Greater Philadelphia Community Alliance 21CCLC FY 26-27 Enrollment Packet

Greater Philadelphia Community Alliance 21CCLC FY 26-27 Enrollment Packet
- Please select a site:
- *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
- *Contact Number (home or cell)
  Format: (000) 000-0000.
- Email
  example@example.com
- School ID Number
- School 2026-2027 Year
- Grade 2026-2027 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
- 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.
- Business 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 2
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- AFTER SCHOOL PROGRAM DATA SHARING CONSENT FORM
- 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 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
- 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 Name:
- Child Name and Program:
- 21CCLC Program Youth Health Report Parent / Guardian Acknowledgment
- All program youth are required to have updated health assessment forms on file with GPCA. Health assessments are due prior to the program's start date. Immunization records alone are not sufficient. Failure to submit updated health assessments will result in a delayed program start date. No youth will be able to attend the program without having an updated heath assessment on file.
- ACKNOWLEGEMENT AND SIGNATURE:
- By signing below, I acknowledge that I have read and understand that my child's health assessment is due prior to the start of the program date and that failure to submit a current assessment will result in my child not being able to attend program until the form is submitted.
- Child Name:
- Parent Name:
- Parent Signature:
- Date:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Greater Philadelphia Community Alliance 21CCLC 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

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

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:

21CCLC Program Youth Health Report Parent / Guardian Acknowledgment

ACKNOWLEGEMENT AND SIGNATURE: