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BCM 2018 Summer Program Application Packet
This is your Summer Program Application Packet. This packet should contain:
A letter outlining guidelines for the registration process (1 page)
A copy of the DYCD Application (7 pages)
A Child & Adolescent Health Examination Form (1 page)
A copy of the Parent/Guardian Participation Agreement (1 page)
Monday,February12th,2018DearParents/Guardians:Wehopethisletterfindsyouwellandlookingforwardtothesummerahead.WithgeneroussupportfromtheDepartmentofYouthandCommunityDevelopment,theBrooklynChildren'sMuseum(BCM)isabletoofferatuition-freesummerprogram,Monday–Fridayfrom8:30amto5:45pm,July–August,2018atP.S.189locatedat1100EastNewYorkAvenue,Brooklyn,NY11212.EnrolledparticipantswilltakefieldtripstotheMuseumandotherculturalinstitutionsacrossthecity.Allparticipantswillbeprovidedbreakfastandlunchduringtheprogram.ThisopportunityisavailabletochildrenenteringGrades1-6intheFall2018academicyear.Childrenenteringfirstgrademustcelebratetheir6thbirthdaybyJuly5,2018.WeareacceptingapplicationsfromMonday,February12toFriday,March23,2018.PlacementnotificationswillbesentduringthelastweekinApril.
Toenrollyourchild(ren):STEP1:CompletetheWebFormFilloutandsubmittheBCMSummer2018WebForm(availableonFebruary12
th2018)at
https://www.brooklynkids.org/education/summer-programs/Thisformallowsustobettercommunicateyourchild’sstatusduringtheregistrationprocess.STEP2:DownloadorPickUpACopyofTheApplicationPickupacopyoftheapplicationandhealthformforeachchild.FormswillbeavailableatthefollowinglocationsfromFebruary12–March23,2018:• BrooklynChildren’sMuseumAdmissionsDesk-Hours:Tuesday-Sunday,10:00am–5:00pm(CLOSEDMONDAYS)• P.S.189–MainOffice.Hours:Monday-Friday,9:00am–5:45pm• Online–https://www.brooklynkids.org/education/summer-programs/• Downloadedapplicationsandhealthformsmustbeprintedout,completed,andsubmittedmanually.STEP3:DropOffyourCompletedApplicationParents/guardiansmustsubmitthefollowingdocumentsforeachchildapplyingtotheprogram:
• acompletedDYCDapplication(evenifthechildhasalreadyparticipatedinanyoftheMuseum'safterschoolorsummerprograms)
• asignedparent/guardianparticipationagreement• acurrenthealthexaminationformstampedbyadoctorevenifthechildhasalreadyparticipatedinanyofthe
Museum'safterschoolorsummerprograms• acopyofthechild’sbirthcertificate
CompletedapplicationsshouldbereturnedtoBrooklynChildren’sMuseum’sadmissionsdeskortoUscisDouglassintheMainOfficeatP.S.189.Incompleteapplicationswillnotbeaccepted.Admissiontotheprogramisdeterminedbyalottery,whichgivespreferencetofamiliesthatattendaparentorientationandtosiblingsofselectedapplicants.
ParentorientationswillbeheldattheMuseumfrom12pm-1pmonthefollowingdates:• Saturday,February17th• Saturday,March10th• Saturday,March17th
PleasedonothesitatetocontactAfterSchoolProgramManagerKwameBrandt-Pierceifyouhaveanyquestions–[email protected](Pleasewrite“BCMSummer2018”inthesubjectoftheemail),orat646-301-2511.Warmly,
KwameBrandt-PierceAfterSchoolProgramManager
Applicant’s First Name Applicant’s Last Name Middle Initial
Applicant’s Primary Address (Number and Street)
Borough Zip Code
Applicant’s (or Parent/Guardian's)Cell Phone Number
Apt. #
Applicant’s Date of Birth (MM/DD/YEAR)
How well does the ApplicantSpeak English?
