DYCD Universal Participant Intake: Youth & Adult Application 8.4.22

Part VII: Consents and Signatures
Pick-up/Dismissal Information

This question must be answered for parents/guardians enrolling their children
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.
If participant is 18 and over:
I acknowledge that I am 18 years of age or older and am authorized to give consent.*

YesNo
Parent/Guardian's Signature*

Clear
Participant: Print Name*
Date*

MonthDayYear
Date
Consent for Emergency Medical Treatment
I am 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 to be obtained on my behalf. I further authorize the emergency contact(s) listed to be contacted.*

Yes, I give my permissionNo, I do not give permission
Participant’s Signature*
Participant: Print Name
Date

MonthDayYear
Date
If participant is under 18 years old:
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 permission
Parent/Guardian’s Signature
Parent/Guardian: Print Name
Date

MonthDayYear
Date

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
If participant is 18 and over:
I acknowledge that I am 18 years of age or older and am authorized to give consent.*

YesNo
Full Name of Participant*
Participant's Signature*

Clear
Date*

MonthDayYear
Date
If participant is under 18 years old:
Full Name of Participant*
Parent/Guardian's Signature*

Clear
Date*

MonthDayYear
Date

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 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 you or your child. Personally identifiable 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 of 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/Applicant Name:*
Parent/Guardian Name*
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Additional Parent/Guardian Name (optional)
Additional Parent/Guardian Signature (optional)

Consent to Make Referrals and Share Information
The New York City Department of Youth and Community (DYCD) invests in programs and services to help our communities and the people who live here. We want to make sure you know about them and make it easy for you to apply.

Why we need your permission

With it, we can:
- send you information about DYCD-funded programs and services you can apply for, and
- share information from your DYCD Participant Application each time you apply.
What we share

We’ll only give information to show you qualify or help you enroll in DYCD-funded programs.

Who sees your information and how we protect it

Only authorized DYCD and funded program staff can see it. We don’t share it with others except to:
- decide if you’re eligible for services,
- enroll you in programs and services, and
- track the results of the services you receive
_______________________________________________________

Please read below, check one of the boxes, and fill in the rest.

I understand why DYCD needs my consent to:
- send me information about programs and services I can apply for,
- refer me to DYCD-funded programs, and/or
- share information from my DYCD Participant Application with the programs I apply for
Yes, I give my permissionNo, I do not give my permission
Full Name of Participant (please print)*
Signature of Participant (or Parent/Guardian for participants under 18 years old)*

Clear
Date*

MonthDayYear
Date

WAIVERS AND CONSENTS
WAIVER OF LIABILITY: I recognize that activities to be engaged in by participants during New York Edge programs may result in personal injury or property damage. I hereby release and hold harmless New York Edge from any and all claims I or my child may have arising from, or in connection with, participation in the program. Such release includes, but is not limited to, any claims, demands or causes of action for injuries to my child, except where due to the negligence of New York Edge.*

YesNo
E-LEARNING CONSENT: I understand that at times my participant may have to engage in E-learning to participate in New York Edge programs. New York Edge will be facilitating any required E-learning, including in response to COVID-19 related closures, through the Google Classroom and Zoom platforms. I provide consent for my child to participate in New York Edge E-learning opportunities using the Google Classroom platform and Zoom. For additional information about E-Learning platforms, please visit:https://gsuite.google.com/terms/education_privacy.html (Google Classroom) & https://zoom/us/terms*

YesNo
PHOTO/VIDEO CONSENT: I consent for my participant to be photographed or otherwise recorded during New York Edge events and activities, whether in school or away from school. I give my permission for any and all such photographs and/or recordings to be displayed by New York Edge in any lawful medium (books, newsletters, websites, social media, etc now or in the future, for which neither I or my participant shall receive ownership rights or monetary compensation.*

YesNo
INTERVIEW/SURVEY CONSENT: I understand that New York Edge holds events, both in-school and away from school, at which media representatives, television reporters, photographers or public-relations personnel may be present. In some cases they may interview, photograph or survey children who participate in these events, including my participant. I understand that my participant may be asked questions concerning New York Edge activities and programs, and that the contents of that interview may be published or aired publicly. I understand that my child will be under the supervision of New York Edge personnel during at all times during any direct interview, photo or survey session. I understand my participant reserves the right to refuse to answer any questions or participate in any discussions, and that my child or the supervising New York Edge personnel may terminate the session at any time for any reason.*

YesNo
I, the undersigned, certify that I am the parent or legal guardian of ________, whose date of birth is __________, that I have read the consents outlined above and give my permission to participate in the New York Edge program.
Participant's Name*
participant's name
Participant's Date of Birth*
participant's date of birth
Parent/Guardian Name*
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Parent Consent to Participate in the Evaluation of the After-School Program
Dear Parent/Guardian,

Your child is enrolled in the after school program at ___ . In order to monitor the effectiveness of the after school program and ensure its future success, New York Edge is conducting ongoing evaluations. It is the intention of the evaluations to learn how these services help students and how they can be improved in order to meet funding requirements.

