Community Evening Resource Center(CERC) Intake Packet

GPCA Media Consent, Release, and Waiver
I hereby give consent to Greater Philadelphia Community Alliance (the "organization") to photograph, videotape, or otherwise digitally record and use images and/or sound recordings of myself or my child or children (if applicable) to use in any public media, including radio, television, internet, social media, print or in any of GPCA's or its partners' publications, productions, or posts. I understand that the intended use of such images and information is solely for the organization's advertising, marketing, fundraising, and/or promotional and public awareness purposes. I hereby waive any rights or interestin the images or recordings as contemplated in this release.
I acknowledge that this consent to use images and/or recordings is being made solely for the organization's benefit and comes without any expectation of monetary compensation or other benefit to me. To the extent that any benefit accrues or might accrue to the organization from the use of images or information, I hereby and forever waive any interest in or claim to such benefits.
I hereby release and forever discharge the organization (including without limitation all corporate affiliates and officers, directors, trustees, donors, employees, agents, and volunteers) from any claims, liability, actions, suits, demands, costs, expenses, or indebtedness arising out of, related to, or in any way connected with the use of images and materials described herein. I hereby waive all rights and interest in and to such information and materials.
I further acknowledge that there is no guarantee that any or all the participants' images or recordings will be used in any released media.
I have been informed that this authorization is voluntary and is subject to revocation at any time, except to the extent that action has been taken in reliance thereon, by notifying the organization in writing at:
Mamie Nichols
1529 S. 22nd Street
Philadelphia, PA 19146
or Email ConnieAlston@gpca-phila.org
Parent's Signature:
Date:

MonthDayYear
Date
Parent Name
1. Child Name and Program
Type your child's name and CERC

Permissions and Policies
Greater Philadelphia Community Alliance Community Evening Resource Center (CERC) is a FREE afterschool and summer program that provides fun, evidence-based programming for youth ages 10 through 17. Daily attendance is essential for student and program success. To maintain "FREE status" eligibility, participants must attend the program at least two (3) days a week. Program hours are Sunday through Sunday, 6 p.m. to 10 p.m.
Parent: (Please initial where appropriate)
My child and I have received the GPCA Parent Handbook and acknowledge the program expectations. (Parent Initials)
My child has permission to use the gym, and Hi-tech equipment like computers, and cameras. (Parent Initials)
My child is hereby granted permission to participate in the GPCA/CERC Program operated by Greater Philadelphia Community Alliance. (Parent Initials)
My child will walk home from the GPCA/CERC program upon dismissal. (Parent Initials)
My child will be picked up by me and should be at the center until my arrival. (Parent Initials)
My child has permission to attend walks and trips planned by GPCA/CERC. (Parent Signature)
My child has permission to swim and participate in water activities. (ParentSginature)
I give GPCA and CERC permission to use my child's photo not limited to web pages, social media, newsletters, or any media outlet. (YouTube, Instagram, Facebook). (Parent Initials)
I the Parent or Guardian of the youth will participate in at least one planned GPCA/CERC event once a month. (Parent Initials)
My child has permission to be transported on the GPCA/CERC vehicles. (Parent Signature)
I allow GPCA to obtain emergency medical care for my child if needed. (Parent Signature)
I allow GPCA to administer minor first-aid procedures for my child if needed. (Parent Signature)

Program Requirements
Please read the below information carefully. It's basic information and program expectations. You are required to sign that you understand and agree to the following
Appropriate Behavior/Discipline
Participation in the GPCA/CERC Teen Program is a privilege. Youth are required to follow program rules and expectations at all times. Disruptive or disrespectful behavior toward any student or staff person is strictly prohibited and grounds for immediate dismissal. Please refer to the Parent Handbook for policies and procedures.
Attendance
Program attendance and participation is MANDATORY. All participants are required to maintain attendance a minimum of (12) days per month, 6 pm to 9 pm. Any child who has been absent for one month consecutively, or who continues NOT to participate in the program and its activities, or who regularly leaves early will be discharged from the program.
1. Youth will participate in programming provided by GPCA/CERC: STEAM and extra-curricular activities and clubs facilitated by CERC mentors, guest speakers, and associate Youth Development Specialists.
2. Youth will participate in three (3) culminating events per school year and one (1) culminating event during the summer attached to their structured activities.
3. Participants will attend at least one (1) industry tour related to the structured activity focus area.
4. Participant will complete pre and post-assessments designed to monitor their progress with their assigned mentor.
5. Youth will participate in one (1) community outreach project during the year.
6. Parents will participate in satisfaction surveys at the end of the school year.
7. Parents must attend periodic family events.
8. Parent supportis critical to the success of youth. Please see the program staff for a list of activities provided by the CERC Program. To see how you can help in the success of this program.
I, Parent Name* and I, Student Name* have read, understand and agree to comply with the expectations outlined above. I realize that failure to comply with these requirements may resultin loss of privileges to participate in the CPA/BGC Teens programming.
Parent/Guardian Signature*
Date*

