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NYCYA Afterschool Program Inquiry Form
Share your information so we can complete a preliminary eligibility review for the Claremont School afterschool program. Program start date: September 14, 2026. Program hours: Monday through Friday, from dismissal until 6:00 p.m. We are initially enrolling Claremont students. Contact: info@nycya.org
Thank you for your interest in the New York Community Youth Academy afterschool program. This form helps NYCYA learn more about your child, assess preliminary program eligibility, and understand any support your child may need. Submitting this form does not guarantee enrollment or placement. NYCYA will contact families with next steps. The information you provide will be kept confidential and used for admissions, eligibility review, and program planning.
Child's Full Legal Name
*
First Name
Last Name
Preferred Name or Nickname
Child's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade Level (for the upcoming school year)
*
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Other
Unsure
Current School
*
School District
*
Primary Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Email Address
*
example@example.com
Best Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Will your child attend Claremont School for the 2026-2027 school year?
*
Yes
No
Unsure
How did you hear about the NYCYA Afterschool Program?
Please Select
School
Friend/Family
Community Center
Online Search
Social Media
Other
Preferred Method of Contact
*
Email
Phone
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Relationship to child
Section 2: Diagnosis and Educational Supports
Formal Autism Diagnosis
*
Yes
No
Currently being evaluated
Other Diagnoses or Relevant Conditions
Does your child have an IEP?
*
Yes
No
In development
Does your child have a 504 Plan?
*
Yes
No
In development
Current classroom setting
Please Select
ICT
General Education
Special Class
8:1:3
12:1:3
Other
Unsure
What school supports does your child currently receive?
Speech Therapy
Occupational Therapy
Physical Therapy
Counseling
ABA or Behavioral Support
1:1 Support
Other
Does your child receive 1:1 support during the school day?
Yes
No
Sometimes
Unsure
Optional supporting documents
Upload a File
Drag and drop files here
Choose a file
You may upload your child’s IEP, 504 Plan, Behavior Intervention Plan, or other relevant documentation. These documents are not required to submit this initial inquiry. NYCYA may request relevant records later as part of the enrollment and individualized safety-planning process.
Cancel
of
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Section 3: Communication and Social Interaction
Primary Communication Methods
Conversational Speech
Short Phrases
Gestures
PECS
AAC Device
Sign Language
Non-Speaking
Other
How does your child communicate needs, discomfort, requests for help, or requests for a break?
Peer Interaction Style
Please Select
Independent Play
Parallel Play
Small Groups
Larger Groups
Needs Adult Support
Varies
Social or Communication Goals for the Child
Section 4: Regulation, Behavior, and Safety
Does your child have a Behavior Intervention Plan?
Yes
No
Unsure
Known triggers or situations that may cause distress
Strategies that help the child feel safe and regulated
Safety awareness
Please Select
Strong
Developing
Limited
Requires Continuous Supervision
Is there anything NYCYA should know to maintain your child’s safety or the safety of others?
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Section 5: Sensory Profile
Sensitivity to noise
Please Select
Low
Moderate
High
Varies
Sensitivity to light
Please Select
Low
Moderate
High
Varies
Sensitivity to touch, crowds, or proximity
Please Select
Low
Moderate
High
Varies
Helpful sensory tools, accommodations, or calming activities
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Section 6: Self-Care and Daily Living
Bathroom support
Please Select
Independent
Needs Reminders or Prompts
Needs Some Assistance
Needs Full Assistance
Feeding, eating, or swallowing concerns
Ability to follow familiar routines
Please Select
Independent
With Occasional Support
Needs Consistent Support
Needs Highly Structured Support
Other daily-living support needs
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Section 7: Health and Medical Information
Please provide only the information necessary for NYCYA’s preliminary eligibility and safety review. Additional medical documentation may be requested after preliminary acceptance.
Allergies
Medical conditions relevant to participation or safety
Would the child need medication administered during program hours?
Yes
No
Unsure
If yes or unsure, please explain
Dietary restrictions
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Section 8: Schedule, Funding, and Logistics
Expected attendance frequency
1-2 days
3-4 days
5 days
Unsure
Funding or payment support anticipated
DSS Child Care Subsidy
Westchester Works Scholarship
OPWDD or Self-Direction
Private Pay
Unsure
Other
Does the family need assistance understanding funding options?
Yes
No
Transportation plan after the program
Parent or Guardian Pickup
Authorized Adult Pickup
Other
Unsure
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Section 9: Program Fit and Family Goals
Primary reason for seeking NYCYA
What would a successful afterschool experience look like for your child?
What would success look like for your family?
Has the child ever been asked to leave, suspended from, or denied continued participation in another childcare or afterschool program?
Yes
No
Prefer Not to Answer
If yes, please share any information that may help NYCYA provide better support
Anything else NYCYA should know
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Section 10: Acknowledgment and Signature
Areas in which support may be needed
Communication
Behavior and regulation
Sensory needs
Self-care and daily living
Health and medical
Social interaction
Other
Days of care needed
Monday
Tuesday
Wednesday
Thursday
Friday
Acknowledgments
*
I understand this is a preliminary inquiry only
I understand submission does not guarantee enrollment
I understand NYCYA may contact me about next steps
I confirm the information provided is accurate
Parent/guardian electronic signature
*
Sign using your finger, mouse, or typed signature.
Date signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please share any additional questions or information:
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