Harlem Grown After-School Program 2024-2025 Application

Dear Families, Community, and Partners: 

Our dedicated team of educators, farmers, chefs, and volunteers are committed to creating a nurturing and inclusive environment where every child can thrive. Whether they're exploring the wonders of science on our farm, unleashing their creativity through art projects, or mastering culinary skills in the kitchen, your child will have the opportunity to discover their passions and develop lifelong skills that will serve them well into the future. 

Details:

Time: Monday through Friday; 3pm - 6pm 

Dates: Monday, September 16th to Friday, June 13th

Fees: Harlem Grown’s After-School is FREE for all participants. 

Due to high demand to attend our program, students will be selected via a lottery.  Completion of this application form does not guarantee admission to after-school. 

Due to high volume of applications, we will not be able to provide individual follow up on application status.

 In order to be considered for our after-school lottery, all children must:

o   Be a K-5th grader for the 2024-2025 school year;

o   Meet the requirements in section five of the application;

o  Be fully immunized and up-to-date on eligible vaccines – no religious exemptions to vaccination are allowed for children attending after-school;

o  Complete this application form in full by August 16th; and

o  Submit a completed copy of the Child & Adolescent Health Examination Form  filled out by a medical professional and dated within the last year once your child is selected for program.

Parent/Guardian's Contact Information:

Emergency Contact Information:

We will always attempt to contact the parents/guardians first, but if a parent/guardian cannot be reached, we will call the following contacts in the order listed.

The emergency contacts provided below should be adults over age 18.

Authorized Pick Up:

Emergency contacts listed above are authorized to pick up the child unless otherwise noted. All people listed will be asked for ID for verification at pick-up.

The following additional people are aged 18 and older and are authorized to pick up my child:

The following people MAY NOT pick up my child:

Please answer the questions below and provide additional details in the space provided.

Many needs or health challenges can be accommodated and may not limit enrollment in the program.

**Applicant is eligible to vote in U.S. federal elections if:
1) You are a U.S. citizen;
2) You meet your state’s residency requirements;
3) You are 18 years old. Some states allow 17-year-olds to vote in primaries and/or register to vote if they will be 18 before the general election. Check your state’s voter registration age requirements.

For all the next set of questions, HOUSEHOLD is defined as any individual or group of individuals (family or non-family members) who are living together as one economic unit.

INCOME is defined as the total annual gross income of all family and non-family members 18+years old living within the household.

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.

Consent and Release for Photography/Videotaping and Use of Original Work:

As a participant enrolled in a Harlem Grown program, please be aware that from time to time Harlem Grown 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, including but not limited to, brochures, books, print and email newsletters, DVDs and videos, websites, social media and blogs or in all manner of media whatsoever, now known or hereafter developed (the “Media”), including unrestricted use for purposes of publicity, advertising and sales promotion, and to use the Child’s name, likeness, voice, and biographical or other information in connection therewith (the “Material”). I understand that Harlem Grown and its After-School exclusively own all rights to the Material irrespective of the form in which it is produced or used.

I hereby authorize and permit Harlem Grown and its 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 Harlem Grown program activities and special events, and I hereby consent to the resulting images, videos and interviews being used and/or edited, without compensation and without further approval by the Authorized Parties solely for non-profit, non-commercial purposes in any and all Media.

If, in the course of participating in Harlem Grown 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 Harlem Grown and its Authorized Parties, without compensation and without further approval, solely for non-profit, non-commercial purposes in any and all Media.

I further agree to release and hold harmless Harlem Grown and its After-School, its licensees, agents, assigns, successors, affiliates and designees from any and all claims and liability for damages, losses, or expenses of any sort arising from the making or use of the Material, including, without limitation, claims with respect to the Child’s right to privacy or publicity.

I have read and understood the contents hereof and have the right and authority to execute this Consent and Release, which is governed by the laws of the State of New York.

Consent to Make Referrals and Share Information

Harlem Grown is invested in creating programs and services that support your family and our community. 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 Harlem Grown programs and services you can apply for, and
• share information from your Harlem Grown Participant Application each time you apply.

What we share

We’ll only give information to show you qualify or help you enroll in Harlem Grown programs.

Who sees your information and how we protect it

Only authorized Harlem Grown 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

Consent to Collect and Share Student Academic Information

Harlem Grown (HG) 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. HG 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 HG 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 HG 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 who will see your child’s individual information are HG and DOE staff who manage the data systems and prepare research reports and program analyses. The limited number of HG staff identified to receive personal information is screened, and provided extensive training to follow strict guidelines on protecting the confidentiality of information that would personally identify you or your child.

Personally identifiable information 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 or 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 HG sponsored programs.

Terms & Conditions:

Knowing and having been informed of the potential dangers and risks associated with after-school and in consideration of my child/ward being allowed to participate in the camp, I hereby agree on behalf of myself, my family members and my child/ward to assume all such risks and, further, to waive, release, discharge and hold harmless any camp chosen facility, the Camp Director, Harlem Grown, its After-School Program and their respective employees, agents, representatives, first responders and volunteers from any and all liability, actions, causes of actions, claims or demands for personal injury, death or property damage of any kind or nature, and any other claims whatsoever arising out of, or in any way connected with, my child’s participation in the above camp. These Terms and Conditions extend to all claims of every kind or nature whatsoever, foreseen or unforeseen, known or unknown. The terms hereof shall serve as an assumption of risk, release and waiver for myself, my family, my child/ward and our heirs, executors, agents and representatives, administrators, guardians or anyone else who might assert a claim on our behalf.

I am aware that the playing, practicing and participation in any activity can be dangerous, involving many risks including serious injury or death. I hereby assume all the risks associated with my child’s participation. I understand that Harlem Grown does not provide medical or accident insurance for camp enrollees.

Disclaimer of liability for lost, stolen or damaged property of myself or my child:

Harlem Grown, its officers, directors, and employees shall not be responsible for clothing, jewelry, cell phones, or other personal possessions that are lost, stolen or damaged.

Acknowledgement of responsibility for property damage by my child:

I understand that I am solely responsible for all expenses related to injuries and/or damage to property incurred in connection with my child’s participation in any Harlem Grown activity.

Entire Application:

I acknowledge that the information I have provided in this application is accurate to the best of my knowledge, and will reach out to Tarik Bell, Program Director if any information about myself or my child changes.