NURTURE After School Application

NURTURE After School Application

Current School Year: 2025-2026
New or returning Student:

NewReturning
Student School:
Choose Your After School Location:

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

First NameMiddle NameLast Name
Student Date of Birth

MonthDayYear
Date
Student Age
Student Grade Level
Student Gender:

FemaleMaleOther
Student Demographics (select all they apply)"

AsianBlack/African AmericanLatin/HispanicNative AmericanWhiteOther
Student Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Medical Information:

(If Yes, Please Specify)
Does Student have any non-medical restrictions?

NoYes
Does Student have medical insurance?

NoYes
Does Student have any allergies?

NoYes
Does Student have any serious health issues?

NoYes
Does Student take any medications?

NoYes
Does Student have any "special healthcare needs"?

NoYes
Disclaimer: The CAOWNY is not responsible or liable for any students damaged, lost or stolen items. 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.
Parent Initials
Student Household Information
Member Household Type:

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

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

YesNo
Yearly Household Income (select a range):

$0 -$18,000$18,001-$24,000$24,001-26,000$26,001-$28,000$28,001-$41,500$41,5001-$55,000$55,001-$68,500$68,501-$75,000$75,001+
Miltary Household:

YesNo
If Yes, List Branch:
If Yes:

Active dutyReserveRetired Veteran
In case of Emergency

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 show a picture identification. The CAOWNY must have a copy of any court orders prohibiting an individual from picking up a student.

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. NO EXCEPTIONS!
Parent Initials
Primary Contact:
Full Name

First NameMiddle NameLast Name
Relationship to Student:

MotherFatherLegal Guardian
Phone #:
Please enter a valid phone number.
Primary e-mail:
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2nd Contact:
Full Name

First NameMiddle NameLast Name
Relationship to Student:

MotherFatherLegal Guardian
Phone #:
Please enter a valid phone number.
Primary e-mail:
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3rd Contact:
Full Name

First NameMiddle NameLast Name
Relationship to Student:

MotherFatherOther
Phone #:
Please enter a valid phone number.
Primary e-mail:
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 toassist 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
Parent/Legal Guardian Name
Signature

Clear
Date
Should be Empty:

Student Medical Information:

Student Household Information

Primary Contact:

2nd Contact:

3rd Contact:

Agreements