Day Camp 08 Eng App

Strycker’s Bay Neighborhood Council Inc. 61 West 87th Street NY, NY 10024 (212) 874-7272 LACASA Youth Program Enrollment Form STUDENT INFORMATION Student Name _____________________________________________ Home Address_____________________________________________ Apt. # ___After-School ___Day Camp This form must be completed and signed by the parent or guardian of any child enrolling in the LACASA Youth Program. Home Phone (______)______________________ Zip Code _________________________________ ο Queens (optional) City: ο Bronx Mo. Day ο Brooklyn Sex Year ο Manhattan οM οF ο Staten Island Birth Date ______/______/______ Race/Ethnicity ____________________________ _______ Grade _____________________________________________ Homeroom Teacher Student I.D. #__ __ __ __ __ __ __ __ __ 9 digit NYC Dept. of Ed. # Will you be enrolling other children into the program? ο Yes ο No If yes, please complete the following: _____ Grade _____________________________________________ Student Name ________________________________ Homeroom Teacher _____________________________________________ Student Name _____ Grade ________________________________ Homeroom Teacher PARENT/GUARDIAN INFORMATION Parent/Guardian #1 Name Live in same home? ο Yes ο No If no, please complete the following: Home Address_____________________________________________ Apt. # Relationship to student ______________________ Home Phone (______)______________________ Zip Code _________________________________ Email ____________________________________ Speaks English? ο Yes ο No City: ο Bronx ο Brooklyn ο Manhattan ο Queens ο Staten Island Work Phone (______)_____________________ Cell Phone (______)_____________________ If no, specify______________________________ Parent/Guardian #2 Name Live in same home? ο Yes ο No If no, please complete the following: Home Address_____________________________________________ City: ο Bronx ο Brooklyn ο Manhattan ο Queens ο Staten Island Work Phone (______)_____________________ Cell Phone (______)_____________________ Relationship to student ______________________ Home Phone (______)______________________ Zip Code _________________________________ Email ____________________________________ Speaks English? ο Yes ο No If no, specify______________________________ 1 Strycker’s Bay Neighborhood Council Inc. 61 West 87th Street NY, NY 10024 (212) 874-7272 RELEASE OF CHILD A. I give my child permission to walk home alone at dismissal. B. My child will be picked up after-school by me or one of the following individuals: Name Home Phone (______)_____________________ Cell Phone (______)_____________________ Relationship to student ______________________ Speaks English? ο Yes ο No ο Yes ο No If not, specify______________________________ ο Yes ο No Following emergency medical care, my child may be released to the above named person Name Home Phone (______)_____________________ Cell Phone (______)_____________________ Relationship to student ______________________ Speaks English? ο Yes ο No If not, specify______________________________ ο Yes ο No Following emergency medical care, my child may be released to the above named person Name Home Phone (______)_____________________ Cell Phone (______)_____________________ Relationship to student ______________________ Speaks English? ο Yes ο No If not, specify______________________________ ο Yes ο No Following emergency medical care, my child may be released to the above named person ο Yes, I have informed the persons above that they are listed as emergency contacts for my child C. DO NOT RELEASE MY CHILD TO THE FOLLOWING PEOPLE: Name Name Relationship to student ______________________ Relationship to student ______________________ PARENT/GUARDIAN SIGNATURE I give my child permission to participate in all the program activities, including academic support, enrichment, social development, arts, sports, recreation, fitness and wellness, and attendance services (for Attendance Improvement Dropout Prevention programs only). I understand that all program activities will be supervised by the community-based-organization providing the services. I agree that the professional staff of the program may meet with my child and review my child’s attendance, achievement and guidance records (for Attendance Improvement Dropout Prevention programs only) when appropriate. ______________________________________________________________________________________________________ Parent/Guardian Signature Date 2 Strycker’s Bay Neighborhood Council Inc. 61 West 87th Street NY, NY 10024 (212) 874-7272 HEALTH RECORD To be completed by the parent or guardian. This confidential health record will only be used to ensure the safety of the children in this program. Feel free to continue your notes on back of this form Student’s Name ___________________________________________________________ PLEASE PROVIDE YOUR CHILD’S MEDICAL HISTORY Allergies to food ο Yes ο No Behavioral/emotional issues Individualized Education Plan Physical Disabilities Corrective Device Asthma Allergies to penicillin Convulsions/seizures Hay Fever ο Yes ο Yes ο Yes ο Yes ο Yes ο Yes ο Yes ο Yes ο No ο No ο No ο No ο No ο No ο No ο No Birth Date ______/______/______ Mo. Day Year Specify_________________________________________________ Specify_________________________________________________ Specify_________________________________________________ Specify_________________________________________________ Specify (glasses, hearing aid, etc.)____________________________ Does your child use an inhaler? Allergy to plants Diabetes Allergy to insect stings ο Yes ο Yes ο Yes ο Yes ο No ο No ο No ο No Other_______________________________________________________________________________________________________ ____________________________________________________________________________________________________________ SPECIAL HEALTH CARE NEEDS ο Yes ο No Does your child have special health care needs that require treatment and/or medication? If yes, describe below. If your child requires treatment and/or medication during after-school hours, complete the Health Care Plan for a Child with Special Health Care Needs form. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ MEDICATION Does your child take medication for any condition or illness? If yes, describe below. If your child requires medication during after-school hours, complete the Medication Consent form. ο Yes ο No ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ACTIVITY PARTICIPATION Are there any activities your child cannot participate in? If yes, describe below. ο Yes ο No ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ο Yes ο No SUNSCREEN AND TOPICAL OINTMENTS Do you give permission to the after-school program to apply sunscreen or other over-the-counter topical ointments on your child? HEALTH/INSURANCE INFORMATION Student’s Doctor: _________________________________________________ Insurance company: _______________________________________________ Phone: (______)_____________________ Policy Holder’s ID:______________________ If my child requires emergency medical care and I cannot be reached, I give my consent to the above after-school program to obtain the necessary medical care for my child. I agree to pay all of the costs associated with the emergency medical care that my child receives. I understand that every effort will be made to contact me before and after medical care is provided. I understand that this consent will be in effect as of the date of my signing this form and will continue as long as my child is enrolled in this after-school program. __________________________________________________________________________________________ Parent/Guardian Signature Date THE NEW YORK CI T Y DEPARTMENT OF EDUCATION JOEL I. KLEIN, Chancellor Office of Communications & Media Relations 52 Chambers Street, New York, NY 10007 Tel.: 212-374-5141 Fax: 212-374-5584 v 08-2004 OMR/OLS CONSENT TO PHOTOGRAPH, FILM OR VIDEOTAPE A STUDENT FOR NON-PROFIT USE (e.g.: educational, public service or health awareness purposes) Name of Student: _________________________________________________________ School: _____________________________________________ Class: ______________ I, _________________________________________, hereby consent to the participation (Parent or Guardian’s Name) in interviews, the use of quotes, and the taking of photographs, movies or video tapes of my son/daughter and his/her program-related work by the LACASA Youth Program. I also grant to THE AFTER-SCHOOL CORPORATION the right to edit, use and reuse said products for non-profit purposes. I also hereby release the New York City Department of Education and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above. __________________________________________ (Signature of Parent/Guardian) ______________________________ (Date) ______________________________________________________________________________ (Address of Parent/Guardian)