Applicant’s Ethnicity Applicant’s Race Applicant’s Sex
Applicant’s Email Address Applicant’s Preferred Method of Contact
– –
Emergency Contact Name Emergency Contact Phone Number
– –
Cell Phone
HomePhone
Email Other:
Female MaleHispanic or Latino Black or African-
AmericanNative Hawaiian & OtherPacific IslanderWhite or Caucasian
American Indian &Alaskan Native
Non-Hispanic or Latino
Fluent/Very Well
Well
Not Well
Not Well at All
(Select One)
(Select One)
Applicant’s Primary Language
English
Albanian
Arabic
Bengali
Hebrew
Hindi
Hungarian
Italian
Chinese
French
Fulani
German
Japanese
Korean
Kru/Ibo/Yorba
Mande
Greek
Gujarati
Hatian/Creole
Punjabi
Persian
Polish
Portuguese
Romanian
Russian
Spanish
Tagalog
Turkish
Urdu
Vietnamese
Yiddish
Other:
Polish
(Select One)
(Select all that apply)
Other:Asian
t er an ua es o en i ant
English
Albanian
Arabic
Bengali
Hebrew
Hindi
Hungarian
Italian
Chinese
French
Fulani
German
Japanese
Korean
Kru/Ibo/Yorba
Mande
Greek
Gujarati
Hatian/Creole
Punjabi
Persian
Polish
Portuguese
Romanian
Russian
Spanish
Tagalog
Turkish
Urdu
Vietnamese
Yiddish
Other:
Polish
(Select All That Apply)
WELCOME! The following application will allow you or your child to be enrolled in this program. One applicationwill be accepted for each person. Submission of an application does not guarantee eligibility or enrollment in the program. If accepted, the program will be at no cost to the participant. The following application items are collected for informational and program planning purposes: Sex, Race, Ethnicity, Income, Household Type, Language, Population Type, Health Insurance. Your responses will not impact your status in receiving benefits or services.
Universal Participant Intake
The New York City Department of Youth & Community Development invests in a network of community-based organizations and programs to alleviate the effects of poverty and to provide opportunities for New Yorkers and communities to flourish.
Applicant’s (or Parent/Guardian's) Home Phone Number
For all the next set of questions, HOUSEHOLD is defined as: any individual or group of individuals (family or non-family members) who are living together as one economic unit. INCOME is defined as the total annual gross income (before taxes) of all family and non-family members 18+years old living within the household. All sources of income must be counted from all persons in the household based on the last 12 months.
Household Size
Universal Participant Intake
Total gross annual income in last 12 months
Head of Household Type: (Select all that apply)
Sources of Applicant’s Household Income: (Select all that apply)
One
Two
Three
Four
Six
Seven
Eight
Nine
Five
Sixteen
Seventeen
Eighteen
Ten
Nineteen
Twenty
Eleven
Twelve
Single Parent – Female
Single Parent – Male
Single Person – No children
Other
Two Adults – No Children
Two Parent Household
Applicant’s School Type (Select One)
Current Grade (Select One)
Is the applicant any of the following: (Select all that Apply)
Is applicant or is any member of the household(0 – 64 years of age) covered by Medicare, Medicaid,Child Health Plus, or private medical insurance? (Select One)
Applicant’s housing type: (Select One)
If no, do you want to be contacted by someone else with information about signing up for public health insurance programs? (Select One)
Full-Time Student Not in SchoolPart-Time Student
Thirteen
Fourteen
$0
$20,161 to $24,300
$36,731 to $40,890
$70,001 to $80,000
$1 to $11,880
$24,301 to $28,440
$40,891 to $50,000
$80,001 to $90,000
Decline to answer
Employment Wages
Supplemental Nutrition Assistance Program (SNAP)Social Security
Workers’ Compensation
Unemployment Wages
Temporary Assistance for Needy Families (TANF)Supplemental Security Insurance (SSI)
Safety Net/Home Relief
Pension
$16,021 to $20,160
$32,581 to $36,730
$60,001 to $70,000
$100,000+
$11,881 to $16,020
Pre-K K 2nd1st 11th 12th10th3rd 4th 5th
$28,441 to $32,580
Disabled
Offender/Justice Involved
Foster Care Participant
Decline to answer
Parent/Guardian
Veteran
Email Via provider U.S. MailPhone
$50,001 to $60,000
$90,001 to $100,000
Fifteen
Elementary School: Middle School:
2nd yr.1st yr.
6th 7th 8th High School: 9th
College/University: Freshman Sophomore Junior Senior3rd yr. 4th yr. 5th yr. 6th yr. +Community College:
High School Equivalency (HSE) Vocational/Trade School Foreign DegreeOther:
NoYes
NoYes
Would you be interested in registering to vote? (Select One)
NoYes
If yes, how would you like to be contacted about this issue?(Select One)
Own
Homeless
Shelter
Other:_________
Rent
Runaway Youth
NYCHA: Development ______________________
DYC
D PR
OG
RA
M
Please answer all the COMPASS specific questions below to help us provide quality services. Those marked with an asterisk (*) are mandatory. If there is a question that you do not understand, please seek help. You can speak with a worker at the CBO that operates the program or call 311 and request the DYCD Youth Hotline. DYCD also has a website www.nyc.gov/dycd and can be followed on Facebook and Twitter for additional information on DYCD services.
School Information
• Student ID/OSIS:
• School Type: �Public �Charter �Private �Other • School Name:• School Address:
Participant Safety: If there is an emergency, please contact the following individuals. ❶ NAME* RELATIONSHIP TO PARTICIPANT:
Pick Up* � This person may pick up my child.
Contact
Write down all numbers and circle the best number to call in case of an emergency: � Home _______________________ � Cell _______________________ � Work _______________________
� Email* ______________________ � No Email
Address
City, State
Zip Code
❷ NAME* RELATIONSHIP TO PARTICIPANT:
Pick Up* � This person may pick up my child.
Contact
Write down all numbers and circle the best number to call in case of an emergency: � Home _______________________ � Cell _______________________ � Work _______________________
� Email* ______________________ � No Email
Address
City, State
Zip Code
Participant Health Information: Please check any of the following that pertain to the participant. Many needs or health challenges can be accommodated and may not limit enrollment in the program.� Allergies to food � Behavioral/Emotional Issues � Diabetes � Physical � Allergies to medications � Convulsions/Seizures � Individualized Education Plan Disabilities � Allergies other (please Specify)
� Congestive Illness (e.g., heart murmur/disease, blood pressure)
� Obesity � Pregnant � Other
� Corrective Devices (e.g., crutches, hearing aid, eye glasses)
(please specify) � Asthma Check off all that apply. � Does your child have special health care needs that require treatment and/or medication? � Does your child take medication for any condition or illness? � Updated Medical Information on File: � Are there any activities your child cannot participate in? (If so, please specify below) Activities your child cannot participate in: ______________________________________________________________________________________
Program Enrollment Packet | Page 1 of 5
@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@
@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ Borough: @@@@@@@ o :@@@@@@@
DYC
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v This section is only for parents enrolling their children. v Pick-up/Dismissal Information:
My child has permission to walk home alone at dismissal. � Yes � No
My child MAY NOT be picked up by: ___________________________________________________________
Signatures:
To the best of my knowledge the information above is true. I agree to its verification and understand that falsification may be grounds for termination of service. Information provided may be used by the City of New York to improve City services or to access additional funding.
Program Enrollment Packet | Page 2 of 5
Organization: _____________________________________________________________________
Intake Specialist/Staff: _______________________________________ Date: ________________
I have completed this application for myself. Applicant: (18 and older) ____________________ _______________________ ________
(Print) (Sign) (Date)
I have completed this application for my child.
Parent/Guardian: __________________________ _______________________ ________ (Print) (Sign) (Date)
DYC
D PR
OG
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M
Parent/Guardian Consent
The Department of Youth and Community Development (DYCD) provides funding for this program as part of its mission to help you assist your child reach his or her full potential. Many of our programs are run by community based organizations. We work to make sure the services you and your children receive are of the highest quality. DYCD is requesting your permission to allow us to collect information we need on your child, their participation and the quality of the services provided.
