Greater Philadelphia Community Alliance K-8 OST FY 26-27 Enrollment Packet

Greater Philadelphia Community Alliance K-8 OST FY 26-27 Enrollment Packet
*Indicates Required Fields
- * First Name
- * Last Name
- * Date of Birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- * Home Street Address
- *City
- *State
- *Home Phone Number
  Format: (000) 000-0000.
- Cell Phone Number
  Format: (000) 000-0000.
- Work Phone Number
  Format: (000) 000-0000.
- Email
  example@example.com
- School ID Number
- School 2026-2027 Year
- Grade 2026-2027 School Year
- School 2025-2026 School Year
- Grade 2025-2026 School Year
- Gender
- Race/Ethnicity
- Primary Language Spoken at Home
- DHS Involved
- Must Provide At Least One Caregiver
- Caregiver 1 Contact Information
- Caregiver 1 Name
  
  First NameLast Name
- Relationship to Student
- Home Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- 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)
- Caregiver 2 Name
  
  First NameLast Name
- Relationship to Student
- Home Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Format: (000) 000-0000.
- Cell Phone Number
  Format: (000) 000-0000.
- Work Phone Number
  Format: (000) 000-0000.
- Email
  example@example.com
- You must provide at least one emergency contact that is not one of the caregivers.
- Emergency Contact 1 Information
- First Name
- Last Name
- Relationship to Student
- Phone Number (When child is in care)
  Format: (000) 000-0000.
- Cell Phone Number
  Format: (000) 000-0000.
- Work Phone Number
  Format: (000) 000-0000.
- Email
  example@example.com
- Authorized to Pick Up?
- Emergency Contact 2 Information
- First Name
- Last Name
- Relationship to Student
- Phone Number (When child is in care)
  Format: (000) 000-0000.
- Cell Phone Number
  Format: (000) 000-0000.
- Work Phone Number
  Format: (000) 000-0000.
- Email
  example@example.com
- Authorized to Pick Up
- Emergency Contact 3 Information
- First Name
- Last Name
- Relationship to Student
- Phone Number (When child is in care)
  Format: (000) 000-0000.
- Cell Phone Number
  Format: (000) 000-0000.
- Work Phone Number
  Format: (000) 000-0000.
- Email
  example@example.com
- Authorized to Pick Up
- 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 will parent/guardian ensure that agency has a medical epi pen for youth onsite provided by parent/guardian? (Please be advised if youth does require an epi pen it is highly recommended that parent/guardian ensures that an additional epi pen is provided by parent/guardian to the agency so it can be kept in a secure location during program hours. GPCA is not responsible for ensuring youth have epi pens onsite, this is the responsibility of the parent/guardian)
- Does the youth have asthma?
- If youth has asthma will the parent/guardian ensure that the youth always has an inhaler onsite 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)
- 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 court designated legal custodian?
- 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 court-ordered SCR and the CCYA is the lead on the child/youth's case?
- Choose Program Site. Please note: There is no charge for OST/EDEY.
- Would you also like to enroll your child in before care? (Childs and Steel Only) Please note: There is no charge for before care.
- Would you like to enroll your child in our mini camps as well? (EDEY Program Sites Only) If so, check all that apply. More details including dates and times will be shared closer to the dates. Please note: There is no charge for our mini camps.
- I attest that the information provided in the above sections is accurate and up to date. Please initial here:
- I understand that completion/submission of the registration packet does not guarantee that my child will be enrolled in my selected program/s and that enrollment is based on availability and completion/submission of all required forms and signed consents. Please initial here:
- I understand that once a program team member reaches out to me to discuss next steps in the process that it is my responsibility to ensure that any additional paperwork and/or signatures needed to complete the enrollment process is provided in a timely fashion and failure to do so will result in my child losing their spot. Please initial here:
- Parent/Guardian Name
- Parent/Guardian Phone Number
  Format: (000) 000-0000.
- Parent/Guardian Email Address
  example@example.com
- Name of Youth
- Parent/Guardian 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:
- Birthdate:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Address:
- Mother's Name/Legal Guardian
- Telephone Number:
  Format: (000) 000-0000.
- Address:
- Business Name:
- Business Telephone Number:
  Format: (000) 000-0000.
- Address:
- Father's Name/Legal Guardian
- Telephone Number:
  Format: (000) 000-0000.
- Address:
- Business Name:
- Business Telephone Number:
  Format: (000) 000-0000.
- Address:
- Person Who Child Can Released (#1)
- Relationship to Child
- Address
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Person Who Child Can Released (#2)
- Relationship to Child
- Address
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Person Who Child Can Released (#3)
- Relationship to Child
- Address
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Name of Child's Physician/Medical Provider :
- Telephone Number:
  Format: (000) 000-0000.
- Special Disabilities (if Any)
- Allergies (Including Medication Reaction)
  Type N/A if not applicable to your child
- Medical or Dietary Information Necessary in an Emergency Situation
  Type N/A if not applicable to your child
- Medical Special Conditions
- Additional Information on Special Needs of Child
- Health Insurance Coverage for Child or Medical Benefits
  Type N/A if not applicable to your child
- Policy Number
  Type N/A if not applicable to your child
- Parent / Guardian signature is required for each of the items below to indicate consent.
- Obtaining Medical Care
- Walking Trips
- Transportation by Facility
- Administer of First Aid Procedures
- PERODIC REVIEW WILL OCCUR EVERY SIX MONTHS
- Signature of Parent/Guardian
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Signature of Parent/Guardian
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- The City of Philadelphia Out-of-School Time Project. CONSENT TO RELEASE EDUCATION RECORDS UNDER FERPA
- 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 conceming 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.
- Parent/Guardian Signature (or Student signature if student is 18 years old or emancipated minor)
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Name of School Student is Currently Enrolled
- Student's Grade
- Name of Student's OST Provider Agency (Please type GPCA)
- Student's Birthdate
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
- Student's OST Provider Location
- AFTER SCHOOL PROGRAM DATA SHARING CONSENT FORM
- 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 Child's Information:
- If you do not give permission for the City to collect, store, and share information (including surveys), please initial here
- 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
- 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:
- 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:
- 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
- Signature
- ACKNOWLEGEMENT AND SIGNATURE:
- By signing below, I acknowledge that I have read and understand this OST Data Sharing Consent Form and agreement to have my child's information shared as described above.
- Child Name:
- Child Address:
- Parent Name:
- Parent Signature:
- Date:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- 55 PA CODE CHAPTERS 3270.123 &181(C):3280.123 &181 (c); 3290.123 &181 (C)
- NAME OF CHILD
- • The program will provide enrichment programing during the out of school time hours.
  
  • There are no fees or payments for this program.
  
  • Extra services to be provided at additional fee if applicable
- I, the parent /guardian:
- Signature of Parent or Guardian
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- I hereby give consent to Greater Philadelphia Community Alliance (the “organization”) to photograph, videotape, or otherwise digitally record and use images and/or sound recordings of myself or my child or children (if applicable) to use in any public media, including radio, television, internet, social media, print or in any of GPCA’s or its partners’ publications, productions, or posts. I understand that the intended use of such images and information is solely for the organization’s advertising, marketing, fundraising, and/or promotional and public awareness purposes. I hereby waive any rights or interest in the images or recordings as contemplated in this release.
- I acknowledge that this consent to use images and/or recordings is being made solely for the organization’s benefit and comes without any expectation of monetary compensation or other benefit to me. To the extent that any benefit accrues or might accrue to the organization from the use of images or information, I hereby and forever waive any interest in or claim to such benefits.
- I hereby release and forever discharge the organization (including without limitation all corporate affiliates and officers, directors, trustees, donors, employees, agents, and volunteers) from any claims, liability, actions, suits, demands, costs, expenses, or indebtedness arising out of, related to, or in any way connected with the use of images and materials described herein. I hereby waive all rights and interest in and to such information and materials.
- I further acknowledge that there is no guarantee that any or all the participants’ images or recordings will be used in any released media.
- I have been informed that this authorization is voluntary and is subject to revocation at any time, except to the extent that action has been taken in reliance thereon, by notifying the organization in writing at:
- Mamie Nichols
  1529 S. 22nd Street
  Philadelphia, PA 19146
  or Email ConnieAlston@gpca-phila.org
- Parent's Signature:
- Date:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Parent Printed Name:
- Child Name and Program:
Should be Empty:

Greater Philadelphia Community Alliance K-8 OST FY 26-27 Enrollment Packet

Caregiver 1 Contact Information

Caregiver 2 Contact Information (Optional)

Emergency Contact 1 Information

Emergency Contact 2 Information

Emergency Contact 3 Information

Additional Information

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

The City of Philadelphia Out-of-School Time Project. CONSENT TO RELEASE EDUCATION RECORDS UNDER FERPA

AFTER SCHOOL PROGRAM DATA SHARING CONSENT FORM

Purpose:

Process:

Information Privacy and Sharing of Information:

Consent to Collection and Use of Child's Information:

ACKNOWLEGEMENT AND SIGNATURE: