CSI / DFSS Combined Form

DFSS PARTICIPANT INTAKE FORM
AGENCY NAME
Program Name:*
Type of Program

Out-of-SchoolCHAMentoring
Which OST program is your child interested in

YMCASchool Enrichment ActivitySchool Academic ActivitySports Activity
PARTICIPANT
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Age*
Grade*
Kindergarten and Pre K = 0
CPS/Student ID# (if applicable)
Gender (check one)*

FemaleMaleTransgenderNon-BinaryChoose not to identify
Pronouns*

He / HimShe / HerThey / ThemOther
Race/Ethnicity*

American Indian / Alaskan NativeAsianBlack / African AmericanMiddle Eastern/North AfricanOther Multi-RacialNative Hawaiian/ Other Pacific IslanderWhiteTwo or more racesChoose not to identify
Do you identify as Latin(x)/ Hispanic?*

YesNo
Primary language spoken at home
Please check all that apply*

English Language Learner / English as a Second Language (ELL/ESL)Connected to foster care systemExperiencing homelessness/unstably housedCurrently out of school AND out of workPregnant or parentingNone of these apply
School Attending: Is the student enrolled at the school where they will be attending CSI programs?

YESNO
If no, what school do they attend during the school day?
Does the participant have a disability?

YESNO
If yes, please specify any accommodations needed
PARENT/GUARDIAN INFORMATION
Parent Guardian Name (First & Last)*
Relationship to student*
Address
Apt No
City
Zip code
Phone
Email
example@example.com
Preferred Method of Contact

EmailPhone / Text
Parent/Guardian 2 (First and Last Name)
Relationship to student
Cell Phone
EMERGENCY CONTACT INFORMATION (must be different from guardian)
Emergency Contact Name (First & Last)
Relation
Phone
I certify that the above information is accurate. I give my permission for the above named to participate in this program and to follow all program requirements.

I certify that the above information is accurate. I give my permission for the above named to participate in this program and to follow all program requirements. I understand that, as part of the agency's contract with the Chicago Department of Family and Support Services (DFSS), the agency is expected to collect and report participant- level demographic, performance, and service data to DFSS. This includes but is not limited to data in this youth registration form, youth attendance, youth survey data, and program outcomes. The agency must implement policies and procedures to ensure privacy and confidentiality of client records for both paper files and electronic databases.
Yes, I certify that the information is accurate.
I give permission for the agency to share the participant's photograph and/or video with the Chicago Department of Family and Support Services for promotional purposes, including posting on social media, per the department's discretion without any NO compensation.*

YesNo
CHICAGO PUBLIC SCHOOLS COMMUNITY SCHOOLS INITIATIVE
Print Student Name*
Print Parent/Guardian Name
CSI APPLICANT INFORMATION
STUDENT NEEDS AND ACCOMMODATIONS
Does your child require specific modifications, accommodations, and/or adaptations to participate in this program?

YESNO
If yes, please list each support. Be specific.
MEDICAL INFORMATION
Does your child have any medical conditions of which CPS Community Schools Initiative should be aware (ex. Asthma, allergies, sensitivities)? If yes, please specify.
Does your child take any medications? (ex. Asthma inhaler, anti seizure medications, etc). Note that CSI program staff cannot administer medication. Please make arrangements for your child to receive medication prior to the start of programming.
Will your child be required to self-administer any medications during activities?

YesNo
MEDIA CONSENT / DATA COLLECTION
I give permission for my student to be photographed and videotaped for the purposes of learning, documentation and promotions for CSI programs.*

YesNo
PARENT/GUARDIAN PERMISSIONS AND AGREEMENTS
I give permission to the school to notify an emergency contact listed on reverse to act on my behalf in the event that I cannot be reached during a medical emergency.
Parent/Guardian Initials
I give permission for the child listed on the reverse to participate in the programs and activities provided by the CPS Community Schools Initiative grant funded program.
Parent/Guardian Initials
I understand that this program focuses on academic tutoring and enrichment, sports and recreation, life skills education, as well as substance abuse prevention.
Parent/Guardian Initials
I understand that any medical bills incurred by an accident are my responsibility and I will not hold CPS Community Schools Initiative or their partners liable for such occurrences.
Parent/Guardian Initials
I understand that enrollment in activities will not begin until | receive written confirmation of enrollment from the CSI Resource Coordinator and I will not send my student to activities until confirmation is received.
Parent/Guardian Initials
We understand and affirm the following student expectations: (1) Every student has the right to learn and participate in the program, unless revoked due to disciplinary measures; (2) Every staff member has a right to teach, coach, or present their materials and activities; (3) Everyone has the right to feel physically and emotionally safe.
Parent/Guardian Initials
We understand and affirm this attendance policy: (1) I agree to attend all sessions of any program for which I register; (2) I agree that missing 3 consecutive sessions, or 5 or more sessions in a semester, without documentation may result in being dropped from the program.
Parent/Guardian Initials
We understand and affirm the following behavior policy: (1) I will maintain appropriate behavior in accordance with the CPS Student Code of Conduct; (2) I understand that my parents/guardians will be notified if I engage in inappropriate behavior (behavior that threatens the physical or emotional safety of anyone else or that disrupts from the educational atmosphere) and that any instance of such will result in my dismissal from the program for the remainder of the quarter in which the instance occurs.
Parent/Guardian Initials
My student will: (select one option below)

My child will walk home from the CPS Community Schools Initiative 21st CCLC Program.My child will be picked up by a parent/guardian.My child will secure his/her own transportation.
Students who leave before the programs end must check out with the CPS Community Schools Initiative Resource Coordinator. Please initial here if you give permission for your child to leave the program early
Please list any additional person(s) who have permission to pick up your child from programs (other than guardians or emergency contacts listed on the front of application) Name:Relationship to student: Name:Relationship to student: Name:Relationship to student:
Name
Relationship to student
Name
Relationship to student
Name
Relationship to student
I am interested in being a volunteer at my child's school

YESNO
SIGNATURE OF PARENT/GUARDIAN

Clear
DATE

MonthDayYear
Date
A 1-2 WEEK REVIEW PERIOD IS REQUIRED PRIOR TO REGISTRATION.

**PLEASE DO NOT SEND YOUR STUDENT TO ACTIVITIES UNTIL YOU RECEIVE WRITTEN CONFIRMATION OF ENROLLMENT FROM YOUR CSI RESOURCE COORDINATOR.**
Funds for this activity were provided by a Nita M. Lowry 21st Century Community Learning Centers (21st CCLC) grant awarded to the Chicago Public Schools (CPS) Community Schools Initiative (CSI
Should be Empty:

DFSS PARTICIPANT INTAKE FORM

PARTICIPANT

PARENT/GUARDIAN INFORMATION

CHICAGO PUBLIC SCHOOLS COMMUNITY SCHOOLS INITIATIVE

CSI APPLICANT INFORMATION

STUDENT NEEDS AND ACCOMMODATIONS

MEDICAL INFORMATION

MEDIA CONSENT / DATA COLLECTION

PARENT/GUARDIAN PERMISSIONS AND AGREEMENTS