Consent to Collect and Share Student Information What information from your child’s student records is DYCD requesting? We are requesting your permission for the NYC Department of Education (DOE) to share personally identifiable information from your child’s student records with DYCD. The information we would like to collect consists of biographical and enrollment information (specifically consisting of your child’s name, address, date of birth, student identification number, grade, school(s) attended and transfer, discharge, and graduation data about your child); data concerning your child’s school attendance (including number of days attended and absences); and academic performance data (including your child’s results on state and national exams, credits earned, grades, promotion and retention status, and fitnessgram score); and data related to any disciplinary actions taken against your child (including number and type of suspensions). We are requesting to collect the information listed above about your child on a past, present and future (i.e., ongoing) basis. We are also requesting your permission for DYCD to share information we collect on the enrollment form from you and/or your child with DOE staff. The information includes registration information, student’s interests and challenges, type of program enrolled-in and frequency of participation. This information will be used to help the school and community organization work together to meet you and your child’s needs.
Who will see my child’s information and how will it be safeguarded? The only people who will see your child’s individual information are DYCD and DOE staff who manage the data systems and prepare research reports and program analyses. The limited number of DYCD staff identified to receive personal information is screened, and provided extensive training to follow strict guidelines on protecting the confidentiality of information that would personally identify you or your child. Personally identifiable information collected from student records will only be shared electronically between DOE and DYCD and will be secured and protected in the DYCD data base. Personally identifiable information will not be shared with any community based organizations or their staff members. We will not use your name or your child’s name in any published report. While we request your consent, your responses to the below requests will not affect your child’s participation in DYCD sponsored programs.
Please check Yes or No to each of the following statements: • I understand why DYCD is asking my permission to access the information listed above from my child’s
student records, and I give permission to DOE to share that information with DYCD on an ongoing basis.___ Yes, I give my permission ___No, I do not give my permission
• I understand why DYCD is asking my permission to share information about my child collected by DYCD withDOE staff and I give my permission to DYCD to share information with DOE on an ongoing basis.___ Yes, I give my permission ___No, I do not give my permission
Student/Applicant Name: _________________________________________Parent/Guardian Name: __________________________________________Parent/Guardian Signature: _______________________________________ Date: ________Additional Parent/Guardian Name: _________________________________Additional Parent/Guardian Signature: (optional) _______________________________________
Program Enrollment Packet | Page 3 of 5
DYC
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Consent for Photo/Videotaping and Use of Youth Work Please be aware that sometimes staff, photographers, newspapers, television reporters, media representatives and public relations personnel may be present during program activities and special events, both at off-site events and events taking place in the usual program location. In some cases, they may photograph, videotape, interview or otherwise record children who participate in these events. The resulting images, videos and interviews may be used solely for non-profit, non-commercial purposes in printed and electronic media such as brochures, books, print and email newsletters, DVDs and videos, websites, social media and blogs (collectively, “Media”). These images, videos and interviews may be used by DYCD and third-party organizations that collaborate with DYCD, without compensation and without further approval, solely for non-profit, non-commercial purposes.
If, in the course of participating in program activities or special events, any original work is created by a participant, DYCD may use the created work in any and all Media to promote the program or for other informational, non-profit and non-commercial purposes, without compensation and without further approval.
• I understand my child may be photographed, interviewed or otherwise recorded during program activitiesand special events and give permission for my child to be photographed, interviewed or otherwise recordedsolely for non-profit, non-commercial purposes of the program.
___Yes, I give my permission ___ No, you do not have permission
• I understand that my child’s work may be used in materials that promote programs, solely for non-profit,non-commercial purposes of the program.
___Yes, I give my permission ___ No, you do not have permission
Consent for Emergency Medical Treatment I give authority to the Program Agency’s staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible. I understand that every effort will be made to contact me before and after medical care is provided.
___Yes, I give permission ___ No, I do not give permission
Consent Statement I the undersigned, certify that I have reviewed all the above consent statements and indicated my wishes. I understand that consent is voluntary and I can withdraw it in writing at any time.
___________________________ _______________________________ Student/Applicant Name Student Signature (if 18 or older)
___________________________ _______________________________ Parent/Guardian Name Parent/Guardian Signature Date
____________________________ _____________________________________ Additional Parent/Guardian Name (optional) Additional Parent/Guardian Signature Date
Program Enrollment Packet | Page 4 of 5
D
YCD
PRO
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Parent Consent for Participation in Data Collection: SONYC Applicants Only
Dear Parent:
Your child is enrolled in a program that is supported by the Department of Youth and Community Development (DYCD). In order to monitor the effectiveness of this program and ensure its future success, DYCD, and its evaluation partner American Institutes for Research (AIR), are collecting information about participants and their experiences in the program. AIR is doing a study of the middle school programs that are part of COMPASS – known as School’s Out New York City (SONYC) programs; the study is called School’s Out NYC: Out-of-School Time Middle School Expansion Evaluation Services. This project has been approved by the Department of Education (DOE). AIR will visit some of the programs to learn more about SONYC and how it can be improved and will collect information from young people in the program.
We ask permission from parents to conduct the following study activities: • Survey children about the DYCD program.• Survey children about themselves (what they have learned).• We may access your child’s school information from NYC DOE, including demographic data, school day attendance,
disciplinary referrals, grade promotion, and academic performance data (e.g., test scores and grades). We will not beable to link their school information to their name or to your family.
This information will help DYCD learn how the program helps students and how it can be improved. Any information we collect will be used only to assess the DYCD program and will not be made public. The only people who will have access to this information are members of the AIR evaluation team. Participating in the evaluation will not affect your child in school, in the program, or in any other way. We will not use your name or your child's name in any report. Participation is voluntary and participants may withdraw at any time. Please contact Deborah Moroney by phone (312-288-7609) or email ([email protected]) with questions about the study.
If you have concerns or questions about your child’s rights as a participant, contact AIR’s Institutional Review Board (which is responsible for the protection of project participants) at [email protected], toll free at 1-800-634-0797, or c/o IRB, 1000 Thomas Jefferson St. NW, Washington, DC 20007.
Please select one of the options below:
Yes, I GIVE PERMISSION FOR MY CHILD, _______________________, TO PARTICIPATE in the following:
� My child WILL complete AIR surveys for SONYC Out-of-School Time Middle School Expansion Evaluation � AIR CAN access my child’s school information for SONYC Out-of-School Time Middle School Expansion Evaluation.
AIR will look at my child’s school data such as attendance, disciplinary referrals, grade promotion, and academic performance data; however, this data is not linked to their name or my family.
� No, I DO NOT WANT MY CHILD, _______________________, TO PARTICIPATE. I have read the above information and I DO NOT give permission for my child to participate in the AIR data collection activities.
For questions about the evaluation, please contact Yael Bat-Chava, [email protected], 646-343-6237. For all other questions please contact Youth Connect, 1-800-246-4646, or http://www.nyc.gov/html/dycd/html/contact/email_youth.shtml.
Program Enrollment Packet | Page 5 of 5
Signature Date
Agency: ______________________ School: _______________________
School: _______________________
TYPE OF EXAM: NAE Current NAE Prior Year(s)
Comments
REVIEWER:
Date Reviewed:
DOHMHONLY
PROVIDER I.D.
__ __ / ___ ___ / ___ ___
I.D. NUMBER
Health Care Provider Signature Date__ __ / ___ ___ / ___ ___
Health Care Provider Name and Degree (print) Provider License No. and State
Facility Name National Provider Identifier (NPI)
Address City State Zip
Telephone ( __ __ __ ) ___ ___ ___ – ___ ___ ___ ___
Fax ( __ __ __ ) ___ ___ ___ – ___ ___ ___ ___
Hep B __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
Rotavirus __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
DTP/DTaP/DT __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
__ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
Hib __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
PCV __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
Polio __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
RECOMMENDATIONS ! Full physical activity ! Full diet
! Restrictions (specify) ___________________________________________________________________________
Follow-up Needed ! No ! Yes, for _________________________ Appt. date: __ __ / ___ ___ / ___ ___
Referral(s): ! None ! Early Intervention ! Special Education ! Dental ! Vision
! Other ________________________________________________________________________
ASSESSMENT ! Well Child (V20.2) ! Diagnoses/Problems (list) ICD-9 Code
_____________________________________________________________ __ __ __ __ __
_____________________________________________________________ __ __ __ __ __
_____________________________________________________________ __ __ __ __ __
Health insurance ! Yes(including Medicaid)? ! No
Does the child/adolescent have a past or present medical history of the following?! Asthma (check severity and attach MAF/Asthma Action Plan): ! Intermittent ! Mild Persistent ! Moderate Persistent ! Severe Persistent
If persistent, check all current medication(s): ! Inhaled corticosteriod ! Other controller ! Quick relief med ! Oral steroid ! None
! Attention Deficit Hyperactivity Disorder ! Orthopedic injury/disability! Chronic or recurrent otitis media ! Seizure disorder! Congenital or acquired heart disorder ! Speech, hearing, or visual impairment! Developmental/learning problem ! Tuberculosis (latent infection or disease)! Diabetes (attach MAF) ! Other (specify) ___________________
Explain all checked items above or on addendum
Birth history (age 0-6 yrs)
! Uncomplicated ! Premature: ________ weeks gestation
! Complicated by _______________________________
Allergies ! None ! Epi pen prescribed
! Drugs (list)
! Foods (list)
! Other (list)
STUDENT ID NUMBEROSIS
CHILD & ADOLESCENT HEALTH EXAMINATION FORMNYC DEPARTMENT OF HEALTH & MENTAL HYGIENE — DEPARTMENT OF EDUCATION
Please Print Clearly
Press Hard
Child’s Last Name First Name Middle Name
Child’s Address
City/Borough State Zip Code
! Parent/Guardian Last Name First Name! Foster Parent
School/Center/Camp Name
Sex ! Female ! Male
Hispanic/Latino?! Yes ! No
Race (Check ALL that apply) ! American Indian ! Asian ! Black ! White! Native Hawaiian/Pacific Islander ! Other ____________________________
PHYSICAL EXAMINATION
Height ____________________ cm ( ___ ___ %ile)
Weight ____________________ kg ( ___ ___ %ile)
BMI ____________________ kg/m2 ( ___ ___ %ile)
Head Circumference (age ≤2 yrs) ______________ cm ( ___ ___ %ile)
Blood Pressure (age ≥3 yrs) _________ / __________
DEVELOPMENTAL (age 0-6 yrs) ! Within normal limits
If delay suspected, specify below
! Cognitive (e.g., play skills) ____________________________
! Communication/Language _________________________
! Social/Emotional __________________________________
! Adaptive/Self-Help ________________________________
! Motor ___________________________________________
SCREENING TESTS Date Done Results
Blood Lead Level (BLL) __ __ / ___ ___ / ___ ___ _________ µg/dL(required at age 1 yr and 2 yrsand for those at risk) __ __ / ___ ___ / ___ ___ _________ µg/dL
Lead Risk Assessment ! At risk (do BLL)(annually, age 6 mo-6 yrs)
__ __ / ___ ___ / ___ ___ ! Not at risk
Hearing ! Pure tone audiometry ! Normal! OAE __ __ / ___ ___ / ___ ___ ! Abnormal
—— Head Start Only ——
Hemoglobin or __________ g/dLHematocrit (age 9–12 mo)
__ __ / ___ ___ / ___ ___ __________ %
Date Done Results
Tuberculosis Only required for students entering intermediate/middle/junior or high schoolwho have not previously attended any NYC public or private school
PPD/Mantoux placed __ __ / ___ ___ / ___ ___ Induration ______mm
