Greater Philadelphia Community Alliance FY 25-26 School Year Enrollment Packet

Greater Philadelphia Community Alliance FY 25-26 School Year Enrollment Packet
- Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Home Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Cell Phone Number
  Please enter a valid phone numberFormat: (000) 000-0000.
- Work Phone Number
  Please enter a valid phone numberFormat: (000) 000-0000.
- Email
  example@example.com
- School ID Number
- School 2025- 2026 School Year
- School 2024- 2025 School Year
- Grade 2025-2026 School Year
- Grade 2024-2025 School Year
- Gender
- Race Ethnicity
- Primary Language Spoken at Home
- DHS Involved
- Caregiver 1 Contact information
- Name
  
  First NameLast Name
- Relationship to Student
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Cell Phone Number
  Format: (000) 000-0000.
- Work Phone Number
  Format: (000) 000-0000.
- Email
  example@example.com
- Caregiver 2 Contact Information (Optional)
- Name
  
  First NameLast Name
- Relationship to Student
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Please enter a valid phone numberFormat: (000) 000-0000.
- Cell Phone Number
  Please enter a valid phone numberFormat: (000) 000-0000.
- Work Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Emergency Contact Information
  
  (Must Provide At least One Emergency Contact that is Not One of the Caregivers)
- Caregiver 1 Contact Information
- Name
  
  First NameLast Name
- Phone Number
  Please enter a valid phone numberFormat: (000) 000-0000.
- Cell Phone Number
  Please enter a valid cell phone numberFormat: (000) 000-0000.
- Work Phone Number
  Please enter a valid work phone numberFormat: (000) 000-0000.
- Email
  example@example.com
- Authorized to pick up
- Emergency Contact 2 Information
- Name
  
  First NameLast Name
- Phone Number
  Please enter a valid phone numberFormat: (000) 000-0000.
- Cell Phone Number
  Please enter a valid cell phone numberFormat: (000) 000-0000.
- Work Phone Number
  Please enter a valid work numberFormat: (000) 000-0000.
- Email
  example@example.com
- Authorized to Pick Up
- Allergies and Asthma Information
  
  If No Allergies or Asthma Exist Then Must Write None In the Space Below
- Please list any allergies youth has (including food, medication, seasonal, etc.
- Does youth require an EPI Pen
- If youth does require an EPI Pen willparent/guardian ensure that agency has amedical epi pen for youth onsite provided byparent/guardian? (Please be advised if youth doesrequire an epi pen it is highly recommended thatparent/guardian ensures that an additional epipen is provided by parent/guardian to the agencyso it can be kept in a secure location duringprogram hours. GPCA is not responsible forensuring youth have epi pens onsite, this is theresponsibility of the parent/guardian)
- Does the youth have asthma?
- *If youth has asthma will the parent/guardianensure that the youth always has an inhaler onsitewith them in the event of an attack? (Please notethat GPCA is not responsible for providing youthwith inhalers and it is the responsibility of theparent/guardian to ensure that the youth alwayshas an inhaler with them)
- Additional Needs
- Does youth have an Individualized Education Plan (IEP)?
- Does youth have limited English proficiency
- Additional Information
- Is the youth/family receiving any of the following? Check all that apply
- Number of Family Members In Household
- Is the youth under the age of 18?
- Is the child/youth living in the home of a parent,other adult specified relative or a courtdesignated legal custodian?
- Is the child/youth one of the following: (a)receiving child welfare services through the CCYA(b) adjudicated dependent (c) Receiving childwelfare services, has court-ordered SCR and theCCYA is the lead on the child/youth's case?
- Program Selection and Location Information
  
