C4S After School Program P.S. 35q Application 2026

Applicant Information
C4S After School Program P.S. 35q Application 2026–2027

Please complete the application for the C4S After School Program P.S. 35q for the 2026–2027 school year. Provide all required participant, parent/guardian, emergency, health and consent
First Name
Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex
Primary Language
Age
Grade
Full Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent / Guardian Contacts
Parent/Guardian #1 Full Name

First NameLast Name
Parent/Guardian #1 Relationship to Applicant
Parent/Guardian #1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #1 Email Address
example@example.com
Parent/Guardian #2 Full Name

First NameLast Name
Preferred Contact Method
Parent/Guardian #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contacts
Emergency Contact #1 Full Name

First NameLast Name
Emergency Contact #1 Relationship
Emergency Contact #1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2 Full Name

First NameLast Name
Emergency Contact #2 Relationship
Emergency Contact #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #3 Full Name

First NameLast Name
Emergency Contact #3 Relationship
Emergency Contact #3 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Pick-Up and Dismissal Permissions
My child has permission to sign themselves out at dismissal.
My child has permission to walk home alone at dismissal.
My child MAY NOT be picked up by:
Participant Health Information

Please check any of the following that pertain to the participant. Many needs or health challenges can be accommodated and may not limit enrollment in the program. (UPDATED MEDICAL REQUIRED WITH APPLICATION)Check off all that apply and list any additional information.
Does the participant have any of the following health conditions or needs?

Other
If allergies are selected, please describe the allergy and any response needed.
If asthma is selected, please describe triggers and any needed support.
If diabetes is selected, please describe any monitoring or care needs.
If behavioral or emotional concerns are selected, please describe any support that helps.
Does the participant use any of the following devices or supports?

Other
Does your child have special health care needs that require treatment and/or medication?
Does your child take medication for any condition or illness?
Is updated medical information already on file?
Upload the Applicant’s Current Medical Form

Cancelof
If not on file or if anything has changed, please provide the updated medical information.
Are there any activities the participant cannot participate in? Please explain.
Consents and Signatures

Please be aware that sometimes staff, photographers, newspapers, television reporters, media representatives and public relations personnel may be present during program activities and special events, both at off-site events and events taking place in the usual program location. In some cases, they may photograph, videotape, interview or otherwise record children who participate in these events. The resulting images, videos and interviews may be used solely for non-profit, non-commercial purposes in printed and electronic media such as brochures, books, print and email newsletters, DVDs and videos, websites, social media and blogs (collectively, “Media”). These images, videos and interviews may be used by S4S and third-party organizations that collaborate with S4S, without compensation and without further approval, solely for non-profit, non-commercial purposes.If, in the course of participating in program activities or special events, any original work is created by a participant, DYCD may use the created work in any and all Media to promote the program or for other informational, non-profit and non-commercial purposes, without compensation and without further approval.
I understand my child may be photographed, interviewed or otherwise recorded during program activities and special events and give permission for my child to be photographed, interviewed or otherwise recorded solely for non-profit, non-commercial purposes of the program.
I understand that my child’s work may be used in materials that promote programs, solely for non-profit, non-commercial purposes of the program.
Parent/Guardian Signature
Consent for emergency medical treatment
I give authority to the Program Agency’s staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible. I understand that every effort will be made to contact me before and after medical care is provided.
Consent Statement

I, the undersigned, certify that I have reviewed all the above consent statements and indicated my wishes. I understand that consent is voluntary, and I can withdraw it in writing at any time.
Parent/Guardian Name:

First NameLast Name
Parent/Guardian Signature
Parent/Guardian Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Additional Parent/Guardian Name:

First NameLast Name
Additional Second Parent/Guardian Signature
Additional Parent/Guardian Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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 Community 4 Success, Inc. for additional services or to access additional funding.

