Scholars for Success Inc. (The Roy Wilkins School PS 136Q)

Scholars for Success Inc. (The Roy Wilkins School PS 136Q)

2025 - 2026 Applicant Intake Form
Applicant's First and last Name *

First NameMiddle NameLast Name
Applicant's Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please enter your primary language Enter primary language spoken*
Applicants Age enter age*
Gender *
Parent/Guardian's Name #1*

First NameMiddle NameLast Name
Relationship to Applicant mother, father, grandparent..etc*
Please enter parent/guardian #1 cell phone number*
Please enter a valid phone number.
Please enter parent/guardian #1 work number*
Please enter a valid phone number.
Please enter parent/guardian #1 home number*
Please enter a valid phone number.
Please enter parent/guardian #1 e-mail*
example@example.com
Parent/Guardian's Name #2*

First NameMiddle NameLast Name
Relationship to Applicant mother, father, grandparent..etc*
Please enter parent/guardian #2 cell phone number*
Please enter a valid phone number.
Please enter parent/guardian #2 work number*
Please enter a valid phone number.
Please enter parent/guardian #2home number*
Please enter a valid phone number.
Please enter parent/guardian #2 e-mail
example@example.com
Emergency Contact #1*

First NameMiddle NameLast Name
Relationship to Applicant mother, father, grandparent..etc*
Emergency Contact #1 cell phone number*
Please enter a valid phone number.
Emergency Contact #1 work number*
Please enter a valid phone number.
Emergency Contact #1 home number*
Please enter a valid phone number.
Emergency Contact #1 e-mail
example@example.com
Emergency Contact #2*

First NameMiddle NameLast Name
Relationship to Applicant mother, father, grandparent..etc*
Emergency Contact #2 cell phone number*
Please enter a valid phone number.
Emergency Contact #2 work number*
Please enter a valid phone number.
Emergency Contact #2 home number*
Please enter a valid phone number.
Emergency Contact #2 e-mail
example@example.com
My child has permission to sign themselves out at dismissal:*

YesNo
My child has permission to walk home alone at dismissal:*

YesNo
My child may NOT be picked up by anyone listed below: (Please provide the names of those NOT authorized to pick up your child. If there are none, please type 'none' as your response.)*
Please check any of the following that pertain to the participant. Many needs or health challenges can be accommodated and may not limit enrollment in the program.*

Allergies to foodBehavioral/Emotional IssuesDiabetesPhysicalAllergies to medicationsConvulsions/SeizuresIndividualized Education Plan (IEP)Allergies other (please Specify)Congestive Illness (e.g., heart murmur/disease, blood pressure)ObesityCorrective Devices (e.g., crutches, hearing aid, eye glasses) (please specify)Asthma
Does your child have special health care needs that require treatment and/or medication? *
Does your child take medication for any condition or illness?*
Is your child's medical updated medical Information on File:*
Are there any activities your child cannot participate in? (If so, please specify below) Activities your child cannot participate in:
Consent for Photo/Videotaping and Use of Youth Work
Please be aware that sometimes staff, photographers, newspapers, television reporters, media representatives and public relations personnel may be present during program activities and special events, both at off-siteevents and events taking place in the usual program location. In some cases, they may photograph, videotape, interview or otherwise record children who participate in these events. The resulting images, videos and interviews may be used solely for non-profit, non-commercial purposes in printed and electronic media such as brochures, books, print and email newsletters, DVDs and videos, websites, social media and blogs (collectively, “Media”). These images, videos and interviews may be used by S4S and third-party organizations that collaborate with S4S, without compensation and without further approval, solely for non-profit, noncommercial purposes.If, in the course of participating in program activities or special events, any original work is created by a participant, we may use the created work in any and all Media to promote the program or for other informational, non-profit and non-commercial purposes, without compensation and without further approval.*

I understand my child may be photographed, interviewed or otherwise recorded during program activities and special events and give permission for my child to be photographed, interviewed or otherwise recorded solely for non-profit, non-commercial purposes of the program.
Do you give permission?:*

Yes, I give my permissionNo, you do not have permission
I understand that my child’s work may be used in materials that promote programs, solely for non-profit, noncommercial purposes of the program.*

Yes, I give my permissionNo, you do not have permission
Consent for Emergency Medical Treatment
I give authority to the Program Agency’s staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible. I understand that every effort will be made to contact me before and after medical care is provided.*

Yes, I give my permissionNo, you do not have permission
Consent Statement
Parent/Guardian Name #1*

First NameLast Name
Date*

MonthDayYear
Date
I, the undersigned, certify that I have reviewed all the above consent statements and indicated my wishes. I understand that consent is voluntary, and I can withdraw it in writing at any time. *

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Parent/Guardian Name #2*

First NameLast Name
Date*

MonthDayYear
Date
I, the undersigned, certify that I have reviewed all the above consent statements and indicated my wishes. I understand that consent is voluntary, and I can withdraw it in writing at any time. *

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Scholars are asked to adhere to the following agreement:

1. Always treat others with respect 2. Use polite, kind words; Inappropriate language is discouraged 3. Always listen to and respect the afterschool staff despite emotions that may arise 4. Respect S4S; Refrain from touching PS136 teacher’s belongings 5. Respect other people and their property 6. Always keep my hands and feet to myself 7. Always ask permission before leaving the afterschool area 8. Avoid fighting, bullying and teasing others 9. Take responsibility of my actions 10. Always stand up for my beliefs 11. Always resolve conflicts nonviolently 12. Respect other people cultural/racial/ethnic background 13. Always help others when they are in need of help 14. Always tell the truth 15. Always clean up after myself 16. Be proud of who I am 17. Eat only in the designated areas provided 18. Always come prepared to learn something new everyday 19. Always try no matter how challenging a task may be 20. Have fun!
Relationship to Applicant mother, father, grandparent..etc*
Date*

MonthDayYear
Date
Scholars name*

First NameLast Name
Parent/Guardian Name:*

First NameLast Name
Scholars Signature*

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Scholars are asked to adhere to the following agreement:

Dear Parents/Guardians, Many times, throughout the year we take field trips around the neighborhood and/or to attractions to enhance and enrich our units. Please fill out this general permission slip and return it as soon as possible. This slip will be kept on file throughout the year and will cover any field trips (within walking distance or once requiring a bus transportation) taken during the 2025-2026 school year. We will continue to send information regarding the events with dates, times, etc. for each trip. If at any time the emergency information changes, please send a note to administration. Complete the bottom portion and return. Thank you, Management
I blanks give permission for my child blanks

to attend all field trips and neighborhood walks throughout the 2025-2026 school year at S4S. I understand that I will receive information regarding these events and will notify the program if the emergency information changes
Parent/Guardian Name:*

First NameLast Name
Parent/Guardian Signature: *

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Emergency Contact information:*
Date*

MonthDayYear
Date
Scholars Payment Schedule
Parent/Guardian #1 Signature*

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Parent/Guardian #2 Signature*

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Date*

MonthDayYear
Date
Program Closure 2025-2026
Should be Empty:

Scholars for Success Inc. (The Roy Wilkins School PS 136Q)

Consent for Photo/Videotaping and Use of Youth Work

Consent for Emergency Medical Treatment

Consent Statement

Scholars are asked to adhere to the following agreement:

Scholars are asked to adhere to the following agreement:

Scholars Payment Schedule

Program Closure 2025-2026