rd Parent Address (if different from child)

Street Address
Street Address Line 2
City State
Zip Code
3rd Parent Mobile Phone Number
3rd Parent Home Phone Number (if Different from child)
3rd Parent Email Address
example@example.com
3rd Parent Employer Name & Address
3rd Parent Business Phone Number

Area Code Phone Number

4th Parent/Guardian/Authorized Representative
4th Parent/Guardian/Authorized Representative Name

Prefix First Name Last Name
4th Parent Address (if different from child)

Street Address
Street Address Line 2
City State
Zip Code
4th Parent Mobile Phone Number
4th Parent Home Phone Number (if Different from child)
4th Parent Email Address
example@example.com
4th Parent Employer Name & Address
4th 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*

Prefix First Name Last Name
Person 1 Phone Number*

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

Street Address
Street Address Line 2
City State
Zip Code
Person 1- Relationship To Child*
When To Contact Person 1 (Choose up to 2)*

Emergency ContactRelease of Child

Person 2- Name*

Prefix First Name Last Name
Person 2- Phone Number*
Person 2- Address (If Different from Child)

Street Address
Street Address Line 2
City State
Zip Code
Person 2- Relationship To Child*
When To Contact Person 2 (Choose up to 2)*

Emergency ContactRelease of Child

Person 3- Name

Prefix First Name Last Name
Person 3- Phone Number
Person 3- Address

Street Address
Street Address Line 2
City State
Zip Code
Person 3- Relationship To Child
When To Contact Person 3 (Choose up to 2)

Emergency ContactRelease of Child

Person 4- Name

Prefix First Name Last Name
Person 4- Phone Number
Person 4- Address

Street Address
Street Address Line 2
City State
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

Prefix First Name Last Name
Restricted Name 2

Prefix First Name Last Name

Physician & Dentist
Physician & Dentist to be called in Emergency & Medical Insurance Information
Medical Insurance Company and Plan
Policy Number
Policy Expiration

MonthDay Year
Date
Physician's Name

First Name Last Name
Physician's Phone Number
Dentist's Name

First Name Last Name
Dentist's Phone Number
If Physician Cannot Be Reached, What Action Should Be Taken?

Authorization & Release for Medical and Dental Treatment
I hereby grant permission for my child to use the play equipment and participate in all the activities C.A.E. provides. I hereby grant permission for my child to leave the C.A.E. premises under the supervision of a staff member for neighborhood walks or field trips in authorized vehicles. The undersigned, as the parent(s) or legal guardian(s) of the above-named person (the minor), authorizes C.A.E. and its Employees, Directors, and Adult Volunteers (collectively “C.A.E.”) to consent to an x-ray, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to the minor by a dentist/physician licensed under the law of the State or other jurisdiction in which care is sought. The undersigned understand and agree that C.A.E. shall not be legally or financially liable for any bills or medical expenses incurred, any cause of action or claim arising from any medical or dental care provided, or the lack of medical care or dental care. The undersigned hereby agree to this indemnity defined and hold C.A.E. harmless from any claim made by or on behalf of the minor’s heirs, parents, or guardian arising out of any medical care or dental care provided. NOTE: The C.A.E. requests that if the minor is in the custody of both of their parents or more than one legal guardian, both or all sign this authorization. The C.A.E. understands that the minor is in the custody only of the person(s) who have signed this authorization. If for religious reasons, you cannot sign this, you must provide a written statement from parent(s) or authorized representative exempting the child from medical assessment, immunizations, and treatment because of adherence to a religious faith that practices healing by prayer or other spiritual means; or physician's statement that immunization is not indicated and C.A.E. must be contacted for a legal waiver, which must be signed for attendance.
Check One*

Yes, I agreeNo, I do not agree
Date*

MonthDay Year
Date
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.

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

Program Agreements
AGREEMENT: I understand agree to and/or acknowledge the following:
Program Agreements

I understand that C.A.E.'s program design is based on a group care model; it is in the best interest of the program and youth experience to share the details describing the needs of your child to ensure the appropriate experience may be offered without causing compromise to program required regulations and to ensure reasonable modifications may be made if necessary.

I acknowledge that I have received a copy of the most current Parent Handbook, which may be located on the C.A.E. website, and will comply with the policies set forth. I acknowledge that I have read and I understand C.A.E.’s policies and procedures related to field trips. I acknowledge that I have read and I understand C.A.E.’s policies and procedures about staff and volunteers not being permitted to babysit, transport, or relate to children anytime outside of C.A.E. programming, found in the Parent Handbook. I understand that I am not allowed to leave my child at the C.A.E. program site unless C.A.E. staff is there to receive and supervise my child. I understand that the C.A.E. staff are not permitted to be alone with one single child, this may impact the location for pick up and or delay drop off as staff must ensure a 2nd staff member is present. I understand should a person arrive to pick up my child who appears to be under the influence of drugs or alcohol, for the child’s safety, staff may have no recourse but to contact the police. I understand that all C.A.E. staff are mandated by state law to report any suspected child abuse or neglect to the appropriate authorities for investigation. I understand that Law Enforcement personnel may request the information in your file and may interview your child if necessary. I understand that, per the Pennsylvania Department of Licensing and Regulatory Affairs, my child’s file is available for review, and representatives from these agencies may interview my child without prior parental/guardian permission. This is a process connected to program self–reporting, in the case this is necessary, the state representatives will involve the guardians as appropriate.

I acknowledge that I have read and understand C.A.E.’s Positive Discipline policies and child suspension/ removal procedures, including pick-up time limits and penalties, found in this packet and in the Parent Handbook, which may be located on C.A.E.'s website. C.A.E.’s Positive Discipline policies and child suspension/ removal procedures, including pick-up time limits and penalties. C.A.E. may terminate my child’s enrollment for any of the following reasons:
- Emergency names and phone numbers are incorrect.
- A parent is late picking up a child after the program closes on a consistent basis.
- Non-payment or late payment
- Failure to adhere to the sign-in and out policy.
- Failure to notify the YMCA that the child is absent.
- Child leaving the program site without authorized permission.
- Behavior that is continually disruptive or dangerous to others and/or self.
- Behavior that is disruptive to property and/or refusal to replace said property.
- Any single incident that is deemed by C.A.E. staff to be dangerous, harmful, or disruptive.
- Harassment, violent behavior, or threat of such behaviors against a staff person or other member by parent/guardian or persons associated with the child (family member, family friend, etc.).
I understand that C.A.E. and the staff employed by C.A.E. will not become involved in custodial disputes between parent/guardian. All documents requested must come from the courts and be signed by a judge. The staff’s responsibility is to provide a safe environment for children.

I understand I am required to give 14-day notice when terminating my child from the C.A.E. program or when making changes to my program option or plan. Without proper 14-day notice, I will still be billed as regularly scheduled. Registration Tuition/Fees are non-refundable. I understand and agree that in the event my child is not picked-up by closing, the Program site will immediately make every attempt to contact me or other persons authorized by me to take my child from the program site. If my authorized individuals or I cannot be located, or if satisfactory arrangements for picking up the child cannot be made, C.A.E. staff will continue to try to locate me or another designed person; but if those efforts are unsuccessful within a reasonable period of time, the appropriate law enforcement and welfare authorities will be contacted. I hereby release C.A.E., its employees, and its agents from all liability for any damage sustained by my child or by me which results directly or indirectly from the procedure outlined above. I further agree that I will indemnify and hold C.A.E. and C.A.E. Program harmless for any damage sustained by my child if this procedure must be utilized because I fail to pick up my child on time from the program site or because any person designated by me fails to pick up my child on time from the program site. I hereby release C.A.E., its employees, and agents from all liability and responsibility for any damages sustained by my child after closing time. I understand and agree that if my child is not picked up at the designated time on a consistent basis, my child and I may be dropped from the program.

I agree to allow and grant permission for my child to participate in all activities which are a part of the C.A.E. Program. These activities include the use of the gymnasium and apparatus (at sites where permissible), woodworking, cooking, messy arts and crafts, sports, fitness, outdoor games, adult-supervised walks in the immediate neighborhood/community of the C.A.E. program site, field trips and other active play experiences typical in an after school program and day camp program. I hereby release and discharge C.A.E., officers, employees, agents, and servants (herein, collectively referred to as the C.A.E.) from all liability associated with camp activities. For the purpose of this agreement, liability means all claims, demands, losses, courses of action, suits, or judgments of any kind that I, my heir, executors, administrators, or assignees may have against C.A.E. because of any loss or damage to property that results from any cause other than the gross negligence of C.A.E.

I understand that college students may make observations at C.A.E. as a part of class assignments and that any observation will be done only under the supervision of the chief learning officer; student observers are not permitted to photograph students.

All of our Out-of-School-Time curriculums are research-based to foster and develop your child (ren) in the four key areas of; emotional and mental wellness, physical wellness, family, and character. To evaluate the effectiveness of these curriculums, we will be surveying all students with a pre-assessment at the beginning of programming and a post-assessment at the end of programming. This brief survey will take no more than 10 minutes for them to complete and asks questions like; have you made a friend during programming, and do you feel safe at the program? All information gathered will be kept confidential, and no personal information will ever be shared. Results will only be shared, aggregated, and de-identified. By agreeing, you give permission for your child to participate in these surveys. Should you or your child choose not to participate in the surveys, your child will simply continue in their regular day camp programming with no repercussions.

I understand my child is required to participate in C.A.E.’s Character & Leadership Development Course. This course is held one day per week for 1.5 hours.

I agree to pay a one-time $50.00 enrollment fee each program year. I understand additional fees may be charged (i.e., program tuition fees, activity supplies, field trips, etc.). Scholarships are made available on a first-come, first-served basis. A 50% discount is available for Mercer County, PA, housing residents. I understand my child will not be discriminated against based on income, race, gender, religion, ethnicity, or disability.

REASONABLE ACCOMMODATIONS CLAUSE:

Children with special needs or challenges will be accepted provided that “reasonable accommodations” can be made for their participation in the program and/or the child’s participation does not require an inordinate amount of staff time that would not allow for the safety and welfare of the other children in the program. I understand that if my child/ren requires a one on one attention, whether due to special needs or behavior, my child may be removed from the program. You are solely responsible for determining if your child/ren is physically fit for the activities contemplated in these programs. It is always advisable, especially if your child/ren has an illness, injury, or impairment, to consult a physician before undertaking any active recreational program.
By signing below, I acknowledge that I have read and agree to all the statements of this Program Agreement document:
Date*

MonthDay Year
Date
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.

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
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*

MonthDay Year
Date
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 Name Last 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*

MonthDay Year
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.
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 PLAN & HOW IT WORKS FINANCIAL POLICIES AGREEMENT
C.A.E. Tuition: The C.A.E. Financial Agreement is a continuous monthly payment plan for C.A.E. program tuition, if applicable. I understand this payment plan will remain in effect for as long as I have my child enrolled in C.A.E. programming, or until ACH/credit card is cancelled or the authorization granted to C.A.E. has been revoked.

Agree
I have read and I understand the tuition payment due dates, if applicable, will be shared at the time of program enrollment. Schedule changes are allowed (pending availability) as long as they are communicated 14 calendar days prior to the start of each week.*

Agree
I understand that program participation requires that my account is in good standing with all balances up to current. This includes tuition fees and membership dues (if applicable). Non-payment of program fees and/or membership dues, will result in my child not allowed to participate in the program and could result in legal referral with the additional costs to myself, until the balance is paid and current. I further understand that there is an administrative processing fee for any payment returned by my bank or credit account and for late payments.

Agree
I understand this completed enrollment packet is a requirement of program participation and must be provided three business prior to the intended start week. Failure to complete this form will result in the non-completion of the enrollment packet and therefore cancel enrollment (less the $40 cancellation fee).*

Agree
By signing below, I acknowledge that I have read and agree to all the statements on Payment Plan and How it Works.
Date*

MonthDay Year
Date
Electronic signature*

GETTING TO KNOW YOU QUESTIONNAIRE
C.A.E. makes safety a high priority in our programs. In order to best serve our participants, we are requesting additional information to ensure we are equipped to provide the best possible experience. Detailing the information below will help ensure we are the right program model to best serve your child’s needs and that your child has the greatest opportunity for success while in our care. Once the information has been submitted, the program lead will review these details. If any information requires a follow-up conversation for further details, the program lead will connect with you directly. Thank you for helping us best serve the youth!
Tell us about your child’s school experience/environment, any supports offered throughout the day or additional services provided?
Are there any supportive services you or your child currently needs? (i.e., Health Services, Housing Services, Recovery Support Services, Respite Care Programs, etc.)*
What types of things does your child enjoy? Hobbies, Heroes, Interests
What things frustrate or overwhelm your child? Sounds, interactions with others
How do they handle frustrations? What are techniques are used for soothing and calming?

Secure Online Payment
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!

Submit Packet & Payment
Please note, payments can also be received at the C.A.E. Arts Academy & Sports Complex (Chavers Center), located at 211 Federal St., Farrell, PA 16121. Please be sure to call Ms. LaShay at (866) 961-2239 x 5 in advance.
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C.A.E. Student Enrollment Fee
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C.A.E. Student Enrollment Fee
C.A.E. STOMP Youth Enrollment Fee Only$50.00
Annual enrollment fee for the fiscal year 2022/2023

C.A.E. Lock-In + STOMP Enrollment Fees$40.00
C.A.E. Youth Lock-In plus STOMP Ambassador Program combined fees.

C.A.E. Event Registration Fee
C.A.E. Lock-In Registration Only$10.00
C.A.E. Youth Lock-In Event Scheduled December 16th

C.A.E. Lock-In + STOMP Enrollment Fees$40.00
C.A.E. Youth Lock-In plus STOMP Ambassador Program combined fees.

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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.

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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

3rd Parent/Guardian/Authorized Representative

4th Parent/Guardian/Authorized Representative

Emergency Contacts/Authorized Pick Up

Restricted Pick Up

Physician & Dentist

CONFIDENTIAL HEALTH HISTORY STATEMENT

Authorization & Release for Medical and Dental Treatment

Child's Health Statement

Program Agreements

TRANSPORTATION RELEASE

Release and Waiver of Liability and Indemnity Agreement

PHOTO & VIDEO/AUDIO RECORDING RELEASE

PAYMENT PLAN & HOW IT WORKS FINANCIAL POLICIES AGREEMENT

GETTING TO KNOW YOU QUESTIONNAIRE

ARE YOU READY?

Secure Online Payment

Submit Packet & Payment

Payment Methods

Enter coupon