MARVEL*US AFTER SCHOOL INTEREST FORM

MARVEL*US LEARNING CENTER

INTEREST FORM
Our MarvelUS PLUS Program is an exceptional academic enrichment and social-emotional learning opportunity for youth aged 11-13. Operating during afterschool hours, our Bootcamps are designed to provide continued learning, physical education, and most importantly, FUN!

NOW ENROLLING

5777 Chantry Drive

Columbus, Ohio 43232

Monday through Thursday, 3:30 - 6:00 PM

Introduce your child to a world of career pathways! Reserve your spot today by completing the interest form below.

Should you have any questions or concerns. you may contact MARVEL*US Staff at 614.321.2576 or camp@columbusliteracy.org.

This program is in part funded by the Franklin County Board of Commissioners and administered by FCDJFS.
What program are you interested in?*

Academic Year 24-25Summer Camp 24
Participant Name*
First Name
Date of Birth*

MonthDayYear
Date
Gender*
Address*
Street Address
Street Address Line 2
City
State
Zip Code
What school does the participant attend?*
Parent or Legal Guardian
Parent/Legal Guardian Name*
First Name
Last Name
Phone Number*
Email*
example@example.com
What is the participant's relationship to Parent/Legal Guardian?*

SonDaughterGrandsonGranddaughterNephewNieceFoster child
Referred By
I am the parent or legal guardian of the above-listed minor child and the information provided on this form is complete and correct to the best of my knowledge.*
Subrecipient:
Site Location:

Participant Legal Name

First NameLast Name
Do you live in Franklin County?

YesNo
What school do you attend?
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
Please take a photo of the social security card, benefits document with social security number visible or filed tax document listing social security number.
Date of Birth

MonthDayYear
Date
Please take a photo of the birth certificate.
E-mail:
example@example.com
phone number :
Participant's Relationship to the adult submitting this application.
Participant's Grade in School
Name of School
School District
Race (Choose all that apply)
Ethnicity

HispanicNon-Hispanic
Country of Origin

USAOther
Resident Status

U.S CitizenLawful Resident Alien
If you are not a US Citizen, please take a photo demonstrating evidence of lawful resident status.

I am the __________ the the participant listed above.

ParentLegal Guardian
First NameMiddle NameLast Name
If you are the parent, please ensure that your name matches the name on the birth certificate previously uploaded. If not, please provide evidence of the name change or a document verify you have the right to enroll this child in the summer program. Legal guardians should upload your guardianship papers.
PARENT/LEGAL GUARDIAN Social Security Number
Address

Street Address

County

CityState / Province

Postal / Zip Code
Is your address the same as the participants?

YesNo
Please enter your e-mail. Please note, we use e-mail and SMS to communicate about the program. Please ensure you enter the correct information.
example@example.com
Number for Text Messages (SMS or WHAT'SAPP):
Number for Telephone Calls:
EMERGENCY CONTACT Phone:
Emergency Contact Name

First NameLast Name
Race (Choose all that apply)
Country of origin
Ethnicity:

HispanicNon-Hispanic
Resident Status (check one):

U.S. CitizenLawful Resident Alien (attach verification)Other - Parent/Legal Guardian Applying for a Minor Citizen
If you are not a US Citizen, please take a photo of your Status documents.

List the Household Member’s Name and Relationship to the Applicant
-Complete the chart below for the members of your household; you must include immediate family members (self, spouse/father of minor child, and minor children)
-You may also include others living in the household
-If you are the non-custodial parent of a child residing in Ohio who is younger than 18 years of age or 18 years of age if still in high school, include him/her in the table

I understand that the MARVEL*US Summer Camp is currently scheduled to be conducted in a VIRTUAL format. My child will need access to the internet and a device each day to connect to the camp.
My child has access to the device:

YESNO
My child will have access to the internet:

YESNO
I am the parent or legal guardian of a minor child and the information provided on this application is complete and correct to the best of my knowledge. I understand that receiving these services will not prevent me from receiving other PRC assistance offered by Franklin County.
Date

MonthDayYear
Date
FOR PROVIDER USE ONLY

Check the Box Representing How Eligibility was Determined - Check All that Apply (boxes 2&3 should not both be marked)
1. Eligibility Based on FCDJFS Benefits
Eligibility Based on FCDJFS Benefits
-This individual(s) receives or is a member of a family that receives FCDJFS benefits and has a minor child
-Qualifying FCDJFS benefits include-- Ohio Works First (cash payments), SNAP (food assistance) or Medical assistance
-Child care assistance cannot be used to determine TANF eligibility because of income requirements
Program Eligible Based on Income at or below 200% of the FPG
Program Eligible Based on Income at or below 200% of the FPG
-Eligibility determination is based upon household income and family has a minor child
-Household income includesgross earned (income from employment)& unearned income (i.e. child support, SSDI, SSI, retirement, zero income statement &, etc.)
Program Eligible Based on income is between 201% to 300% of the FPG
Program Eligible Based on income is between 201% to 300% of the FPG

-Eligibility determination is based upon household income and family has a minor child
-Household income includesgross earned (income from employment)& unearned income (i.e. child support, SSDI, SSI, retirement, zero income statement &, etc.)
Signature of Agency Representative
Title
Date

MonthDayYear
Date
Should be Empty:

MARVEL*US LEARNING CENTER