HCZ/DYCD 2020-2021 Afterschool Digital Intake

Harlem Children's Zone/ DYCD
2020-2021 Afterschool Program Application
Student Information
Student Name*
First Name Middle NameLast Name
Birth Date*
MonthDayYear
Grade*
Gender*
FemaleMaleX ( not female or male)Not sure
Address*
Street Address
Apartment #
CityState
Zip Code
Student Lives in a NYCHA Development? (Please Provide Name)
School Name*
School Address*
Street Address
Apartment #
CityState
Zip Code
Site*
P.S. 76P.S. 149P.S. 154P.S. 197
What is you D.O.E Status?*
Remote LearningBlended Learning
Race*
American Indian and Alaskan NativeAsianBlack or African-AmericanMiddle Eastern/North AfricanNative Hawaiian and Other Pacific IslanderWhite or CaucasianOther
Ethnicity (Check One):*
Hispanic or LatinxNot Hispanic or Latinx
How well does the student speak English?*
Fluent/Very WellWellNot WellNot well at all
Student's Primary Language (Select One) :*
EnglishAlbanianArabicBengaliChinese (Cantonese and/or Mandarin)FrenchFulaniGermanGujaratiHaitian CreoleHebrewHindiHungarianItalianJapaneseKoreanKru, Ibo, or YorubaMandePunjabiPersianPolishPortugueseRomanianRussianSpanishTagalogTurkishUrduVietnameseYiddishOther
Other Languages Spoken by student (Select all that Apply):*
EnglishAlbanianArabicBengaliChinese (Cantonese and/or Mandarin)FrenchFulaniGermanGujaratiHaitian CreoleHebrewHindiHungarianItalianJapaneseKoreanKru, Ibo, or YorubaMandePunjabiPersianPolishPortugueseRomanianRussianSpanishTagalogTurkishUrduVietnameseYiddishN/AOther
Do the student have any allergies*
NoYes
If Yes, name allergies
Do the student have Asthma*
NoYes
Do the student have special health care needs?*
NoYes
If Yes, list special health care needs
Does the student take medication for any condition or illness?*
NoYes
If Yes, list medication
Are there activities the student cannot participate in?*
NoYes
If Yes, list activities.
Please provide any additional health information details, if needed:
Do the student have health insurance?*
YesNoDecline to Answer
If yes, what kind of health insurance does the applicant have?(Check all that Apply):
MedicaidMedicareState Children’s HealthInsurance ProgramEmployment-BasedDirect-PurchaseState Children’s HealthInsurance for AdultsMilitary Health CareDecline to Answer
If you do not have health insurance, do you want to be contacted by someone else with information about signing up for public health insurance? (Select One):
YesNoDecline to Answer
If you would like to be contacted about signing up for public health insurance, what is your preferred method of contact? (Select One):
EmailPhoneUS MailVia ProviderDecline to Answer
Is the student any of the following (Select all that apply):*
If the student is an individual with a disability, please select disability type(s)(Select all that Apply):):*
Emergency Contacts
List People who are also authorized to pick up student
Contact # 1
First NameLast Name
Phone Number
Area CodePhone Number
Relationship to student
Contact # 2
First NameLast Name
Phone Number
Area CodePhone Number
Relationship to student
Contact # 3
First NameLast Name
Phone Number
Area CodePhone Number
Relationship to student
Contact # 4
First NameLast Name
Phone Number
Area CodePhone Number
Relationship to student
Contact # 5
First NameLast Name
Phone Number
Area CodePhone Number
Relationship to student
Parent/Guardian Information
Parent/Guardian Name*
First Name Last Name
Birth Date*
MonthDayYear
Address*
Street Address
Apartment #
CityState / Province
Postal / Zip Code
Gender*
FemaleMaleOther
Home Number
Area CodePhone Number
Cell Number
Area CodePhone Number
Work Number
Area CodePhone Number
Email*
example@example.com
Best Method to contact you*
Home NumberCell NumberWork NumberEmail
Marital Status*
SingleMarriedDomestic PartnerSeparatedDivorcedWidowed
Highest Educational Achievement*
High School GraduateSome college, no degreeAssociate's DegreeBachelor's DegreeMaster's DegreeDoctoral DegreeN/A
Household Information
Total Household Income in the last 12 Months (Select One):*
$0$1 to $12,060$12,061 to $16,240$16,241 to $20,420$20,421 to $24,600$24,601 to $28,780$28,781 to $32,960$32,961 to $37,140$37,141 to $41,320$41,321 to $50,000$50,001 to $60,000$60,001 to $70,000$70,001 to $80,000$80,001 to $90,000$90,001 to $100,000$100,000+Decline to Answer
Sources of Household Income (Select all that Apply):*
Employment WagesAffordable Care ActSubsidyAlimony or other Spousal SupportChild SupportChildcare VoucherEarned Income TaxCredit (EITC)Employment Tax CreditGeneral AssistanceHousing Choice VoucherHUD-VASHLIEHEAPPensionPermanent Supportive HousingPrivate Disability InsurancePublic HousingSafety Net/Home ReliefRetirement Income from Social SecuritySocial SecurityDisability Income(SSDI)Supplemental SecurityIncome (SSI)Supplemental NutritionAssistance Program(SNAP)Temporary Assistance forNeedy Families (TANF)Unemployment InsuranceVA Non-ServiceConnected DisabilityPensionVA Service-ConnectedDisability CompensationWICWorker’s CompensationDecline to AnswerOther