  Must Select Program
- Program Site Selection
- Before Care (Only for Childs, Vare, & Steel School Students)
- Parent/Caregiver Acknowledgement and Signature Section
- I attest that the information provided in the above sections is accurate and up to date.
- I understand that completion/submission of the registration packet does not guarantee that my child will beenrolled in my selected program/s and that enrollment is based on availability and completion/submission of allrequired forms and signed consents.
- I understand that once a program team member reaches out to me to discuss next steps in the process that itis my responsibility to ensure that any additional paperwork and/or signatures needed to complete the enrollmentprocess is provided in a timely fashion and failure to do so will result in my child losing their spot.
- ParentGuardian Name
- Parent/Guardian Phone Number
  Please enter a valid phone numberFormat: (000) 000-0000.
- Parent/Guardian Email Address
  example@example.com
- Name of Youth
- ParentGuardian Signature
- 55 PA CODE CHAPTERS 3270.124 (a) (b), 3270.181 & 182; 3280.124 (a) (b), 3280.181 & .182; 3290.124 (a) (b), 3290.181 & .182
- Child's Name
  
  First NameLast Name
- Birthdate
  
  MonthDayYear
  Date
- Child's Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Mother's Name/ Legal Guardian
  
  First NameLast Name
- Mother's/Legal Guardian's Telephone Number
  Please enter mother's phone numberFormat: (000) 000-0000.
- Mother's / Legal Guardian's Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Business Name
- Business Telephone Number
  Enter a valid work telephoneFormat: (000) 000-0000.
- Business Address
- Father's Name/ Legal Guardian
  
  First NameLast Name
- Father's/ Legal Guardian Telephone Number
  Please enter father's phone numberFormat: (000) 000-0000.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Business Name
- Business Telephone Number
  Format: (000) 000-0000.
- Business Address
- 1. Emergency Contact Name
  
  First NameLast Name
- 1. Relationship to Child
- 1. Phone Number When Child is in Care
  Please enter a valid phone number.Format: (000) 000-0000.
- 2. Emergency Contact Name
  
  First NameLast Name
- 2. Relationship to Child
- 2. Phone Number When Child is in Care
  Please enter a valid phone number.Format: (000) 000-0000.
- 3. Emergency Contact
  
  First NameLast Name
- 3. Relationship to Child
- 3. Phone Number When Child is in Care
  Please enter a valid phone number.Format: (000) 000-0000.
- Person's To Whom Child Can be Released
- 1. Name
  
  First NameLast Name
- 1. Relationship to Child
- 1. Address
- 1. Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- 2. Name
  
  First NameLast Name
- 2. Relationship to Child
- 2. Address
- 2. Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- 3. Name
  
  First NameLast Name
- 3. Relationship to Child
- 3. Address
- 3. Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Name of Childs Physician/ Medical Provider
- Physician Phone
  Please enter doctor's phone numberFormat: (000) 000-0000.
- Special Disabilities If Any
- Allergies (Including Medication Reaction)
- Medical or Dietary Information Necessary in a Emergency Situation
- Medication Special Conditions
- Additional Information on Special Needs of Child
- Health Insurance Coverage for Child or Medical Benefits
- Policy Number
- PARENT SIGNITURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT
- OBTAINING MEDICAL CARE
- Signature
  
  signature
- ADMINISTER OF FIRST AID PROCEDURES
  
  signature
- WALKING TRIPS
  
  signature
- TRANSPORTATION BY FACILITY
  
  signature
- PERODIC REVIEW WILL OCCUR EVERY SIX MONTHS
- Signature of ParentGuardian
  
  signature
- Date
  
  MonthDayYear
  Date
- Signature of ParentGuardian
- Date
  
  MonthDayYear
  Date
- The City of Philadelphia Out-of-School Time Project
  
  CONSENT TO RELEASE EDUCATION RECORDS UNDER FERPA
- Student
- Student ID
- The Out-of-School Time Project ("OST") is a Philadelphia effort to improve the well-being of children and youth through effective academic support, enrichment and youth development activities during non-school hours. OST programming provides safe, constructive activities to children when they are not in school, and has been demonstrated to improve in-school performance.
  
  In order to assess and improve the quality of OST programs, The City of Philadelphia Department of Human Services (the "City") asks for permission to collect personally identifiable information from education records regarding children's school performance. The City will collect standardized test scores, report cards and school attendance, disciplinary and other relevant school records ("education records" The City will use these education records to measure the impact of OST programming on childrens' school performance and to improve the quality of those programs.
  
