Summer Camp Registration

Summer Camp Registration - Summer 2025
Thank you for your interest in the 2025 CAOWNY Summer Program!
We are excited to offer enriching summer experiences at the following community centers: Angola, Edward Saunders (ES), and JFK.

Our Edward Saunders and JFK locations will host the Say Yes Summer Camp, while the JFK location will also feature our Leadership Academy, designed for youth ages 11–14.

For program fees and cost details, please refer to the Summer Camp Fee Schedule. Proof of income and household size will be required as part of the application process.

We look forward to a fun, safe, and impactful summer with your family!

Summer Camp Fee Sheet

Individual Health Care Plan
Student's Current School*
New or returning student? (Has the child ever attended summer camp?)*

NewReturning
Choose Your Summer Camp Location:*

JFK, 114 Hickory Street, Buffalo, NY 14204Edward Saunders Unity Center, 2777 Bailey Avenue, Buffalo, NY 14215Angola Community Center, 251 N. Main Street, Angola, NY 14006
Student Name*

First NameMiddle NameLast Name
Student Date of Birth*

MonthDayYear
Date
Student Age*
Student Grade Level*
Student Gender*

FemaleMaleOther
Student Demographics (select all that apply):*

AsianBlack/African AmericanLatin/HispanicNative AmericanWhiteOther
Student Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Medical Information:
Any non-medical restrictions? If yes, please specify.*
Does Student have medical insurance? If yes, please specify.*
Does student have any allergies? If yes, please specify.*
Does Student have any serious health issues? If yes, please specify.*
Does student take any medications? If yes, please specify.*
Does student have any “special healthcare needs”? If yes, please specify.*
Disclaimer: If a student has special health-care needs, an individual health-care plan form must be completed and submitted to the CAOWNY prior to the student’s start in the CAOWNY program.

The Individual Healthcare Plan is at the top of the page.
Parent Initials*
Student Household Information:

Proof of Household Income and Size Required
Member Household Type:*

Both ParentsJoint CustodySingle ParentFoster CareGroup HomeOther
Free/Reduced or Paid Lunch*

Free/ReducedPaid
Number of adults in the household:*
Number of children in the household:*
Language spoken in the household:*
Student does not speak English:*

YesNo
Yearly Household Income (Select a Range):*

$0-$18K$18K-$24K$24K-$26K$26K-$28K$28K-$41.5K$41.5K-$55K$55K-$68.5K$68.5K-$75K$75K+
Military Household:*

YesNo
If yes, list branch and current status below:
Branch
Current status:

Active dutyReserveRetired Veteran
In case of Emergency – A Minimum of Two (2) Emergency Contacts Required.

Contact Information: The CAOWNY will only release the student to the parent or legal guardian listed on this form. Individuals authorized to pick up the student may be asked to provide a picture identification. The CAOWNY must have a copy of any court orders prohibiting and/or authorizing an individual from picking up a student enrolled in programming.

Parents are responsible for updating the emergency contact list. We will not release a student to an individual not listed on this form unless written permission is given by the parent or legal guardian. NO EXCEPTIONS!
Parent Initials*
Primary Contact
Name*

First NameMiddle NameLast Name
Relationship to Student*

MotherFatherLegal Guardian
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Contact
Name*

First NameMiddle NameLast Name
Relationship to Student:*

MotherFatherLegal Guardian
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Third Contact (Optional)
Name

First NameMiddle NameLast Name
Relationship to Student

MotherFatherOther
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agreements
Agreement: I, the primary contact, consent to the enrollment of my child in the CAOWNY program and have been advised of the policies regarding the administration of medications, fees, transportation and services provided by CAOWNY, Buffalo Public School and Office of Child and Family Services.*

YesNo
Emergency: In case of accident or injury, I authorize any and all necessary emergency medical, dental, and/or surgical care and hospitalization advised by the physician, surgeon to ensure the proper health and well-being of my child.*

YesNo
Medical: I have provided information regarding my child’s special needs (allergies, diet, disabilities, and/or medical information). I understand this information may be required to assist the medical facility staff in properly caring for my child in the event of an emergency.*

YesNo
Surveys: I give consent for my child to participate in evaluation survey that will assist CAOWNY in measuring the success of the program.*

YesNo
Report Cards: I give consent for the CAOWNY to obtain my child’s report card, Buffalo Public Schools assessment scores during the school year.*

YesNo
Photo Release: I give consent for my child’s photograph to be taken and used in publications, mailings, illustrations, advertising, web content, etc. for marketing during the current school year.*

YesNo
Final Signatures

Please double-check above information before submitting.
Parent/Legal Guardian Name*
Parent/Legal Guardian Signature*

Clear
Current Date*

MonthDayYear
Date
Should be Empty:

Summer Camp Registration - Summer 2025

Student Medical Information:

Student Household Information:

Primary Contact

Secondary Contact

Third Contact (Optional)

Agreements

Final Signatures