NYCID at PS 78 Advantage Program 2020-2021 Enrollment Form
P.S. 78
Student's First Name *
Student's Last Name *
Student's Date of Birth *
Students' Address *
Student's Gender *
Phone number *
Language(s) spoken at home: *
Racial/Ethnic Group *
Student (OSIS) ID Number
Student Grade as of September 2020 *
Name of Person Enrolling Student: *
Relationship to Student *
Address of Person Enrolling Student (if different than student):
Phone Number(s) of Person Enrolling student: *
Email of Person Enrolling student: *
Student's Email
Emergency Contact Names: Please add name and contact information ( phone number and email) for three people authorized to pick up your child: *
I give my child permission to walk alone at dismissal *
My child will be picked up afterschool by me or one of the following individuals: PLEASE INCLUDE NAMES, PHONE NUMBERS, AND RELATIONSHIP TO STUDENT *
My child MAY NOT be picked by the following individuals:
Student’s Health Information. (All information is confidential and is used by the program staff to ensure the safety of students.) Does your child have any of the following? Please check all that apply
Please list your child's allergies
Does your child have special diet needs, other health needs, or behavioral/emotional needs? If yes, please describe:
I give my child permission to enroll and participate in the NYCID Advantage at PS 78 program. *
I understand that following agreements and consents are not pre-conditions for approval to participate in the NYCID Advantage at PS 78 program. *
I consent to emergency medical treatment for my child *
I consent for my child to participate in interviews, the use of quotes, and the taking of photographs, movies, or videotapes by NYCID. I also grant NYCID the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I also hereby release NYCID and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above. *
I consent for my child to take part in field trips, away from the program site, under supervision *
I understand the program may need additional permissions for situations such as transportation, medication, release of information, and field trips. *
I provided information on my child’s special needs to the program to assist in the safety of my child *
I understand that information regarding my child’s special learning needs will be shared by my child’s school of enrollment with Advantage at PS 78 program staff on a need to know basis for my child’s educational benefit *
I agree to review and update this information whenever a change occurs and at least once every year. *
I agree to talk to the program staff about my child’s progress and participation in the 21st CCLC program. *
If at any time I change my mind about my child’s participation (any or all aspects), I will contact the site coordinator *
I consent to the program obtaining demographic data including but not limited to racial/ethnic group, gender, grade level, English proficiency, free or reduced-price lunch eligibility, and special needs from the [district/NYSED] for students in the 21st CCLC program. *
I consent for the program to obtain my child’s records from [school/district/NYSED] showing his/her progress, information including but not limited to enrollment, grades, city and/or statewide test scores, and NYCID Advantage at PS 78 program attendance *
I consent to for my child and I to participate in surveys and/or interviews about the NYCID Advantage at PS 78 program and its effects *
Parent/Guardian E-Signature *
By signing above, I certify that all information (above) is true and correct to the best of my knowledge. *
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