  I am the parent or guardian of the student named above ("Student" As authorized by applicable law, including but not limited to the Family Education Rights and Privacy Act, 20 U.S.C. 1232g, and 34 C.F.R. Part 99 ("FERPA"), I consent and authorize The School District of Philadelphia (the "School District") to release education records concerning the Student, including confidential records of the School District, to the City's Department of Human Services, the Public Health Management Corporation, and my Student's OST program ("Recipients")
  
  The School District releases these education records in connection with the Student's participation in an OST program. The School District may disclose these education records only to the Recipients, and the Recipients may share this information only with other named Recipients, and with the Recipients' officers, staff, administrators and independent contractors under the Recipients' control. The Recipients may use these education records to research, study or evaluate OST programs.
  
  If I ask, the School District will provide me with a copy of the records disclosed.
  
  FERPA and other applicable laws protect the confidentiality of and your right to privacy concerning the Student's education records. The Recipients shall keep all information concerning the Student confidential and private to the fullest extent provided by applicable laws, including FERPA. Neither The School District nor the Recipients require me to waive any rights under these laws, and I give my consent voluntarily.
- ParentGuardian Signature (or Student signature if student is 18 years old or emancipated minor)
- Date
  
  MonthDayYear
  Date
- Name of School Student is Currently Enrolled
- Students Grade
- Name of Students OST Provider Agency
- Students Birthdate
  
  MonthDayYear
  Date
- Name of Students OST Provider Location
- AFTER SCHOOL PROGRAM DATA SHARING CONSENT FORM
  
  Greater Philadelphia Community Alliance
- Agency Name Program Location
- Purpose:
  
  The City of Philadelphia (the City) funds after school programs, also called "Out of School Time" (OST) through various city agencies and departments; other OST programs are funded and run by independent providers (collectively "OST programs") When you enroll your child in an afterschool program, the City will collect information from you and your child and from OST programs and the School District of Philadelphia and store it in a secure centralized system, where it may be shared with other OST programs in order to help to manage the programs, provide academic assistance, identify unused participant public benefits, as well as improve programming, services, and participant safety.
  
  Process:
  - When you sign up for an afterschool program, you will be asked to provide information about your child, including but not limited to his or her name, age, address, and other demographic information.
  - OST program staff may also visit the program and talk to your child about being at that program and may also ask you or your child to complete short, voluntary surveys about the program to learn more about the experience; these visits are a part of afterschool programs for every child and every afterschool site.
  - Additional information may be added to your child's file, including from the School District (if you agree) and other OST programs your child has attended including but not limited to: date of birth, gender, race, ethnicity, phone, ID, school name, grade, and attendance.
  Information Privacy and Sharing of Information:
  - The information that is collected about your child will be shared with staff at the afterschool program.
  - In addition, the information about your child will be shared with approved City and OST program and administrative staff.
  - If the City ever allows the information to be used for research or evaluation purposes, no identifying information about your child or your family will be shared.
  - All of the information will be stored in a database that complies with requirements for managing student education records as set forth in the Family Educational Rights and Privacy Act (FERPA)
  - Furthermore, the system is guarded by layered security protocols that prevents unauthorized persons from accessing the system. You also have the right to inspect and review documents collected and maintained in that system.
- Consent to Collection and Use of Childs Information
  
