John Southard Youth Recreation Commission (JSYRC) Summer Program

Child's Information

Child's Name
Child's Name

Parent/Guardian Information

Parent/Guardian Name
Parent/Guardian Name
I am interested in Volunteering for the JSYRC program on Wednesdays and/or Thursdays.

Emergency Contact Information

These are the people you are choosing as emergency contacts if you cannot be reached while your child is participating in the JSYRC program.

Emergency Contact #1 Name (do not use the parent/guardian listed above)
Emergency Contact #1 Name (do not use the parent/guardian listed above)
Can Contact #1 sign your child in and out of the program
Emergency Contact #2 Name (do not use the parent/guardian listed above)
Emergency Contact #2 Name (do not use the parent/guardian listed above)
Can Contact #2 sign your child in and out of the program
Emergency Contact #3 Name (do not use the parent/guardian listed above)
Emergency Contact #3 Name (do not use the parent/guardian listed above)
Can Contact #3 sign your child in and out of the program
In case of accident, injury, or medical emergency when parents and persons designated cannot be reached, the program may authorize emergency medical treatment (i.e. take to the hospital.)
I grant permission for my child's to be photographed and or appear in videos while in the JSYRC program

Photo Release

Please sign this form allowing Catholic Charities Steuben/Livingston, JSYRC and the Dormann Library permission to use images (photos or videos) of you or an individual you are responsible for purposes as noted below.

Photographs and or Videos may be used for historical, educational, biographical, informational, or promotional purposes in a variety of multimedia including but not limited to: print (flyers, posters ,brochures, newsletters). Television (ads or interviews). Online (Facebook Page, Twitter Account, Flickr account, YouTube, Remind  or Website and or Presentations for live audiences (PowerPoint or Similar Software).

I grant permission for my child's photographs and/or videos to be shared on Social Media or in presentations
I understand that I can change my mind about photographs and videos of my child at any time by sending an email to or by calling (607) 776-8085, extension 2228.

Parental Permission

I hereby give my child permission to participate in the JSYRC program in the Summer of 2022. I hereby release and hold harmless JSYRC, Dormann Library and their employees, and/or volunteers from any all liability which may be incurred by my child, and/ or property from participation in the program. I understand that there is a risk for participants to contact COVID19 by attending our program.
My Child will participate in JSYRC program on Monday through Wednesday from 1pm to 3pm.
My Child will participate in Cornell Cooperative Extension program Tuesdays 1pm-2pm. After the program they will stay for outdoor games till 3pm.
My child will participate in the free Summer Lunch program at the Dorman Library on Monday through Wednesday between 11:30 and 12:30 . This is offered by the School free Summer Lunch program and Dormann Library and open to all children under the age of 18. Then my child will sign in to JSYRC at 1pm.
My child will participate in the JSYRC Arts and Crafts on Monday and/or Wednesday 1pm-3pm at the Dormann Library.
My child will attend field trips Thursdays. Trips departure time can range from 9am to 12:30pm.
My Child has permission to sign in and out of the JSYRC program without an adult

By typing my name below I am granting permission for my child to participate in the JSYRC program at the Dormann Library.

Behavior Contract 2022

Code of Conduct:

  • Possession or consumption of alcoholic beverages or the possession or use of illegal drugs or drug paraphernalia or the possession of weapons will not be tolerated. Failure to comply will result in IMMEDIATE DISMISSAL from event and suspension for remainder of the JSYRC program 2022.
  • CIGARETTE SMOKING AND CHEWING OF TOBACCO WILL NOT BE ALLOWED.  Children and adults signing into and out of the program are not allowed to be using Tobacco in any form.
  • Use of Vapes, Electronic Cigarettes will not be allowed on the Program Site by Children and adults signing them into and out of the program.
    * Participants must attend and remain with chaperones during all scheduled activities and events and remain in areas designated for program events.
  • Participants are expected to obey the direction of all program staff and volunteers
  • Appropriate Behavior, language and clothing are expected.  We are a child focused program.
  • No dangerous or rough play will be tolerated.
  • Respect, Honesty and Dignity is expected towards everyone, whether they are part of our group or not.
  • Children may not leave the JSYRC program once signed in and return to the JSYRC program.  JSYRC program is Monday and Wednesday from 9am to 11am and Tuesday and Thursday from 10:30am to 11:30am.

2022 Discipline Policy:

  • Depending on the severity of the behavior exhibited, the child and parent will need to report to a mandatory meeting with the Director or person designated in charge of the program in the directors absence to determine a solution before the child returns to the JSYRC program
  • EXPULSION, SUSPENSION OR OTHER LOSS OF PRIVILIEGES from the Summer Program for that current year may be a result based by the JSYRC official rulings.  Program director decision regarding participants is final.
  • Parent/Guardian will be notified in writing in any large behavior infractions or after a second verbal warning has been issued to the child for a repeated behavior.
We have read the information/expectations and agree to abide by the Code of Conduct. If these rules are violated . I understand that I will be notified by phone if there is a behavior issue and if the behavior continues or it is determined that the child needs to leave the program I will be responsible for going to picking up my child from the event regardless of where the event is held for that day. We also understand that the Summer Recreation program is voluntary and is being offered as a privilege that may be taken away. Inappropriate behaviors will not be tolerated and will result in dismissal all summer JSYRC Events, Arts and Crafts.  Please type Parent/Guardian Name below to agree to the Code of Conduct.

Income Guidelines

*** Please only complete this form if it applies to your family.  Otherwise leave blank.***

Number of People Annual Income Monthly Income
1 $25,520 $2,127
2 $34,480 $2,873
3 $43,440 $3,620
4 $52,400 $4,367
5 $61,360 $5,113
6 $70,320 $5,860
7 $79,280 $6,607
8 $88,240 $7,353
9 $97,200 $8,100
10 $106,160 $8,847
Each extra person add $8,960 $746


200% Poverty for 2020 - 2021
2021-2022 Federal Income Guidelines
Effective through June 30, 2022

Income is below the poverty rate listed above based on number of people living in household

By signing (typing my name), I am swearing, under penalty of perjury, that I have examined the above 2020-2021 Poverty Guideline table and that based on income level and family size I am eligible for services provided to those individuals/families at or below the 200% of poverty income guidelines.