Urban Youth Impact: Summer Jam Registration 2022

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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! There will be regularly scheduled academic lesson plans, spiritual enhancement activities, field trips, life skills, and team-building challenges.

Summer Jam times are 9:00 am- 3:30 pm, Monday through Friday. Dismissal will be 3:30 - 3:45 pm. A parent handbook is provided on the first week of Summer Jam with a calendar and important dates. Please review the handbook with your child(ren). The handbook will be sent to you prior to enrollment for your electronic signature.

The theme of this year's Summer Jam is:

HESED

The happiest place is the kingdom of Hesed! Hesed is a word for love in the bible that is the all encompassing love of the kingdom of God. It is a word that best describes love as an action rather than a feeling. We will be focusing on the kingdom mindset as we dive deep into the themes of God's love being enduring, steadfast, equal, and devoted.

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 21st - July 15th, 2022.

Summer Jam applications must be completed by Tuesday, May 31st, 2022 for guaranteed enrollment in our summer program. Please note that children currently enrolled in TLA and live in the Tamarind Avenue Corridor take priority enrollment. Applications are accepted on a first come first serve basis.

We provide breakfast, 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.

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

Kind regards,

Will Mydock

Programs Administrator

Daniella Darling

Program Manager

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Only one child per application. Summer Jam ages are Rising 1st-9th Grades.This application must be completed by Tuesday, May 31st, 2022.

*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 the upcoming 2022-2023 School Year

Grade student is going into (The grade your child will be in the upcoming 2022-2023 School Year).

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.

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