First NameLast Name
Organization: Community 4 Success Inc. Scholars for Success Intake Specialist/Staff:

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Scholar Agreement

Scholars are asked to adhere to the following agreement: As a member of Scholars for Success’s extended day program, I promise to:
1. Always treat others with respect.
2. Respect other people’s cultural, racial, and ethnic backgrounds.
3. Use polite, kind words; inappropriate language is discouraged.
4. Always help others when they need help.
5. Always listen to and respect the afterschool staff, despite any emotions that may arise.
6. Respect S4S; refrain from touching PS 270 teachers’ belongings.
7. Always tell the truth.
8. Respect other people and their property.
9. Always clean up after myself.
10. Always keep my hands and feet to myself.
11. Be proud of who I am.
12. Always ask permission before leaving the afterschool area.
13. Eat only in the designated areas provided.
14. Avoid fighting, bullying, and teasing others.
15. Always come prepared to learn something new every day.
16. Take responsibility for my actions.
17. Always try, no matter how challenging a task may be.
18. Always stand up for my beliefs.
19. Always resolve conflicts nonviolently.
20. Have fun!
I have read and understood the Rules and Regulations and discussed them with my scholar. My signature and my scholar’s signature below indicate consent to these agreements.
Parent/Guardian Name:

First NameLast Name
Relationship to Scholar:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Scholar Name:
Scholar Signature:
GENERAL FIELD TRIP PERMISSION SLIP
Dear Parents/Guardians,
Many times throughout the year, we take field trips around the neighborhood and/or to attractions to enhance and enrich our units. Please fill out this general permission slip and return it as soon as possible. This slip will be kept on file throughout the year and will cover any field trips (within walking distance or once requiring a bus transportation) taken during the 2023-2024 school year. We will continue to send home information regarding the events with dates, times, etc. for each trip. If at any time the emergency information changes, please send a note to Administration.
Complete the bottom portion and return.
Thank you,
Management
I,
give permission for my child,
to attend all field trips and neighborhood walks throughout the 2026-2027 school year at S4S. I understand that I will receive information regarding these events and will notify the program if the emergency information changes.
Parent/Guardian Name:

First NameLast Name
Parent / Guardian Signature
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Welcome to the Department of Youth and Community Development (DYCD)! This form lets you or your child apply to a DYCD Comprehensive Afterschool System (COMPASS), Beacon or Cornerstone youth program. You can only submit one application per person, per location.

Submitting a form does not guarantee eligibility or enrollment in the program, and we might ask for more information to see if you are eligible. If accepted, the program will not cost you anything.

We collect information such as gender, race, ethnicity, language, and health insurance status for planning purposes only. Your answers to these questions will not affect your eligibility for benefits or services and will not be shared outside of DYCD without your permission. Income, household information, and education/work status might affect eligibility for certain programs.

Gathering your information helps DYCD understand who benefits from our programs. This helps us improve our programs and continue providing communities with the support they need.
PART I: APPLICANT INFORMATION
For the purposes of this application, “applicant” refers to the person applying to receive services. Please select one:
Applicant’s

First NameLast Name
Applicant’s Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Applicant’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does the applicant live in a NYCHA development?
If yes, please provide the name of the NYCHA development.
Applicant’s Sex at Birth — Select one:
How well does the applicant speak English? — Select one:
Applicant’s Race/Ethnicity — Select all that apply:
Is the applicant an individual with a disability?
Is the applicant a parent/legal guardian?
Is the applicant an offender or justice-involved individual?
Is the applicant a foster care participant?
Is the applicant a runaway youth?
Is the applicant a veteran?
Is the applicant active military personnel?
If of Native Hawaiian or Other Pacific Islander origin, please select from the following — Select all that apply:
If of Asian origin, please select from the following — Select all that apply:
If of Hispanic or Latinx/e/a/o origin, please select from the following — Select all that apply:
Applicant’s Primary Language — Select one:
Other Languages Spoken by Applicant — Select all that apply
Did you or any member of your household serve in the armed forces, National Guard, or reserves of the United States?
If yes, would you or your household member want to be contacted by the NYC Department of Veterans’ Services?
If the applicant is an individual with a disability, please select the disability type(s) — Select all that apply:
How did you learn about the DYCD program(s) you’re applying to? — Select all that apply:
If website, please specify which one.
PART II: APPLICANT’S CONTACT INFORMATION

Contact information below is for the applicant
Phone Number #1
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number #1 Type:
Phone Number #2
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number #2 Type:
Parent/Guardian’s Email Address
example@example.com
Preferred Method of Contact — Select all that apply:
PARENT/GUARDIAN’S CONTACT INFORMATION

