SONYC Afterschool Application @ JHS123

Parent/Guardian Information (Page 2 on DYCD form)

At least one form of contact is required.
Parent/Guardian Name:*
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email (if applicable)
example@example.com
Is this person's address the same as the student's? (If yes, skip to next section)*

YesNo
Address (Number and Street)
City
State
Zip Code
Emergency Contact #1 Information (Page 2 on DYCD form)

At least one emergency contact must be identified. At least one form of contact is required.
Emergency Contact #1 Name:*
Relationship to Student:*
For example: mother, father, sibling, . . .
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email (if applicable)
example@example.com
Is this person's address the same as the student's? (If yes, skip to next section)*

YesNo
Address (Number and Street)
City
State
Zip Code
Emergency Contact #2 Information (Page 2 on DYCD form)

[OPTIONAL] At least one emergency contact must be identified, at least one form of contact is required
Emergency Contact #2 Name:
Relationship to Student:
For example: mother, father, sibling, . . .
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email (if applicable)
example@example.com
Is this person's address the same as the student's? (If yes, skip to next section)

YesNo
Address (Number and Street)
City
State
Zip Code

[OPTIONAL] Additional people who can pick up my child (Page 3 on DYCD form)

The Emergency Contacts above are already authorized to pick up your child. Do not write them again here.
Person #1 Name:
[OPTIONAL]
Phone Number
Please enter a valid phone number.
Person #1 Relationship to Student
For example: mother, father, sibling, . . .
Person #2 Name:
[OPTIONAL]
Phone Number
Please enter a valid phone number.
Person #2 Relationship to Student
For example: mother, father, sibling, . . .
Person #3 Name:
[OPTIONAL]
Phone Number
Please enter a valid phone number.
Person #3 Relationship to Student
For example: mother, father, sibling, . . .
[OPTIONAL] The following people MAY NOT pick up my child (Page 3 on DYCD form)

If applicable, please fill out the following boxes.
Name:
Name:
Name:
Before proceeding, remember that the people in the boxes above MAY NOT pick up my child.
Child’s Education/Work Status (Page 3 on DYCD form)

If your child is not working, please pick "Full-Time Student" for Education Status and "Not applicable (applicant is under 14 years of age)" for Current Work Status
Child’s Education Status (Select One):*

Full-Time StudentPart-Time Student
Grade of Child:*

6th7th8th
Child's Current Work Status (Select One):*

Not applicable (applicant is under 14 years of age)Employed Part-Time
School Type:

Public
School Name:
School Address:
School City:
School Zip Code:

Pick-up/Dismissal Information (Page 7 of DYCD form)
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.
Parent/Guardian's Signature*

Clear
Parent/Guardian's Name*
Please re-enter the name of the parent/guardian of the student
Date

MonthDayYear
Please select today's date
Consent for Emergency Medical Treatment (Page 7 of DYCD form)
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.*

Yes, I give my permissionNo, I do not give my permission
Parent/Guardian's Signature*

Clear
Parent/Guardian: Print Name*
Please re-enter the name of the parent/guardian of the student
Date

MonthDayYear
Please select today's date

Consent for Photography/Videotaping and Use of Original Work (Page 8 of DYCD form)
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
Parent/Guardian Signature*

Clear
Full Name of Student*
Please re-enter the full name of the student
Date

MonthDayYear
Date

Parent/Guardian Consent to Collect and Share Student Information (Page 9 of DYCD form)
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's student records, and I give permission to DOE to share that information with DYCD on an ongoing basis.*

Yes, I give my permissionNo, I do not give my permission
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 my permissionNo, I do not give my permission
Student Name:*
Please re-enter the name of the student
Parent/Guardian Signature*

Clear
Parent/Guardian Name:*
Please re-enter the name of the parent/guardian of the student
Date:

MonthDayYear
Date
Additional Parent/Guardian Signature (optional)*

Clear
Additional Parent/Guardian Name (optional):

Parent Consent for Participation in Afterschool Evaluation Data Collection (AIR Consent-SONYC & COMPASS High pages attached to end of SONYC form)

For more reading, refer to attached SONYC file.
School
Please select from the options below:*

Yes, I give permission for my child to participate in the AIR data collection activitiesNo, I DO NOT want my child to participate in the AIR data collection activities.
If you answered yes, then select the AIR data collection activities you give permission for: (Select all that apply)

My child CAN complete AIR surveys about youth leadership development.My child CAN attend focus groups and interviews about their experience in the afterschool program and their perceptions of youth leadership development.I would like to receive SMS text message updates about the evaluation of DYCD afterschool programs. AIR can send me text messages for future voluntary surveys. I understand that standard messaging may apply, and I can cancel at any time.
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date
If you gave your child permission to participate in focus groups and interviews, AIR researchers may record the student focus groups and interviews for note-taking purposes. If you allow AIR to record the focus group and interviews, please sign below. No one outside of the research team will hear the recording, and the recording will be deleted when the study is concluded. Students can request to have the recorder turned off ay any point.

Yes, I allow my child to be audio-recorded in the focus groups and interviews.No, I do not allow my child to be audio-recorded in the focus groups and interviews.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

DYCD Universal Participant Intake: Youth & Adult Application

Student Information (Page 1 on DYCD form)

Parent/Guardian Information (Page 2 on DYCD form)

Emergency Contact #1 Information (Page 2 on DYCD form)

Emergency Contact #2 Information (Page 2 on DYCD form)

[OPTIONAL] Additional people who can pick up my child (Page 3 on DYCD form)

[OPTIONAL] The following people MAY NOT pick up my child (Page 3 on DYCD form)

Child’s Education/Work Status (Page 3 on DYCD form)

Health Information (Page 4 on DYCD form)

Student’s Health Insurance Status (Page 4 on DYCD form)

Additional Applicant Information (Page 5 on DYCD form)

Household Information (Page 6 of DYCD form)

Pick-up/Dismissal Information (Page 7 of DYCD form)

Consent to Participate

Consent for Emergency Medical Treatment (Page 7 of DYCD form)

Consent for Photography/Videotaping and Use of Original Work (Page 8 of DYCD form)

Parent/Guardian Consent to Collect and Share Student Information (Page 9 of DYCD form)

Parent Consent for Participation in Afterschool Evaluation Data Collection (AIR Consent-SONYC & COMPASS High pages attached to end of SONYC form)