NYCID at PS 78 Advantage Program 2020-2021 Enrollment Form

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P.S. 78

Student's First Name *

Student's Last Name *

Student's Date of Birth *

YYYY

Students' Address *

Student's Gender *

Female

Male

Prefer not to say

Other:

Language(s) spoken at home: *

Racial/Ethnic Group *

American Indian/Alaska Native

Black or African American

Hispanic or Latino

Asian

White

Native Hawaiian/Pacific Islander

Two or more races

Other:

Student (OSIS) ID Number

Student Grade as of September 2020 *

Student group/cohort *

Cohort A

Cohort B

Remote

Name of Person Enrolling Student: *

Relationship to Student *

Parent

Guardian

Caretaker

Relative

Other:

Phone Number(s) of Person Enrolling student: *

Email of Person Enrolling student: *

Emergency Contact Names: *

Emergency Contact Phone Numbers *

I give my child permission to walk alone at dismissal *

Yes

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 *

allergies

your child uses an EpiPen

Ashtma

your child uses an inhaler or any other medicine

Diabetes:

your child needs medication or blood glucose monitoring

Seizure Disorder

Option 8

your child needs medication for preventing or treating seizures

Vision Condition

your child needs aids at school other than wearing glasses or contacts

Hearing Condition

your child needs aids at school other than wearing a hearing aid

Physical Limitations

None

Other:

Required

Please list your child's allergies

I give my child permission to enroll and participate in the NYCID Advantage at PS 78 program. *

Yes

I consent to emergency medical treatment for my child *

Yes

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. *

Yes

Parent/Guardian E-Signature *

By signing above, I certify that all information (above) is true and correct to the best of my knowledge. *

YYYY

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