CAMBA Inc. Online Enrollment Form

1
DYCD is a New York City agency that funds programs for youth and families. These programs are operated by Community Based Organizations (CBOs). This form will allow you or your child to apply to a DYCD Comprehensive Afterschool System (COMPASS), Beacon, or Cornerstone youth or adult program. Please complete this form fully and return to the CBO that operates the program. One application will be accepted per person per site. Submission of an application does not guarantee enrollment in the program. Further paperwork and information may be required to determine program eligibility. If accepted, the program will be at no cost to the participant. The following application items are collected for informational and program planning purposes only: Income, Gender, Race, Ethnicity, Language, Population Type, Household Information and Health Insurance Status. Responses to these questions will not impact your eligibility to receive services and will not be shared outside of DYCD without the applicant’s permission.
2
Applicant Full Name* This field is required.
First Name
Last Name
3
Applicant Birth Date* This field is required.
Month
Day
Year
4
Applicant Grade* This field is required.
5
Choose a CAMBA location:* This field is required.
Albany Cornerstone
Brevoort Cornerstone
Boulevard Cornerstone
Cypress Hills Cornerstone
Howard Cornerstone
Penn Wortman Cornerstone
Pink Houses Cornerstone
Sheepshead Bay Cornerstone
Stuyvesant Gardens Cornerstone
Beacon @ P.S. 164
Beacon @ P.S. 166
Beacon @ P.S. 271
Beacon @ P.S. 361
6
Applicant Sex at Birth:* This field is required.
Male
Female
X (Not Male or Female)
Not Sure
7
Applicant Race:* This field is required.
American Indian or Alaskan Native
Black or African American
Native Hawaiian or Other Pacific Islander
White or Caucasian
Asian
Middle Eastern/North African
Other
8
Applicant Ethnicity:* This field is required.
Hispanic or Latinx
Not Hispanic or Latinx
9
Applicant Primary Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
10
Applicant or Parent Cell Phone Number* This field is required.
Area Code
Phone Number
11
Applicant or Parent E-mail Address* This field is required.
example@example.com
12
How well does applicant speak English?* This field is required.
Fluent/Very well
Well
Not well
Not well at all
13
Enter applicant's Primary Language* This field is required.
14
Is the applicant a Parent/Legal Guardian?* This field is required.
YESNO
15
Is the applicant an offender/justice offender?* This field is required.
YESNO
16
Is the applicant a foster care participant?* This field is required.
YESNO
17
Is the applicant a runaway youth?* This field is required.
YESNO
18
Is the applicant a veteran?* This field is required.
YESNO
19
Is the applicant an active military personnel?* This field is required.
YESNO
20
Is the applicant interested in registering to vote?* This field is required.
YESNO
21
Is the applicant an individual with a disability?* This field is required.
YESNO
22
Applicant Gender Identity* This field is required.
Male
Female
Non-Binary (not female or male)
Two-Spirit (Native American/First Nations
Gender Nonconforming
Not Sure
Another Gender
Do no understand the question
Decline to Answer
23
Does applicant identify as transgender?* This field is required.
Yes
No
Not sure
Do not understand the question
Decline to Answer
24
Applicant gender pronoun* This field is required.
He/Him/His
She/Her/Hers
They/Them/Theirs
Decine to Answer
Another Pronoun
25
Applicant Sexual Orientation
Heterosexual (Straight)
Gay
Lesbian
Bisexual
Pansexual
Asexual
Queer
Questioning
Not Sure
Decline to Answer
26
Parent / Guardian Full NameSkip this if the applicant is over 18 years old.
First Name
Last Name
27
Parent / Guardian Phone NumberSkip this if the applicant is over 18 years old.
Area Code
Phone Number
28
Additional Emergency Contact Full Name* This field is required.Required for applicants of all ages.
First Name
Last Name
29
Additional Emergency Contact Cell Phone* This field is required.Required for applicants of all ages.
Area Code
Phone Number
30
Emergency Contact Relationship to applicant* This field is required.Required for applicants of all ages.
31
Applicant Education Status:* This field is required.
Full-Time Student
Part-Time Student
Not in school
32
School Type * This field is required.
Public School
Charter School
Private School
Not Applicable (I'm not a student)
33
School Name - Type in N/A if you're not a student* This field is required.
34
Applicant's Current Work Status* This field is required.
Not applicable (applicant under 14 years old)
Employed Full-Time
Employed Part-Time
Retired
Unemployed (short-term, 6 months or less)
Unemployed (long-term, more than 6 months)
Unemployed (not in labor force)
Migrant Seasonal Farm Worker
35
Applicant lives in a household that is headed by:* This field is required.
Single Parent - Female
Single Parent - male
Two Adults - No Children
Two-Parent Household
Single Person - No Children
Multigenerational Household
Non-related Adults with Children
36
Applicant's Housing Type:
Own
Rent
NYCHA
Homeless
Shelter
Other Permanent Housing
37
Applicant's Household Size:* This field is required.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
38
Total Household Income in the last 12 Months:* This field is required.
$0 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+
39
Sources of Household Income (select all that apply):* This field is required.
Employment Wages
Affordable Care Act Subsidy
Alimony or Other Spousal Support
Child Support
Childcare Voucher
Earned Income Tax Credit (EITC)
Employment Tax Credit
General Assistance
Housing Choice Voucher
HUD-VASH
LIEHEAP
Pension
Permanent Supportive Housing
Private Disability Insurance
Public Housing
Retirement Income from Social Security
Safety Net/Home Relief
Social Security Disability Income (SSDI)
Supplemental Nutrition Assistance Program (SNAP)
Supplemental Security Insurance (SSI)
Temporary Assistance for Needy Families (TANF)
Unemployment Insurance
VA Non-Service Connected Disability Pension
VA Service-Connected Disability Compensation
WIC
Workers' Compensation
Decline to Answer
Other
40
Does applicant have health insurance?* This field is required.
Yes
No
Decline to Answer
41
Does applicant have any allergies?* This field is required.
YESNO
42
If YES, please provide additional details:Skip this questions if you selected NO.
43
Does applicant have asthma?* This field is required.
YESNO
44
Does applicant have special health care needs?* This field is required.
YESNO
45
Are there activities the applicant cannot participate in?
YESNO
46
Does applicant take medication for any condition or illness?
YESNO
47
Please provide any additional health information details and/or activities the applicant cannot participate in. (skip if not applicable)
48
DYCD: Consent for Emergency Medical Treatment - Parent/Guardian
49
DYCD: Participant Consent for Photo/Videotaping
50
CAMBA: Permission and Release
51
CAMBA: DYCD / DOH / ACS Permission & Release
52
DYCD: Participant Consent for Use of Original Work
53
DYCD: Consent to Make Referrals and Share Information
54
Verification of Information* This field is required.
55
Applicant or Parent/Legal Guardian Signature* This field is required.Please use your finger to sign the document electronically.
Clear
56
Today's Date* This field is required.
Date
Year
Month
Day
Should be Empty: