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No I choose not to allow my child s information to be used as part of the program evaluation. QUESTIONS OR CONCERNS Contact either Kristina Woznicki Walnut Street YMCA Associate Executive Director kwoznicki ymcade. For more information about DECHIP call 1-800-996-9969. IF YOU DO NOT CHECK THIS BOX YOUR INFORMATION WILL BE SHARED WITH MEDICAID AND/OR DECHIP. Ascr. usda.gov/complaintfilingcust. html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the...
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