Safe Haven OST Program - Enrollment Application

Safe Haven OST Program - Enrollment Application

Thank you for your interest in enrolling your child(ren) in ADAC's out-of-school time (OST) program! Please complete a separate application form for each child you wish to enroll.
Email*
example@example.com
How did you hear about this program? *

Child's Information
Child's First and Last Name*

First NameLast Name
What school does the child attend?*
Child's Classroom Number and/or Teacher Name*
Please write your child's classroom/homeroom number and classroom/homeroom teacher's name.
Child's Current Grade*
Child's Current Street Address (including apartment number if applicable)*

Street Address

Street Address Line 2

CityState

Zip Code
Child's Date of Birth*

MonthDayYear
Date
Child's Gender*
Child’s Race*
Child's Nationality*
Does Your Child Have an Individualized Education Plan (IEP)*
Please upload your child's Individualized Education Plan (IEP) here, if applicable.

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Is your Child Involved with the Department of Human Services (DHS) system? *
If “Yes”, Check all that apply

Community Umbrella Agency (CUA)Foster/Group Home PlacementKinship CareJuvenile Justice System/Teen CourtSchool-linked Behavioral HealthcareTruancy Prevention ProgramServices to Children in Their Own HomesOther
Please share any additional information you feel we should know about your child

Child Health Information
Does your Child have Asthma? *
Does your Child carry an Inhaler? *
Does your Child have any Allergies?*
Please list your Child's Allergies (if applicable)
Please list your child's DIET restrictions (etc. personal, religious, medical)
Does your Child carry an Epi-pen? *
Does your child have any special medical needs or requirements that was not mentioned?*
If "Yes," Please describe your child's medical needs and/or requirements.
Does your child have any restrictions preventing participation in physical activities?*
If "Yes," List your child's physical restrictions.
Is your Child fully vaccinated against Covid-19?*
This information will help us respond appropriately to any positive cases according to the applicable guidance of the moment. "Fully vaccinated" is defined as being 15+ days past the administration of the second dose of vaccine. If you do not disclose your child's vaccination status, we will treat any exposure or positive case as if they are unvaccinated.
I understand that in case of any emergency requiring medical treatment, every effort will be made to reach one of the guardians or emergency contacts listed on this application. If none of these people can be contacted, I authorize the Safe Haven/ADAC staff to give consent to treatment as deemed necessary by emergency responders.*
Parent/Guardian Signature*

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Primary Contact Information
Primary Contact Full Name*

First NameLast Name
Primary Contact's Relationship to Student*
Home Address (if different from child)

Street Address

Street Address Line 2

CityState

Zip Code
Cell#*
Please enter a valid phone number.
Home/Other Telephone #
Please enter a valid phone number.
Primary Contact's Email Address*
example@example.com

Secondary Parent/Caregiver
Secondary Contact’s Full Name: *

First NameLast Name
Secondary Contact's Relationship to Student*
Secondary Contact's Home Address (if different from child)

Street Address

Street Address Line 2

CityState

Zip Code
Secondary Contact's Cell#*
Please enter a valid phone number.
Secondary Contact's Home/Other Telephone #
Please enter a valid phone number.
Secondary Contact's Email Address*
example@example.com

Emergency Contact Information
Emergency Contact’s Full Name: *

First NameLast Name
Emergency Contact's Relationship to Student*
Emergency Contact's Home Address (if different from child)

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact's Cell#*
Please enter a valid phone number.
Emergency Contact's Home/Other Telephone #
Please enter a valid phone number.
Emergency Contact #2 Full Name: *

First NameLast Name
Emergency Contact #2 Relationship to Student*
Emergency Contact #2 Home Address (if different from child)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #2 Cell#*
Please enter a valid phone number.
Emergency Contact #2 Home/Other Telephone #
Please enter a valid phone number.

Pickups/Dismissal
Names of the people (NOT Parent/Guardian) who will pick up the student at the end of dismissal
If another individual (not listed above) is to pick up the student, advanced written notice must be given ahead of time for safety reasons.*

I understand
Participants in the program may, if given permission by their caregiver, sign themselves out and leave unaccompanied at the end of programming. It is our policy to contact the caregiver if a child tries to sign out early without prior permission from the caregiver.*
*My child is ONLY permitted to walk home with the named Safe Haven OST participant(s) below:

Family Information
The below questions are required by ADAC's funders in order to receive State and City support. This information enables ADAC to offer programming to all families for free. These data are not reported on an individual level and are de-identified before reporting. No family will be turned away based on their answers to these questions.
Household Annual Income*
Number of Family Members in Household*
Is your child eligible for free or reduced price lunch?*
Does your family have a custody or court parenting order or parenting plan that you can share with us?*

Consents and Releases
Photo/Media Release Consent - I consent to the use by ADAC, my child’s first name, grade, likeness, photograph, artwork, or quotation for all forms and manners for educational, instructional, or promotional purposes.*
Student Information Release Consent - I consent to use by ADAC and its partners of my child’s/children's de-identified demographic information for program evaluation purposes: *
I consent for my child (check ALL that apply)*

ADMIN. OF MINOR FIRST-AID PROCEDUREObtaining Emergency Medical CareParticipating on Walks & TripsTo have transportation by agencyParticipating in Wading/water playSwimming
I understand that my child may be asked to take surveys and tests at the beginning and/or end of programming sessions to evaluate the effectiveness of the program. Personal information will be kept confidential.*
My signature confirms my decisions for the above consents. I understand my decision to give or not give consent can be changed at anytime with a written notice emailed to SafeHavenOST@ADACPhilly.org. *

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Release of Liability Waiver
I understand that the program activities are designed with the safety of the children in mind and offer very little, if any, risk of injury. (My child and) I knowingly and freely assume all risks, both known and unknown, even if arising from the negligence of the releases of others, and assume full responsibility for my participation. (My child and) I, hereby release and hold harmless the above named agency, their employees, other participants, sponsoring agencies, and, if applicable owners and leasers on premises used to conduct the program (“releases”) with respect to any injury, disability, death, or loss or damage to personal belongings, that occur during participation in the program, whether arising from negligence of the agency, its employees or otherwise. *

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Data and Referral Waiver
All information released will be used exclusively for programming, reporting, and evaluation purposes. All personal and personally identifiable information will not be shared without your further consent. No health information (other than verification that the agency is in receipt of the child’s recent physical and the date of the exam) will be entered into the database. Please note that the client database is password protected and can be accessed only by trained representatives of the above-named agency and its partners. I also understand that a referral might be made to an ADAC partner based on the information provided in this application. The youth and parent will be notified when such a referral is being made. *

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ADAC Notice of Privacy Practices
I also give general consent for my child to participate in the Safe Haven OST program and acknowledge that I have received a copy of the Notice of Privacy Practices that explains the Federal HIPAA.*

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I hereby attest that this Enrollment Application is complete and accurate. *

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Next Steps in the Application Process
In order to complete your child’s enrollment there may be some additional documents that need to be completed.

ADAC's Site Coordinator will email or call you with:
1) any information missing from this application, and
2) instructions on how to complete additional required forms or to schedule a time to assist you with completing those forms in person.

Children will be accepted into this program in the order of submission of complete application materials.

PLEASE CLICK "Submit" BELOW TO COMPLETE YOUR CHILD'S APPLICATION.
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