24-25 After School Program Registration Form

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 NameLast Name
Student's Social Security Number
Mother/Guardian's Name

First NameLast Name
Mother/Guardian's Social Security Number
Father/Guardian's Social Security Number

First NameLast Name
Father/Guardian's Social Security Number
Ethnicity/Race:*
Housing*
Source of Family Income:*
Family Type:*
Other Forms of Assistance:*
Family Size:*
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:

Program Release

I hereby grant permission for my child to participate in the activities of The Pittsburgh Project's program during the school year. 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. I also grant permission to The Pittsburgh Project to share all information collected with the Allegheny County Department of Human Services. This release will remain valid and binding for the current school year.
I consentI 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 consentI 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, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.
To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by: mail:U.S. Department of AgricultureOffice of the Assistant Secretary for Civil Rights1400 Independence Avenue, SWWashington, D.C. 20250-9410; Or2. fax:(833) 256-1665 or (202) 690-7442;z Or 3. email:program.intake@usda.gov This institution is an equal opportunity provider.05/05/2022
Parent/guardian signature*

Clear
Parent/guardian name*

First NameLast Name
Date*

MonthDayYear
Date

theDREAMlab 2024 Summer Agreement

Dear Parents/Guardians- The Pittsburgh Project is very proud to say that we are operating a Makerspace called theDREAMlab for all of our program participants. It is a hands-on learning environment where our students will learn some real life skills like sewing, wood working, and basic circuitry as well as the problem solving and team work skills that go along with those activities.
While the students are in the makerspace they will be supervised by TPP staff and trained on how to safely use the tools and equipment. However, there are risks associated with these types of activities. The students will be introduced to a number of new tools including hammers, screwdrivers, hand saws (no power saws), sewing machines, and hot glue guns. While the students will be supervised, accidents can happen.
Access to the makerspace is a privilege and students who do not conduct themselves in a safe manner will not be permitted to use the space. This determination is at the discretion of the program coordinator. If you have any questions about the makerspace, or would like to come and see it for yourself, please do not hesitate to contact Natasha Thrasher at 412-321-1678 ext.550.
By signing this release, you will grant permission for your child(s) to participate in the Makerspace. Your signature will indicate that you understand the normal risks associated with these activities with your child’s participation, and you agree not to hold liable The Pittsburgh Project staff and our Board of Directors for any harm resulting from these activities for the duration of the after school program.
Parent/Guardian Signature*

Clear
Parent/Guardian name*

First NameLast Name
Date*

MonthDayYear
Date

Cell Phone Policy Agreement

Students in kindergarten through fifth grade may not have cell phones during Pittsburgh Project After school program hours. There are several reasons for this:1.) Phones distract from program activities. The school day has been carefully planned and when students have phones they often become a distraction from those plans. 2.) Elementary school students often break and/or lose phones. When students’ phones are lost or damaged it becomes a big program issue. Often students blame someone else for breaking or taking their phone. 3.) There has been an issue in the past because students were accusing each other of taking photos or videos of them without permission.
If parents need to get in touch with students, they can do so by calling the main office number, 412-321-1678. The receptionist will be able to get in touch with either the child’s counselor or the program coordinator, who can have your child return the call quickly.
If TPP staff sees a student with a phone, the phone will be confiscated. On the first offense, students can retrieve their phone from the office at the end of the day. After the first offense, an adult (not siblings in middle or high school) will have to come to TPP to get it back. If a student refuses to give their phone to a staff member when asked for it, a suspension from the program will follow.
This policy has been put into place in order to help students have the best experience possible and we apologize if it causes any inconvenience to your family. Any questions about the policy can be directed to the director of programs, Natasha Thrasher.
Parent/Guardian Siganture*

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Parent/Guardian Signature*

First NameLast Name
Date*

MonthDayYear
Date

Service Plan Agreement

The Elementary and Middle School After school programs (grades K-entering 9th) nurture and provide our youth with assets through extensive after school activities. Teachers and volunteer tutors empower young people to succeed academically through:
§ One-on-one Educational activities

§ Creative outlets for students, including age appropriate field trips, ecology, and sport and recreation
After school program is designed to provide an environment where students consistently feel nurtured and cared for. Many of our program participants face significant obstacles to academic success and self–sufficiency. The following is a list of challenges facing many of the young people attending the programs of The Pittsburgh Project:
• Most live at or below 150% of the poverty level
• Most live in a neighborhood where violence and drug use is frequent
• Most students attend poorly performing schools
• Most are reading below grade level
• Most live in single parent households
• Some have parents who are or were incarcerated
• Some are being raised by grandparents
• Some are or were a part of the foster care system
To ensure high quality services and individual attention, we limit class size to a maximum of 6 students, with one adult teacher in each class. Teachers provide consistent and caring adult relationships and facilitate the work of volunteers.

Students recieve snack each day. They then follow a schedule of activities to support their school assignments and engage them in new learning activities. Each student receives opportunities to gain computer skills, performing and visual arts skills, and enhanced academics.

From Sept 16, 2024 to May 16, 2025 will be the duration of this years after school program for both Elementary School and Middle school.
Parent/guardian signature*

Clear
Parent/guardian name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

TPP After School Program Application

Family Information

Medical Information

Program Release

Photo/Image Consent

USDA Nondiscrimination Statement

theDREAMlab 2024 Summer Agreement

Cell Phone Policy Agreement

Service Plan Agreement