PPD/Mantoux read __ __ / ___ ___ / ___ ___ ! Neg ! Pos
Interferon Test __ __ / ___ ___ / ___ ___ ! Neg ! Pos
Chest x-ray ! Nl ! Not(if PPD or Interferon positive)
__ __ / ___ ___ / ___ ___! Abnl Indicated
Vision
__ __ / ___ ___ / ___ ___
Acuity Right ___ / ___(required for new school entrants Left ___ / ___and children age 4–7 yrs) ! with glasses Strabismus ! No ! Yes
General Appearance:
Nl Abnl Nl Abnl Nl Abnl Nl Abnl Nl Abnl! ! HEENT ! ! Lymph nodes ! ! Abdomen ! ! Skin ! ! Psychosocial Development! ! Dental ! ! Lungs ! ! Genitourinary ! ! Neurological ! ! Language! ! Neck ! ! Cardiovascular ! ! Extremities ! ! Back/spine ! ! Behavioral
Date of Birth (Month/Day/Year )__ __ / ___ ___ / ___ ___ ___ ___
Phone Numbers
Home _____________________
Cell ______________________
Work ______________________
TO BE COMPLETED BY PARENT OR GUARDIAN
TO BE COMPLETED BY HEALTH CARE PROVIDER If “yes” to any item, please explain (attach addendum, if needed)
CH-205 (5/08) Copies: White School/Child Care/Early Intervention/Camp, Canary Health Care Provider, Pink Parent/Guardian
Medications (attach MAF if in-school medication needed)! None ! Yes (list below)
Dietary Restrictions! None ! Yes (list below)
Influenza __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
MMR __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
Varicella __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
Td __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
Tdap __ __ / ___ ___ / ___ ___ Hep A __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
Meningococcal __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
HPV __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___
Other, specify: ____________ __ __ / ___ ___ / ___ ___ ; _______________ __ __ / ___ ___ / ___ ___
IMMUNIZATIONS – DATES CIR Number of Child
Describe abnormalities:
District __ __Number __ __ __
Parent/GuardianName:______________________________________________________________________________________ Parent/GuardianContactNumber:______________________________________________________________________________Parent/GuardianEmail:_______________________________________________________________________________________Child/ren’sName(s):_________________________________________________________________________________________Child/ren’sAge(s):__________________________________________________________________________________________
Summer2018Parent/GuardianParticipationAgreement
AttendancePolicy:Ifyourchildisselectedfortheprogram,dailyparticipationisexpected.Only3unexcusedabsenceswillbepermittedforthedurationoftheprogram.Morethan3unexcusedabsencesmayresultinyourchildbeingexcusedfromtheprogram.AnunexcusedabsenceisdefinedasanyabsencenotcommunicatedtotheAfterSchoolProgramManagerwithin5days.Absencesduetoillnessmustbeaccompaniedbyanotefromadoctor.EarlyPickupPolicy:Ifyourchildisselectedfortheprogram,he/sheisexpectedtoparticipateeachdayfortheentireday.Only3earlypickupswillbepermittedforthedurationoftheprogram.Morethan3unexcusedearlypickupsmayresultinyourchildbeingexcusedfromtheprogram.Anunexcusedearlypickupisdefinedasanypickupbeforetheprogram’sregulardismissaltimethatisnotcommunicatedtotheAfterSchoolProgramManagerwithin5days.LatePickupPolicy:Theprogramendsat5:45pm,MondaythroughFriday.Ifyourchildisselectedfortheprogram,youareexpectedtopickupyourchildpromptlyat5:45pm.Failuretopickupyourchildontimemayresultinyourchildbeingexcusedfromtheprogram.Onlyanadultthatislistedonourapprovedguardianlistmaypickupachild.Ifyouneedtomakearrangementsforanunlistedadulttopickupyourchild,thosemustbecommunicatedinwritinginadvancetokbpierce@brooklynkids.orgEmergencyContactPolicy:Intheeventofanemergency,itisimportantthatprogramstaffhaveaworkingcontactnumberforparents/guardians.Ifyourchildisselectedfortheprogram,youareexpectedtomaintainaworkingcontactnumberforemergencies.Ifthisnumbershouldchangeforanyreason,youmustcommunicatethischangetoKwameBrandt-Pierce,AfterSchoolProgramManager,assoonaspossibleatkbpierce@brooklynkids.orgor6463012511.ParentOrientation:Preferencewillbegiventofamiliesthatattendaparentorientation.ParentorientationswillbeheldatBrooklynChildren’sMuseumfrom12pm-1pmonthefollowingdates:
• SaturdayFebruary17th• Saturday,March10th• Saturday,March17th
Ifyouagreetotheabove-mentionedtermsandpolicies,pleasesignanddatethisformbelow.
Signature___________________________________________Date___________________________________