  Signature
- • I give permission to the City Out of School Time program to collect, store, and share the information I provide on my child for use in the OST program as outlined above and for my child and/or me to complete programmatic surveys that may be shared with other OST programs.
- If you do not give permission for the City to collect, store, and share information (including surveys), please initial here
- • I give permission for the OST program to provide the School District of Philadelphia with information about my child’s attendance in the OST program for the purposes of programming for my child and overall program evaluation.
- If you do not give permission for the City to share OST attendance information with the School District ofPhiladelphia for the purposes of programming and evaluation, please initial here
- • I give permission for the OST program to check my child’s name against any public benefit databases administered by or for the City for the purposes of locating additional benefits to which my child or family may be entitled.
- If you do not give permission for the City to check your child’s name against any public benefit databasesadministered by or for the City for the purposes of locating additional benefits, please initial here
- • I give permission for the School District of Philadelphia to release my child’s educational reports to the OST programs that have need for it. The information to be released under this consent is: all records; grades, test scores; AIMS scores; attendance; and any other measurements of academic performance tracking programmatic progress. The information will be released for the following purposes: programming for my child and overall program evaluation.
- If you do not give permission for the School District to release your child’s educational records, please initialhere
- • I give permission for the OST program to photograph, digitally record, videotape, or audio tape my child while s/he is participating in the OST program. I further agree that any material may be used in publications, promotional literature, or in other similar ways, and that such use shall be without payment of
  fees. I understand that any photographs, videotapes, or audio tapes shall remain the property of the City and that I do not have the right to prior approval of their use. I release and hold harmless the City of Philadelphia, the City OST program, OST providers and their officers, employees, and agents from all claims and causes of action that I or my child may have as a result of the use of my child’s photograph,
  videotape, or audio tape in connection with the program.
- If you do not give permission for the OST program to use your child’s image, please initial here
- • I understand that I may revoke this consent upon providing written notice to the OST program that my child attends. I further understand that until this revocation is made, this consent shall remain in effect and my educational records will continue to be provided to the OST program for the reasons described above.
- Child Name
- Child Address
- Parent Name
- Parent Signature
- Date
  
  MonthDayYear
  Date
- AGREEMENT
- 55 PA CODE CHAPTERS 3270.123 &181(C):3280.123 &181 (c); 3290.123 &181 (C)
- Child Name
  
  First NameLast Name
- Services to be provided as part of the daycare fee (examples: transportation, care, meals, etc.):
  
  The program will provide enrichment programing during the out of school time hours
- CHILDS ARRIVAL TIME
- CHILDS DEPARTURE TIME
- PERSONS DESIGNATED BY PARENT TO WHOM CHILD CAN BE RELASED
- Extra services to be provided at additional fee if applicable
- I, the parent/guardian
- GREATER PHILADELPHIA COMMUNITY ALLIANCE
- SIGNATURE-OPERATOR
- DATE
  
  MonthDayYear
  Date
- Signature Parent or Guardian
- SIGNITURE-PARENT OR GUARDIAN DATE
- DATE OF CHILDS ADMISSION
  
  MonthDayYear
  Date
- PERODIC REVIEW
- DATE OF CHILDS WITHDRAWAL
  
  MonthDayYear
  Date
- SIGNATURE OF PARENT OR GUARDIAN
- DATE
  
  MonthDayYear
  Date
- Authorization for Media Release
- I hereby give permission for my child
  
  First NameLast Name
- to participate in academic enrichment activities sponsored by Greater Philadelphia Community Alliance. I agree that Greater Philadelphi Community Alliance is allowed to have photographs of my child(ren) taken as related to any academic and/c enrichment activity sponsored by the organization including, but not limited to, summer programs, after-schoc activities, and field trips. Such photographs may be used in promotional brochures, annual reports, and othe reasonable circumstances that serve to enhance awareness of the program.
- CHECK ONE ONLY
- Parent Guardian Signature
- Date
  
  MonthDayYear
  Date
- Should be Empty:

Greater Philadelphia Community Alliance FY 25-26 School Year Enrollment Packet

Caregiver 1 Contact information

Emergency Contact Information

Allergies and Asthma Information

Additional Needs

Additional Information

Program Selection and Location Information

Parent/Caregiver Acknowledgement and Signature Section

Person's To Whom Child Can be Released

PARENT SIGNITURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT

OBTAINING MEDICAL CARE

PERODIC REVIEW WILL OCCUR EVERY SIX MONTHS

The City of Philadelphia Out-of-School Time Project

AFTER SCHOOL PROGRAM DATA SHARING CONSENT FORM

AGREEMENT

GREATER PHILADELPHIA COMMUNITY ALLIANCE

SIGNITURE-PARENT OR GUARDIAN DATE

Authorization for Media Release