2025 High School - Leader in Training (LIT) Application
Family Information
Student Name
*
First Name
Last Name
Student's Age
*
Student's Date of Birth
*
Nickname
Gender
*
Male
Female
Other
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Grade Student will be Entering in fall
*
Students T-Shirt Size
*
What school is your child attending in the fall
*
Mother/Guardian's Name
*
First Name
Last Name
Phone Number:
*
Father/Guardian's Name
First Name
Last Name
Phone Number:
Student's Email
*
example@example.com
Students Phone Number:
*
Who is the primary caretaker/contact person for this child? (Note: This is the person who we will call for specific information about the student and who will receive our mailings.)
*
Primary caretaker's email address:
*
example@example.com
Is this student in foster care?
*
Yes
No
Names of siblings enrolled in The Pittsburgh Project's programs:
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In the event of an emergency, please provide the name and phone number of two additional contact people:
*
Full Name
Phone Number
*
Full Name
Phone Number
In order to provide low cost programs for your child, The Pittsburgh Project receives funding from Allegheny County and a number of other sources. The following demographic information is needed to report on the children who we serve. As with all information you provide, this data will be kept confidential. Thank you for your assistance.
Student's Name
First Name
Last Name
Student's Social Security Number
Mother/Guardian's Name
First Name
Last Name
Mother/Guardian's Social Security Number
Father/Guardian's Social Security Number
First Name
Last Name
Father/Guardian's Social Security Number
Ethnicity/Race:
*
Black/Non-Hispanic
Native American
Asian/Pacific Islander
White/Non-Hispanic
Hispanic Origin
Other
Housing:
*
Own
Rent
Other
Source of Family Income:
*
No Income
Unemployment
TANF
SSI
Employment Only
Employment + Other Income
Social Security
Pension
General Assistance
Other
Family Type:
*
Single Parent/Female
Single Parent/Male
Two-Parent
Other
Other Forms of Assistance:
*
Receives Food Stamps
Receives Medical Assistance
None
Family Size:
*
One
Two
Three
Four
Five
Six
Seven
Eight or more
Additional Household Member
Additional Household Member
Additional Household Member
Additional Household Member
Additional Household Member
Additional Household Member
Additional Household Member
Additional Household Member
Approximate Monthly Household Income:
*
Place(s) of Employment:
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Medical Information
Student's Physician:
Physician Phone Number:
Please list any allergies - drug, food, etc.:
Please list any chronic illnesses or medical conditions:
Please list any dietary restrictions:
Please list any regular medications:
Are immunizations up to date?
Yes
No
If no, please explain:
Note that any medications that your child must take while at The Pittsburgh Project - including emergency medications like inhalers and Epi Pens - must be sent with your child IN THE ORIGINAL CONTAINER
AUTHORIZATION FOR ADMINISTRATION OF MEDICATION
Do you give permission to administer Tylenol to your child, if needed?
*
Yes
No
Do you give permission to administer Motrin to your child, if needed?
*
Yes
No
I hereby authorize and instruct The Pittsburgh Project Youth Development staff to administer the above medication in the age/weight appropriate dosages.
*
I agree
I do not agree
Is there any extra information to help us to better serve your child? (Ex. known behavioral issues, coping strategies, etc.)
PERMISSION FOR MEDICAL TREATMENT AND RELEASE
In the event of an emergency and in the event that (1) a parent or legal guardian cannot be reached; or (2) immediate attention is necessary, I consent to have The Pittsburgh Project staff act on my behalf and I hereby grant permission for emergency treatment to be administered for my child until a parent or legal guardian can be reached. I agree not to hold The Pittsburgh Project or its staff members liable for decisions made in good faith or for any emergency medical treatment made under this authorization. This release will remain valid and binding for the entire duration my child is enrolled in the after school program.
*
I consent
I do not consent
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Program Release
I hereby grant permission for my child to participate in the activities of The Pittsburgh Project's program during the duration of the LIT program. I understand that this program occasionally involves physical activity and may involve transportation to and from The Pittsburgh Project. I understand the normal risks associated with these activities and with participating in this program and I agree not to hold liable The Pittsburgh Project staff and board of directors for any harm resulting from these activities. I also grant permission for staff to collect information on my child's academic and social outcomes for evaluation purposes on this program's effectiveness. This release will remain valid and binding for the current school year.
*
I consent
I do not consent
Photo/Image Consent
Occasionally, The Pittsburgh Project staff members wish to photograph, videotape, or otherwise record the activities of program participants for the purpose of recording, promoting, and reporting outcomes of the youth development programs. I hereby give permission for my child to be photographed, videotaped, or otherwise have their image or voice recorded, in connection with the youth development programs of The Pittsburgh Project. I give permission to The Pittsburgh Project to indefinitely use the photographed, videotaped, and/or recorded materials in any publications, promotional materials, reports, websites, CD's, DVD's, social, and other media for publicity, reporting purposes, or in any other non-commercial manner that it chooses. Additionally, I give permission for said recordings to be shared with or used by direct partners of The Pittsburgh Project at the discretion of The Pittsburgh Project staff. I hereby waive and release any rights that I may have to the said videotaped, recorded, and/or photographed materials. This release will remain valid and binding for the length of time my child is enrolled in The Pittsburgh Project's program.
*
I consent
I do not consent
USDA Nondiscrimination Statement
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the UDSA Program Discrimination Complaint Form, (AD-3027) found online at http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by (1) Mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington D.C. 20250-9410; (2) Fax: (202) 690-7442; or (3) Email; program.intake@usda.gov. This institution is an equal opportunity provider.
Parent/guardian signature
*
Parent/guardian name
*
First Name
Last Name
Date
*
/
Month
/
Day
Year
Date
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Should be Empty: