IMPORTANT: 

• This for must be completed by the Parent/Guardian of the participant.
• PAL After-School and Summer Day Camp participants must be between 5 and 13 years of age by the time they join the program. Furthermore, all 5-year-old applicants must also be enrolled in Kindergarten during the current school year.
• All required documents (see below) must be submitted along with this form. 

 Documentation

• Current Medical and Immunization Records (DOHMH Child & Adolescent Health Examination Form) (Required with this form.)
• Birth Certificate/Passport
• Current Bill or Lease (address must match Parent/Guardian's information)
• Recent Report Card
• Current headshot picture only

*Applicant is eligible to vote in U.S. federal elections if: 1) You are a U.S. citizen; 2) You meet your state's residency requirements; 3) You are 18 years old. Some states allow 17-year-olds to vote in primaries and/or register to vote if they will be 18 before the general election. Check your state's voter registration age requirements.

Emergency contacts listed in Part III are authorized to pick up the child unless otherwise noted. The following additional people are authorized to pick up my child:

The following people MAY NOT pick up my child:

For all the next set of questions, HOUSEHOLD is defined as: any individual or group of individuals (family or non-family members) who are living together as one economic unit. INCOME is defined as the total annual gross income of all family and non-family members 18+years old living within the household.

Please answer the questions below and provide additional details in the space provided. Many needs or health challenges can be accommodated and may not limit enrollment in the program.

This question must be answered for parents/guardians enrolling their children.

To the best of my knowledge the information above is true. I agree to its verification and understand that falsification may be grounds for termination of service. Information provided may be used by the City of New York to improve City services and access to those services, and to access additional funding.

As a participant enrolled in a DYCD-funded program, please be aware that from time to time DYCD and the City of New York, its contracted providers, authorized agents, third-party organizations with which it collaborates, or other government, representatives (collectively, "Authorized Parties") may be present during program activities and special events associated with program services, both at the usual program location and at off-site events. In some cases, they may photograph, videotape, interview or otherwise record participants and their families and friends in these programs. The resulting images, videos, and interviews may be used, with or without the participant's name, in printed and electronic media such as brochures, books, print and email newsletters, DVDs and videos, websites, social media and blogs (collectively, "Media").

I hereby authorize and permit the Authorized Parties, without compensation and without further approval, to photograph and/or record my and my child's image, name, likeness, and the sound of my and my child's voice during DYCD-funded program activities and special events, and I hereby consent to the resulting images, videos and interviews being used, without compensation and without further approval by the Authorized Parties solely for non-profit, non-commercial purposes in any and all Media.

If, in the course of participating in DYCD-funded program activities and special events, any original work such as art, music, choreography, poetry, or prose (collectively, "Original Work") is created by me or my child, I hereby consent to such Original Work being used by the Authorized Parties, without compensation and without further approval, solely for non-profit, non-commercial purposes in any and all Media.

The Department of Youth and Community Development (DYCD) provides funding for this program as part of its mission to help you assist your child reach his or her full potential. Many of our programs are run by community-based organizations. We work to make sure the services you and your children receive are of the highest quality. DYCD is requesting your permission to allow us to collect information we need on your child, their participation and the quality of the services provided.

We are requesting your permission for the New York City Public Schools (NYCPS) to share personally identifiable information from your child's student records with DYCD. The information we would like to collect consists of biographical and enrollment information (specifically consisting of your child's name, address, date of birth, student identification number, grade, school(s) attended and transfer, discharge, and graduation data about your child); data concerning your child's school attendance (including number of days attended and absences); and academic performance data (including your child's results on state and national exams, credits eamed, grades, promotion and retention status, and fitnessgram score); and data related to any disciplinary actions taken against your child (including number and type of suspensions).

We are also requesting your permission for DYCD to share information we collect on the enrollment form from you and/or your child with NYCPS staff. The information includes registration information, student's interests and challenges, type of program enrolled-in and frequency of participation. This information will be used to help the school and community organization work together to meet you and your child's needs.

The only people who will see your child's individual information are DYCD and NYCPS staff who manage the data systems and prepare research reports and program analyses. The limited number of DYCD staff identified to receive personal information is screened, and provided extensive training to follow strict guidelines on protecting the confidentiality of information that would personally identify you or your child. Personally identifiable information collected from student records will only be shared electronically between NYCPS and DYCD and will be secured and protected in the DYCD database. Personally identifiable information will not be shared with any community-based organizations or their staff members. We will not use your name or your child's name in any published report. While we request your consent, your responses to the below requests will not affect your child's participation in DYCD sponsored programs.

The New York City Department of Youth and Community (DYCD) invests in programs and services to help our communities and the people who live here. We want to make sure you know about them and make it easy for you to apply.

With it, we can:

• decide if you are eligible for services;
• send you information about DYCD-funded programs and services you can apply for;
• send you information about research activities, focus groups, and surveys related to program improvement;
• share information from your DYCD Participant Application with the programs you apply for
• track the results of the services you receive.

We'll only give information to show you qualify or help you enroll in DYCD-funded programs.

Only authorized employees at DYCD and the programs DYCD funds can see it.

Please read below, check one of the boxes, and fill in the rest.

I understand that DYCD needs my consent to:

• decide if I am eligible for services;
• send me information about programs and services I can apply for;
• refer me to DYCD-funded programs;
• send me information about research activities, focus groups, and surveys related to program improvement;
• share information from my DYCD Participant Application with the programs I apply for
• track the results of the services I receive.

I understand that it is the responsibility of the child, parent, or guardian to ensure that required medication is taken when needed. The medication should be kept in the child's backpack or cooler. PAL is not responsible for dispensing any medication or reminding any child to take his/her medication. Additionally PAL staff cannot administer any over-the-counter medication.

If my child requires emergency medical care and I cannot be reached, I give my consent to PAL to obtain the necessary medical care for my child. I agree to pay all of the costs associated with the emergency medical care that my child receives. I understand that every effort will be made to contact me before and after medical care is provided.

I understand that this consent will be in effect as of the date of my signing this form and will continue as long as my child is enrolled in the PAL program.

If someone other than the Parent/Guardian is picking up a child, they must be 16 years or older, listed as an authorized escort on this form, and present a picture ID upon pick-up. No child will be released to an unauthorized person, even if the child knows the individual.

It is the responsibility of the Parent/Guardian to ensure that all contact information listed on this form is current and accurate. Should any changes be required, the primary parent/guardian must submit a written request.

By signing this page, you authorize the individual(s) named on this form to pick up your child on your behalf.

Parents, guardians, participants, and Police Athletic League recognize that the activities to be engaged in by the participants may occasionally result in injury to a child. The staff of PAL will make sure the proper attention is given in the event of illness/accidents, and emergency care. No liability will be asserted nor claim made against PAL or any of the individuals employed by PAL by reason of such an event. I acknowledge that I have read this consent form, and knowingly, on behalf of my child, assume all of the risks associated with participating in any way in the Police Athletic League program.

I understand that PAL special events where media, photographers, and news personnel may be present. In some cases, they may interview or photograph participants in these events, including my child. Their photographs, videos, and interviews will only be used to promote PAL.

I understand that PAL personnel will be supervising the interview or photo session. I understand that there may not be PAL personnel supervision if the photographs or video or voice recordings are part of a general background scene in which I understand that my child is not identified.