Greater Philadelphia Community Alliance FY 25-26 Spring Break Camp Enrollment Packet

Greater Philadelphia Community Alliance FY 25-26 Spring Break Camp Enrollment Packet
Please complete this application in its entirety. If a section does not apply to you, please indicate "N/A." Incomplete applications may delay the processing and enrollment of your student.
- The Spring Break Camp Schedule is as Follows:
  - Monday, March 30th, 8:30am - 5:30pm
  - Tuesday, March 31st, 8:30am - 5:30pm
  - Wednesday, April 1st, 8:30am - 5:30pm
  - Thursday, April 2nd, 8:30am - 5:30pm
  Winter Break Camp Includes:
  - Trips
  - Meals
  - Enrichment Activities
  - Gaming (Film & Media)
  - Culinary Arts
  - Arts & Design Class
- Please Select One Program Site*
  
  Vare Elementary, 1139 South 5th Street, Philadelphia, PA 19147Childs Elementary, 1599 Wharton Street, Philadelphia, PA 19146Steel Elementary, 4301 Wayne Avenue, Philadelphia, PA 19140
- First Name*
- Last Name*
- Date of Birth*
  
  MonthDayYear
  Date
- Address*
  
  Home Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- State*
  Example: PA, NJ, DE
- Home Phone Number*
- Cell Phone Number
- Work Phone Number
- Email*
  example@example.com
- School ID Number*
- School for the 2025-2026 Year*
- Gender*
  
  MaleFemalePrefer not to say
- Race/Ethnicity*
  
  Hispanic or Latino of any raceWhite or CaucasianAmerican Indian or Alaska Native RacesAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderTwo or moreOther
- DHS Involved?*
  
  YesNo
- Primary Language Spoken at Home*
- First Name*
- Last Name*
- Relationship to Student*
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number*
  Please enter a valid phone number.
- Cell Phone Number
- Work Phone Number
- Email*
  example@example.com
- Please list any allergies the youth has including food medication seasonal etc. If no allergies or asthma exist then write none in the space below.*
- Does youth require an EPI Pen?*
  
  YesNo
- If the youth does require an EPI Pen, will the parent/guardian ensure that the agencyPen has a medical EPI Pen for the youth onsite, provided by the parent/guardian? Please be advised that if the youth requires an EPI pen, it is highly recommended that the parent/guardian ensure that an additional EPI pen is provided by the parent/guardian to the agency so it can be kept in a securefor location during program hours. GPCA is not responsible for ensuring youth have EPIs on-site; this is the responsibility of the parent/guardian.*
  
  Yes, I will ensure that I provide GPCA with an additional EPI Pen which will be kept in a secure location onsite.No, I will not provide the GPCA program site with an additional EPI Pen to keep on-site for my child in the event of an emergency, and understand that GPCA is not responsible for securing an EPI Pen for my child.
- Does youth have asthma?*
  
  YesNo
- If a youth has asthma, will the parent/guardian ensure that the youth always has an inhaler on-site with them in the event of an attack? Please note that GPCA is not responsible for providing youth with inhalers, and it is the responsibility of the parent/guardian to ensure that the youth always has an inhaler with them.*
  
  Yes, I will ensure that my child has an inhaler onsite during program hours and will work with program staff accordinglyNo, I will not ensure that my child has an inhaler onsite with them at all times in the event of an attack, and understand that GPCA OST Programs are not responsible for ensuring my child has an inhaler onsite if not provided by the parent/guardian or if the youth does not carry one with them
- Does the youth have an Individualized Education Plan (IEP)?*
  
  YesNo
- Does the youth have limited English proficiency?*
  
  YesNo
- Is the youth/family receiving any of the following? Check all that apply:
  
  TANF (Cash Assistance)SNAPSSIMedicaid
- Number of family members in household*
- Is youth under the age of 18?*
  
  YesNo
- Is the child/youth living in the home of aparent, other adult specified relative, or acourt-designated legal custodian?*
  
  YesNo
- Is the child/youth one of the following: (a)receiving child welfare services through the CCYA, (b) adjudicated dependent, (c)receiving child welfare services, has a court-ordered SCR, and the CCYA is the lead on the child/youth's case?*
  
  YesNo
- 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 ofall required forms and signed consents.
  
  I understand that once a program team member reaches out to me to discuss next steps in the process that itIt is my responsibility to ensure that any additional paperwork and/or signatures needed to complete thee nrollment are obtained. The process is provided in a timely fashion, and failure to do so will result in my child losing their spot.
- Parent / Guardian Name*
- Parent / Guardian Phone Number*
- Parent / Guardian Email Address*
  example@example.com
- Name of Youth*
- ParentGuardian Signature*
  
  Powered by Jotform SignClear
- 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
- Mother's Name / Legal Guardian*
- Phone Number*
- Address*
  Street address, City, State, Zip
- Business Name
- Business Telephone Number
- Address
  Street address, City, State, Zip
- Father's Name / Legal Guardian 2
- Telephone Number
- Address
  Street address, City, State, Zip
- Business Name
- Address
  Street address, City, State, Zip
- Business Phone
- Emergency Contacts
- Emergency Contact #1 - Name*
- Emergency Contact #1 - Relationship to Child*
- Emergency Contact #1 - Telephone Number When Child is In Care*
- Emergency Contact #2 - Name
- Emergency Contact #2 - Relationship to Child
- Emergency Contact #2 - Telephone Number When Child is In Care
- Emergency Contact #3 - Name
- Emergency Contact #3 - Relationship to Child
- Emergency Contact #3 - Telephone Number When Child is In Care
- People who your child can be released to
- Person #1 - To Whom Child Can Be Released*
- Person #1 - Relationship to Child*
- Person #1 - Address*
  Street, City, State, Zip
- Person #1 - Telephone Number*
- Person #2 - To Whom Child Can Be Released
- Person #2 - Relationship to Child
- Person #1 - Address
  Street, City, State, Zip
- Person #2 - Telephone Number
- Person #3 - To Whom Child Can Be Released
- Person #3 - Relationship to Child
- Person #1 - Address
  Street, City, State, Zip
- Person #3 - Telephone Number
- Name of Child's Physician Medical Provider*
- Telephone Number*
- Special Disabilities (If Any)
- Medical or Dietary Information Necessary in an Emergency Situation
- Allergies (Including Medication Reaction)*
  Type N/A if child does not have allergies
- Medication Special Conditions:
- Additional Information on Special Needs of Child
- Health Insurance Coverage for Child or Medical Benefits*
  Type N/A if child does not have health insurance or medical benefits.
- Policy Number*
  Type N/A if child does not have health insurance or medical benefits.
- Parent / Guardian Signature is required for each of the items below to indicate parental consent.
- Obtaining Medical Care*
  
  Powered by Jotform SignClear
- Administer of First Aid Procedures*
  
  Powered by Jotform SignClear
- Walking Trips*
  
  Powered by Jotform SignClear
- Transportation by Facility*
  
  Powered by Jotform SignClear
- Please note: A Periodic review will occur every 6 months
- Signature of Parent / Guardian 1*
  
  Powered by Jotform SignClear
- Date*
  
  MonthDayYear
  Date
- Signature of Parent / Guardian 2
  
  Powered by Jotform SignClear
- Date
  
  MonthDayYear
  Date
- 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 children's 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 requires me to waive any rights under these laws, and I give my consent voluntarily.
- Parent/Guardian Signature (or Student signature if student is 18 years old or an emancipated minor)*
  
  Powered by Jotform SignClear
- Date*
  
  MonthDayYear
  Date
- Name of School Student is Currently Enrolled*
- Student's Grade*
- Name of Student's OST Provider Agency*
  Type: Greater Philadelphia Community Alliance (GPCA)
- Name of Student's OST Provider 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 after-school program.
  - In addition, the information about your child will be shared with approved City and OST programs 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 prevent 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 Child’s Information:
  - 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 .
  
  Powered by Jotform SignClear
- - 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 of Philadelphia for the purposes of programming and evaluation, please initial here:
  
  Powered by Jotform SignClear
- - 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 databases administered by or for the City for the purposes of locating additional benefits, please initial here:
  
  Powered by Jotform SignClear
- - 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 initial here.
  
  Powered by Jotform SignClear
- - I give permission for the OST program to photograph, digitally record, videotape, or audiotape my childwhile s/he is participating in the OST program. I further agree that any material may be used inpublications, promotional literature, or in other similar ways, and that such use shall be without payment offees. 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 ofPhiladelphia, the City OST program, OST providers, and their officers, employees, and agents from allclaims and causes of action that I or my child may have as a result of the use of my child’s photograph,videotape, or audiotape in connection with the program.
- If you do not give permission for the OST program to use your child’s image, please initial here:
  
  Powered by Jotform SignClear
- 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.
  
  By signing below, I acknowledge that I have read and understand this OST Data Sharing Consent Form and agree to have my child's information shared as described above.
- Child Name*
- Child Address*
- Parent Name*
- Parent Signature*
  
  Powered by Jotform SignClear
- Date*
  
  MonthDayYear
  Date
- Camp Fee Amount: $0.00
  
  Services to be provided: transportation, care, meals, etc.
  
  The program will provide enrichment programming during the winter break camp. The program will take students on trips and providemeals
  
  Child's Arrival Time: 8:30am
  
  Child's Departure Time: 5:30pm all days except 12/31 which is 12:30pm
- I, the parent / guardian:*
  
  agree to update the emergency contact/parental consent form information whenever changes occur or every 6 months at a minimum. (9 3270.124, 3280.124, 3290.124)
- I, the parent / guardian:*
  
  Received complete written program information at the time of enrollment (9 3270. 121, 3280.121, 3290.121)
- SIGNATURE OF PARENT OR GUARDIAN*
  
  Powered by Jotform SignClear
- DATE*
  
  MonthDayYear
  Date
- I hereby give permission for my child, enrichment activities sponsored by Greater Philadelphia Community Alliance. I agree that Greater Philadelph: 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.
- I agreeI do not agree
- Parent Guardian Signature*
  
  Powered by Jotform SignClear
- Date*
  
  MonthDayYear
  Date
- Should be Empty:

Greater Philadelphia Community Alliance FY 25-26 Spring Break Camp Enrollment Packet

Emergency Contacts

People who your child can be released to

Parent / Guardian Signature is required for each of the items below to indicate parental consent.