Urban Youth Impact: Summer Jam Registration 2021

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Dear Parents/Guardians,

We are very excited that you have expressed an interest in Urban Youth Impact's summer program, Summer Jam! We are very excited for a fun filled, COVID safe and friendly summer. There will be regularly scheduled academic lesson plans, spiritual enhancement activities, field trips, life skills, and team-building challenges all within CDC COVID guidelines.

Summer Jam times are from 9:00 am- 4:00 pm, Monday through Friday with a half-day on the last day. A parent handbook is provided on the first week of Summer Jam with a calendar, important dates, COVID guidelines and with a page that must be signed and returned upon reading it with your child. The fee per child is $50 for the summer. Your application is not considered complete until your payment is submitted.

The theme of this year's Summer Jam is:

HEROES & VILLAINS.

When we compare the stories of Jesus and his his disciples to those in the Marvel Superhero Universe, we can see how these stories are relevant for our lives today, and how Jesus, the true hero of the story, inspires us to be heroic in the battles of our lives.

The goal of Summer Jam is to make camp exciting, engaging, realistic, and most of all, memorable for all the campers.

Please read the following important information regarding Summer Jam:

Summer Jam dates are June 28-August 6th, 2021.

Summer Jam applications must be completed by Monday, June 15, 2021 for all children who you would like to attend to our summer program. Please note that children currently enrolled in TLA and TAC students take priority enrollment and each application is accepted on a first come first serve basis.

We provide lunch and snack everyday of Summer Jam. In the event that we are unable to do so, parents/guardians will be required to provide lunch for their children. We do require every child wear a face mask and that every child participates in a temperature check upon entry of the building.

If you have any other questions, comments and/or concerns, please do not hesitate to contact me at ddarling@urbanyouthimpact.com.

Kind regards,

Daniella Darling

Programs Administrator

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Only one child per application. This application must be completed by Monday, June 15, 2021.

*Please notify Urban Youth Impact if any of the following information changes*

Summer Jam Application

Date of application

MM/DD/YYYY

How did you hear about us?

If other, please specify in the box below.

Which community/neighborhood do you live in?

Child's Information

First Name

Last Name

Nickname

Date of Birth

MM/DD/YYYY

Gender

Race/Ethnicity

If you indicated "other" under race/ethnicity, please explain here:

Home Address

Street Address

City

State

Zip Code

Is your mailing address different from your actual address?

If different, please enter mailing address.

City, State

Zip Code

School child will attend in 2021-2022

Grade student is going into.

Does your child receive free lunch?

Student's School I.D Number (PBS Number):

ALL INFORMATION IS CONFIDENTIAL

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Family Data

Parent/Guardian 1 first name

Parent/Guardian 1 last name

Relationship to child:

Parent/Guardian 1 cell phone

Cell phone carrier

Parent/Guardian 1 optional phone

Parent/Guardian 1 email

Total number of people in household

Total annual household income

Please use proper capitalization.

Parent/Guardian 2 first name

Parent guardian 2 last name

Parent Guardian 2 cell phone

Relationship to child:

Parent/Guardian 2 email

Optional phone

Parent or Legal Guardian's Information

Are we authorized to release your child to Parent/Guardian 2?

Authorized to release to father?

YesNo

Authorized to release to mother?

YesNo

Do you authorize your child to be picked up by someone other than the parent/guardian on this application?

If you answered "yes" to the above question, please enter the full name, phone number and the relation of the person(s) picking up your child. Your child will ONLY be released to people listed within this application. We will not release your child to anyone who is not identified on this application without parent/guardian consent. All individuals picking up children are required to present photo ID.

Please add (Name - Relationship - Phone Number)

Who does the child live with?

If other, who?

Who is the child's custodial or legal guardian?

If other, please write name of the custodial or legal guardian:

Emergency Contact's Information

Adult to be notified in case of emergency

Relationship to student

Emergency contact person's phone

ALL INFORMATION IS CONFIDENTIAL

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Transportation

The transportation radius listed below is our transportation zone.

Northbound: 36th Street

Eastbound: Spruce Avenue/Broadway/Rosemary

Westbound: Australian/Mangonia Circle/7th Street

Southbound: 3rd Street

Will your child be using UYI transportation to and/or from Summer Jam?

Please select one UYI bus or van transportation service option:

Please enter the address of the preferred pick-up location

Mark N/A if not applicable

Please enter the address of the preferred drop-off location.

Mark N/A if not applicable

*** Please note: If you do not live in our transportation zone, it will be your responsibility to provide transportation to and from program for your child.***

ALL INFORMATION IS CONFIDENTIAL

Signature/Authorization to Review

Please print your name to authorize processing of this application.

Enrollment Conditions

Please note that Urban Youth Impact is making every effort to follow all health department and CDC COVID guidelines as well as to implement sanitization processes. All staff who are working with children will adhere to the CDC and health department suggested guidelines. By submitting this application, you waive the right to hold Urban Youth Impact liable should your child contract any illness or virus during their time at our summer program.

You can submit your payment with cash or card by calling our mainline at 561-832-9220. You an also come to our main administration building and pay online. Remember, your application is not considered complete until payment is submitted.

I agree to the terms and conditions within this application. The information that I have provided is accurate and I am ready to submit it for my child to participate in Urban Youth Impact's summer programming.

YesNo