MonthDayYear
Date
Student Signature*
Date*

MonthDayYear
Date

Emergency Contact / Parental Consent Form

55 PA CODE CHAPTERS 3270.124 (a) (b), 3270.181 & 182: 3280.124 (a) (b), 3280.181 & 182; 3290.124 (a) (b), 3290.181 & 182
CHILD'S NAME*
DATE OF BIRTH*

MonthDayYear
Date
ADDRESS*
Parent / Guardian Information
PARENT'S NAME/LEGAL GUARDIAN 1*
HOME TELEPHONE NUMBER*
Format: (000) 000-0000.
ADDRESS*
BUSINESS NAME
BUSINESS TELEPHONE NUMBER
Format: (000) 000-0000.
BUSINESS ADDRESS
PARENT'S NAME/LEGAL GUARDIAN 2
HOME TELEPHONE NUMBER
Format: (000) 000-0000.
ADDRESS
BUSINESS NAME
BUSINESS TELEPHONE NUMBER
Format: (000) 000-0000.
BUSINESS ADDRESS
Emergency Contact Information
EMERGENCY CONTACT PERSON NAME (1)*
TELEPHONE NUMBER WHEN CHILD IS IN CARE (1)*
Format: (000) 000-0000.
EMERGENCY CONTACT PERSON NAME (2)
TELEPHONE NUMBER WHEN CHILD IS IN CARE (2)
Format: (000) 000-0000.
Authorized Pick-up Person Information

List those individuals authorized to pick up your child (include yourself). Your child will be permitted to leave with these individuals only and photo identification will be required at sign-out. They must be 18 years old or older.
PERSON TO WHOM CHILD MAY BE RELEASED #1*
RELATIONSHIP TO YOUTH*
ADDRESS*
TELEPHONE NUMBER WHEN CHILD IS IN CARE*
Format: (000) 000-0000.
PERSON TO WHOM CHILD MAY BE RELEASED #2
RELATIONSHIP TO YOUTH
ADDRESS
TELEPHONE NUMBER WHEN CHILD IS IN CARE
Format: (000) 000-0000.
PERSON TO WHOM CHILD MAY BE RELEASED #3
RELATIONSHIP TO YOUTH
ADDRESS
TELEPHONE NUMBER WHEN CHILD IS IN CARE
Format: (000) 000-0000.
PERSON TO WHOM CHILD MAY BE RELEASED #4
RELATIONSHIP TO CHILD
ADDRESS
TELEPHONE NUMBER WHEN CHILD IS IN CARE
Format: (000) 000-0000.
Name of persons not permitted to pick up youth (appropriate authorized custody documents must be attached if a parent is not allowed to pick up youth):
NAME OF CHILD'S PHYSICIAN/MEDICAL CARE PROVIDER*
TELEPHONE NUMBER*
Format: (000) 000-0000.
ADDRESS*
SPECIAL DISABILITIES (IF ANY)
ALLERGIES (INCLUDING MEDICATION REACTION)*
Type "none" if no allergies
MEDICAL or DIETARY INFORMATION NECESSARY IN AN EMERGENCY SITUATION
MEDICATION, SPECIAL SITUATION
ADDITIONAL INFORMATION ON SPECIAL NEEDS OF CHILD
HEALTH INSURANCE COVERAGE FOR CHILD or MEDICAL ASSISTANCE BENEFITS*
POLICY NUMBER (REQUIRED)*
PERIODIC REVIEW
SIGNATURE OF PARENT or GUARDIAN 1*
DATE*

MonthDayYear
Date
SIGNATURE OF PARENT or GUARDIAN 2*
DATE*

MonthDayYear
Date
Community Evening Resource Center Staff:

Copy authorized individual's photo identification and place it in youth's file.
CY 867 10/22

If you have any questions or concerns, please contact:
Director of Youth Services:
Jewel Felder-James M.Ed.
267-981-0254
jewelfelder-james@gpca-phila.org
Should be Empty:

Community Evening Resource Center(CERC) Intake Packet

Member Health and Special Needs Form

GPCA Media Consent, Release, and Waiver

Permissions and Policies

Parent: (Please initial where appropriate)

Program Requirements

Appropriate Behavior/Discipline

Attendance

Emergency Contact / Parental Consent Form

Parent / Guardian Information

Emergency Contact Information

Authorized Pick-up Person Information

Community Evening Resource Center Staff: