Friends Inc. @ Dorothy J Collier Community Center After School/Summer Camp Program Application

How did you hear about our program?

Which program are are you enrolling your student in?

Preferred Method of Contact:

Your child must be at least 5 years old to enroll in the summer camp program. Will your child be at least 5 years old at the start of the program on July 6, 2026?

Have you been approved to receive Erie County Department of Social Services Childcare Assistance Payments?:

Student Name

School

Child's Current Grade (2025-2026 School Year)

Address

City

State

Zip Code

Date of Birth

Date

Student ID #

Student Gender

Student's preferred language

T shirt size

Does student have: Individualized Education Program?

Please list any other children you plan to enroll in camp/after school (YOU MUST FILL OUT A SEPARATE APPLICATION FOR EACH CHILD)

Parent/Guardian #1 Name

Parent/Guardian #1 Relationship

Parent/Guardian #1 Preferred Language

Parent/Guardian #1 Phone Number (Cell)

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian #1 Work Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian #1 Email Address

example@example.com

Parent/Guardian #2 Name

Parent/Guardian #2 Relationship

Parent/Guardian #2 Preferred Language

Parent/Guardian #2 Phone Number (Cell)

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian #2 Work Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Name

Emergency Contact Relationship to Child

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Email Address

example@example.com

Annual Household income

I approve pictures, video recording, etc. to be taken of my child at afterschool/summer camp, and to be used in marketing efforts and publications including social media.

My child will be dismissed to walk home each day at the end of camp.

Will you pick your child up daily from after-school/camp?

The following is the ONLY other individuals authorized to pick up my child from camp (must present photo ID):

Relationship

Phone

Format: (000) 000-0000.

I understand participation in the alter-school/camp program involves certain inherent risks of injury, despite all safety precautions taken by after-school/camp staff. Therefore, as the guardian will assume all risks, injury or illness, for my child that may occur during the participation in camp activities. I certify that my child is fully covered by medical insurance and/or that am financially responsible for costs associated with any medical/dental treatment as deemed necessary by after school/camp staff and/or medical professionals. I agree to hold harmless Child & Family Services, Buffalo Public School District, Buffalo Board of Education, partnering organizations, their respective subsidiaries or affiliates, or their respective management. agents, employees. directors, officers, and other representatives in the event of injury to my child. - do further release, absolve, indemnify, and hold harmless the same parties against any claim of injury or death to my child in connection with any andall after school/camp activities. I HAVE READ AND I UNDERSTANDTHIS AGREEMENT AND VOLUNTARILY SIGN THIS INDEMNITY

Parent/Guardian Printed Name

Parent/Guardian Signature

Date

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. Friends Inc. has put in place health and safety protocols to reduce the spread of COVID-19; however, Friends Inc. cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending a Friends Inc. After- School Program/Summer Camp could increase your risk and your child(ren)'s risk of contracting COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending Friends Inc. After-School Program/Summer Camp and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at Friends Inc. After-School Program/Summer Camp may result from the actions, omissions, or negligence of myself and others, including, but not limited to, program participants and their families, employees, volunteers, directors, officers, agents and other representatives of Friends Inc., Child & Family Services, Buffalo Public School District, Buffalo Board of Education, partnering organizations operating after-school/camp programs, and their respective subsidiaries or affiliates. Ivoluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)'s attendance at Friends Inc. After-School Program/Summer Camp or participation in Friends Inc. After-School Program/Summer Camp ("Claims" On my behalf, and on behalf of my child(ren), I hereby release, covenant not to sue, discharge, and hold harmless Friends Inc., Child & Family Services, Buffalo Public School District, Buffalo Board of Education, partnering organizations, their respective subsidiaries or affiliates, or other respective management, agents, employees, directors, officers and other representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Friends Inc., Child & Family Services, Buffalo Public School District, Buffalo Board of Education, partnering organizations, their respective subsidiaries or affiliates, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any. Friends Inc. After-School Program/Summer Camp.

Parent/Guardian Printed Name

Parent/Guardian Signature

Date

Family Physician Name

Phone

Format: (000) 000-0000.

Dentist/Orthodontist Name

Phone

Format: (000) 000-0000.

SECTION II - INSURANCE INFORMATIONIs the child covered by family medical/hospital insurance? ONo.

If yes, Insurance Carrier

Group #

Policy#

Policy Holder's Name

Relationship to participant

SECTION II - INSURANCE INFORMATION Is the child covered by family medical/hospital insurance?

SECTION III - HEALTH HISTORY Does your child have a history of or is prone to any of the following (Please check all that apply

Please explain any items checked above

Physical activities to be limited or restricted by child

Does child have any allergies? (If yes, please complete below)

Does your child require an Epipen? (Please check one)

I acknowledge that my child can self-administer his/her EPIPEN as prescribed by a physician:

Does your child require an Inhaler? (Please check one)

I give permission for my child to self-administer his/her INHALER at after-school/camp

Does your child require medications administered at after school/camp? (Please check one. If yes, a note is required from prescribing physician)

If yes, what is the name, dosage and time that the medication should be administered?

I give permission for site staff to apply sunscreen and/or bug spray. If "yes", I will send such to camp with my child.

My child has permission to engage in all camp activities except as noted. The information provided on this form is accurate to the best of my knowledge. have indicated any special health conditions, including required medication and activity limitations. I give consent in advance for medical treatment at an appropriate facility in case of illness or injury.

Parent or Guardian Printed Name

Parent or Guardian Signature

Date

Please describe any vision, hearing, mobility, healthcare and/or behavioral needs your child may have.

What motivators (e.g., toys, activities, foods) will be strong reinforcers for your child?

Please list any triggers that might agitate your child (e.g., loud noises, large groups, etc.).

What is the best way to assist your child if he/she gets overwhelmed or upset?

Does your child have a caseworker?

Caseworker name

Organization

Email address

example@example.com

Phone number

Format: (000) 000-0000.

With whom does your child live?

Please list any of your child's dislikes or fears of which we should be aware.

What are your child's favorite activities?

How well does your child follow directions?

Has your child previously attended an after school/summer camp?

If yes, was it a positive experience? Please explain:

Please explain

Friends Inc. @ Dorothy J Collier Community Center After-School/Camp Release of Information Form (Optional)

By signing this form, I,hereby authorize Friends Parent/guardian name Inc. /Child & Family Services, Buffalo Public Schools and if applicable, my child's charter school to exchange academic and medical records pertaining to my child identified below.

Parent/guardian name

Charter school name (write "N/A" if not applicable)

Name

Child's First NameChild's Middle InitialChild's Last Name

Child's Date of Birth

Date

I understand that this form is optional and that I do not need to sign it for my child to attend After- School/Camp. If I do not sign this form, Buffalo Public Schools, and if applicable, my child's charter school will not release any information to the above-named parties. I also understand that Friends Inc. and Child & Family Services may not deny me any services simply because I choose not to sign this authorization. I understand that the information to be released is confidential and protected from sharing. If I choose to sign this authorization, I know that I have the right to cancel my authorization to the release of information in writing at any time, except to the extent that the above-named parties have already used it to exchange records. Written cancellations must be mailed to the following: Roberta Fulton, Friends Inc., 118 E Utica St, Buffalo, NY 14209.

My authorization to the exchange of information shall expire one year from the date that I signed below.

Exceptions or limitation to this authorization are as follows:

Signature

Date

Friends Inc. @ Dorothy J Collier Community Center After School/Summer Camp Program Application

SECTION VI-AUTHORIZATION