The applicant lives in a household that is headed by(Select One):*
Single Parent - FemaleSingle Parent - MaleTwo Parent HouseholdSingle Person - No childrenTwo Adults – No ChildrenNon-related adults with childrenMultigenerational HouseholdOther
Housing Type (Select One):*
OwnRentNYCHAShelterHomelessOther Permanent HousingOther
Household Size (Select One):*
1234567891011121314151617181920+
Consent and Signatures
My child has permission to travel home alone at dismissal:*
YesNO
Consent to Participate
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 and access to those services, and to access additional funding.
Signature
Clear
Consent for Emergency Medical Treatment
My child is enrolled as a participant in a DYCD-funded program. In the event of a medical emergency, I hereby
give consent for necessary emergency medical treatment for my child to be obtained, with the understanding that
I will be notified as soon as possible. I understand that every effort will be made to contact me, or, if I am
unavailable, the emergency contact(s) listed, before and after medical care is provided.
Give Permission?*
YesNo
Signature
Clear
Consent for Photography/Videotaping and Use of Original Work
As a participant enrolled in a DYCD-funded program, please be aware that from time to time DYCD
and the City of New York, its contracted providers, authorized agents, third-party organizations with
which it collaborates, or other government, representatives (collectively, “Authorized Parties”) may
be present during program activities and special events associated with program services, both at
the usual program location and at off-site events. In some cases, they may photograph, videotape,
interview or otherwise record participants and their families and friends in these programs. The
resulting images, videos, and interviews may be used, with or without the participant’s name, in
printed and electronic media such as brochures, books, print and email newsletters, DVDs and
videos, websites, social media and blogs (collectively, “Media”).
I hereby authorize and permit the Authorized Parties, without compensation and without further
approval, to photograph and/or record my and my child’s image, name, likeness, and the sound of
my and my child’s voice during DYCD-funded program activities and special events, and I hereby
consent to the resulting images, videos and interviews being used, without compensation and
without further approval by the Authorized Parties solely for non-profit, non-commercial purposes
in any and all Media.
YesNo
If, in the course of participating in DYCD-funded program activities and special events, any original
work such as art, music, choreography, poetry, or prose (collectively, “Original Work”) is created by
me or my child, I hereby consent to such Original Work being used by the Authorized Parties,
without compensation and without further approval, solely for non-profit, non-commercial purposes
in any and all Media.
YesNo
Signature
Clear
Parent/Guardian Consent to Collect and Share Student Information
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.
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’sstudent records, and I give permission to DOE to share that information with DYCD on an ongoing basis.*
Yes, I give permissionNo, I do not give my permission
Please check Yes or No to each of the following statements: I understand why DYCD is asking my permission to share information about my child collected by DYCD with DOE staff and I give my permission to DYCD to share information with DOE on an ongoing basis.*
Yes, I give permissionNo, I do not give my permission
Student Name*
Parent/Guardian Name*
Parent/Guardian Signature*
Clear
Media Release
I understand that for educational and/or promotional purposes, HCZ may record, film, and/or photograph the programs in which I, my
child(ren), and/or my family members are taking part. I understand that these recordings may be used for educational or promotional
materials that may be distributed through various media, including print, television, and on-line.
Therefore, I grant permission to HCZ to use the likenesses, words, and names of me, my children, and family members who are
participating in a Harlem Children’s Zone program or event.
Signature
Clear
Records & Data Sharing and Release
I give my consent for the program to obtain any and all printed records from the school(s) my child(ren) attend or have attended
(including, but not limited to, report cards and standardized test results).
Signature
Clear
Should be Empty:

Harlem Children's Zone/ DYCD