Chemung County Youth Bureau Keycode Request

Chemung County Youth Bureau Keycode Request
PLEASE READ CAREFULLY!!

In order to register your child(ren) at a reduce fee or program scholarship, you must meet all of the following:

1)Create an account at https://chemungcountyny.myrec.com

2)Add your child(ren) as members to your account. If your child is not added to your account, you will have to add them before the Youth Bureau can apply their key code and you can register them for Summer Cohesion.

3)Fill out the information below to authorize the release of information for the Youth Bureau to verify your child(ren) recieve SNAP, HEAP, or Medicaid, in which they may be eligible to attend Summer Cohesion at a reduced fee. If your child(ren) receives CASH assistance, they may be eligible to receive a program scholarship.

The deadline to have a key code applied to your child(ren) within the registration system is May 23rd. If you miss the deadline to apply for a keycode, you will be responsible to pay the full fee.

Please be advised that having a key code applied to your child(ren) DOES NOT guarantee a spot nor is it registering your child(ren) within the Summer Cohesion program. If your child(ren) are successfully verified as receiving a service listed above, you will be emailed (at the email address provided below) that the key code(s) have been successfully added to your child.

IF YOU DO NOT RECEIVE AN EMAIL THAT YOUR SUBMISSION HAS BEEN RECEIVED, PLEASE CHECK YOUR JUNK MAIL.

If your child(ren) DO NOT receive any of the above services, please refer to the income guidelines below to help determine if you will qualify for a reduced fee. If you meet the guidelines, please contact the Youth Bureau to set up an appointment to verify your eligibility according to your adjusted gross income on your 2024 tax forms.
Parent Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address to send Keycode information*
example@example.com
Phone Number*
Case Type*
If no case, type "none".
Case Number*
Child 1's Name

First NameLast Name
Child 1' Birthdate

MonthDayYear
Date
Child 2's Name

First NameLast Name
Child 2' Birthdate

MonthDayYear
Date
Child 3's Name

First NameLast Name
Child 3's Birthdate

MonthDayYear
Date
Child 4's Name

First NameLast Name
Child 4's Birthdate

MonthDayYear
Date
Authorization for Release of Information
By signing below you will grant authority to the Chemung County Department of Human Services, or a representative thereof, to:

Obtain from andRelease to
Name of Organization/Agency OR Person: Chemung County Youth Bureau
Nature of Information to be Disclosed:

Attendance and participationShare identifying information between the Youth Bureau and DSS to confirmIncome/Government benefits (SNAP/TA/MA/HEAP)
This form is used to authorize use or disclosure of an individual's protected health information for the purposes state below:

To allow for verbal/written communicationTo verify eligibility, address, and date of birth for childrenTo secure and/or maintain public benefits
This information has been disclosed from records protected by Federal confidentiality rules, 42 CFR Part 2, as well as the Health Insurance Portability and Accountability Act of (HIPAA) of 1996. The Federal rules prohibit any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2 and/or Section 33.13 of the NYS Mental Hygiene Law.

I, the undersigned, have read the above and authorize the disclosing agency/person named to disclose such information as herein contained. I understand that this authorization may be revoked by me at any time, in writing, except to the extent that action has been taken in reliance upon it. This authorization shall expire twelve (12) months from its signing, unless a different time period, event or condition is specified below, in which case such time period, event or condition shall apply.
Parent/Guardian/Personal Representative Signature:*

Clear
Date

MonthDayYear
Should be Empty:

Chemung County Youth Bureau Keycode Request

Authorization for Release of Information