Specifically we ask permission from parents to:
- Talk to teachers and after-school staff about children’s progress and participation in the after-school program, and review program records on participation in the after-school program.
- Survey and/or interview parents and children about the after-school program and its effects. There will be a survey distributed via text/email over the course of the year. The survey will take approximately 15 minutes. Group discussions may also be held, that would take up to 30 minutes.
Any information we collect will be used only to assess the after-school program and will not be made public. Participation in the evaluation is completely voluntary, and participants may withdraw at any time without consequence. Personal information will not be used for any purposes after the evaluation is complete.

Please select one of the options below and return this form to the program coordinator/ director.
YES, I GIVE PERMISSION FOR MY CHILD TO PARTICIPATE. I have read the above information and I give permission for my child to participate in the evaluation of the after-school program.NO, I DO NOT WANT MY CHILD TO PARTICIPATE. I have read the above information and I do not give permission for my child to participate in the evaluation of the after-school program.
SIGNATURE OF PARENT OR GUARDIAN*

Clear

Parent/Guardian Data Release Consent Form
I. Information being requested.

New York Edge is requesting your permission to collect academic performance and enrollment data on your child. This information will be used for the purposes of establishing program outcomes and may be used in a combined, not individualized, format to help advocate for continued funding.
- Contact their children’s school and obtain records showing their progress, including report cards, grades, citywide and statewide test scores, attendance, school choice, and any other reports pertaining to academic progress.
- 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)
- Academic performance data (including your child’s results on state and national exams, credits earned, grades, promotion and retention status, and fitness gram score)
- Data related to any disciplinary actions taken against your child (including number and type of suspensions)
II.How will your child’s data remain confidential?

We will not use your name or your child’s name in any published report. While we request your consent, your responses to the requests below will not affect your child’s participation in our programs.

Please select Yes or No to the following statement:
- I understand why New York Edge 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 New York Edge on an ongoing basis
Type a question*

Yes, I authorize New York Edge and DOE to share my child’s information/student records.No, I do not authorize New York Edge and DOE to share my child’s information/student records
Student/Applicant Name*
Parent/Guardian Name:(Please Print)*
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Additional Parent/Guardian Name:(optional)
Additional Parent/Guardian Signature: (optional)

Clear
58-12 Queens Boulevard Suite 1, Woodside, NY 11377 · Telephone: 718-786-7110 · www.newyorkedge.org

EMERGENCY MEDICAL CARE FORM

(To be completed by the parent or guardian)
Participant's Name:*

First NameLast Name
Date of Birth*

MonthDayYear
Date
1. I authorize New York Edge (“Program”) to, if necessary, provided basic first aid in accordance to their level of training. Injury assessment and intervention will include the use of topical skin antibiotic as appropriate.

2. If my child requires emergency medical care as determined by an appropriately trained employee of the Program, I give my consent to the above Program to obtain the necessary medical care for my child. I agree to pay all of the costs associated with the emergency medical care that my child receives.

3. I hereby release the Program from any and all claims which I or my child may have against New York Edge arising from or in connection with the providing of First Aid as described herein, except where due to the negligence of New York Edge staff. This agreement is signed for the purpose of fully and completely releasing, discharging, and indemnifying the program from all liability as described herein.

4. Following emergency medical care, my child may be released to the following people:
Name*
Relationship to Child*
Age*
Address*
Employer
Home Phone
Work Phone*
Name
Relationship to Child
Age
Address
Employer
Home Phone
Work Phone
Name
Relationship to Child
Age
Address
Employer
Home Phone
Work Phone
5. Health Information:
Allergies*
Religious Preference: (optional)
Last Tetanus*
Medication(s) being taken*
Student's Doctor (Name)*
Student’s Doctor (Phone)*
Medical history or other pertinent facts that should be known*
6. I understand that this consent will be in effect as of the date of my signing this form and will continue as long as my child is enrolled in the Program.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

DYCD Universal Participant Intake: Youth & Adult Application

Part I: Applicant Information

Part II: Applicant’s (or Parent/Guardian’s) Contact Information

This section is for parents/guardians enrolling their children

Part III: Applicant’s Education/Work Status

Part IV: Health Information

Applicant’s Health Insurance Status

Part V: Additional Applicant Information

Is the applicant any of the following:

Part VI: Household Information

Part VII: Consents and Signatures

Pick-up/Dismissal Information

Consent to Participate

Consent for Emergency Medical Treatment

Consent for Photography/Videotaping and Use of Original Work

Parent/Guardian Consent to Collect and Share Student Information

Consent to Make Referrals and Share Information

Parent Involvement

Certification Statement

WAIVERS AND CONSENTS

Parent Consent to Participate in the Evaluation of the After-School Program

Parent/Guardian Data Release Consent Form

EMERGENCY MEDICAL CARE FORM