This section is required for applicants under 18. Contact information below is for the parent/guardian
Parent/Guardian Name

First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number Type:
Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the address the same as the applicant’s address?
Preferred Method of Contact — Select all that apply:
PART III: EMERGENCY CONTACT INFORMATION
Emergency Contact #1

First NameLast Name
Emergency Contact #1 Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #1’s Relationship to Applicant
Emergency Contact #2

First NameLast Name
Emergency Contact #2 Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #2’s Relationship to Applicant
This section is for parents/guardians enrolling their children

Emergency contacts listed in Section II are authorized to pick up the child unless otherwise noted.
The following additional people are authorized to pick up my child:
Authorized Person #1

First NameLast Name
Authorized Person #1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Person #1 Relationship to Child
Authorized Person #2

First NameLast Name
Authorized Person #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Person #2 Relationship to Child
Authorized Person #3

First NameLast Name
Authorized Person #3 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Person #3 Relationship to Child
The following people MAY NOT pick up my child:
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
PART IV: Applicant’s Education/Work Status

If the applicant is a part-time or full-time student, select the applicant’s current grade. If the applicant is not in school, select the last grade completed by the applicant.
Applicant’s School Type (Select One):
Applicant’s Current Work Status (Select One):
Elementary school
High School
Community College
Vocational or Trade School
4-Year College/University
Master’s Degree
Professional Degree
Doctorate Degree
Other
Required for Full-Time Students
Student ID/OSIS
School Type:
School Name
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PART V: Household Information

For the next set of questions, household is defined as any individual or group of individuals—family or non-family members—who live together as one economic unit. Income is defined as the total annual gross income of all family and non-family household members who are 18 years or older.
The Applicant Lives in a Household Headed By (Select One):
Applicant’s Housing Type (Select One):
Applicant’s Household Size (Select One):
Estimated Household Income in the Last 12 Months: (ex 45,000)
Estimated Household Income in the Last 12 Months:
Sources of Applicant’s Household Income (Select All That Apply):
PART VI: Applicant’s Health Information
Does the applicant have health insurance? (Select One):
If yes, what kind of health insurance does the applicant have? (Select All That Apply):
If you do not have health insurance, do you want to be contacted by someone with information about signing up for public health insurance? (Select One):
If you would like to be contacted about signing up for public health insurance, what is your preferred method of contact? (Select One
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.
Does the applicant have any allergies (e.g., food, medication, etc.)?
If yes, please explain:
Does the applicant have asthma?
Does the applicant have special health care needs?
If yes, please explain:
Does the applicant take medication for any condition or illness?
If yes, please explain:
Are there activities the applicant cannot participate in?
If yes, please explain:
Please provide any additional health information or details:
Please list any accommodations you are requesting for the applicant:
PART VII: Consents and Signatures

Pick-Up/Dismissal Information This question must be answered by parents/guardians enrolling their children.
My child has permission to travel home alone at dismissal:
Consent to Participate

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.
If the Participant Is 18 or Older
I acknowledge that I am 18 years of age or older and am authorized to give consent.
Participant’s Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Participant’s Signature
If the Participant Is Under 18 Years Old
Parent/Guardian’s Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian’s Signature
Consent for Emergency Medical Treatment
If the Participant Is 18 or Older

I am enrolled as a participant in a DYCD-funded program. In the event of a medical emergency, I hereby give consent for necessary emergency medical treatment to be obtained on my behalf. I further authorize the emergency contact(s) listed to be contacted.
Permission
Participant’s Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Participant’s Signature
If the Participant Is Under 18 Years Old

My child is enrolled as a participant in a DYCD-funded program. In the event of a medical emergency, I hereby give consent for necessary emergency medical treatment for my child to be obtained, with the understanding that I will be notified as soon as possible. I understand that every effort will be made to contact me or, if I am unavailable, the emergency contact(s) listed, before and after medical care is provided.
Permission
Parent/Guardian’s Name

First NameLast Name
Parent/Guardian’s Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Consent for Photography/Videotaping and Use of Original Work

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. I consent to the resulting images, videos, and interviews being used by the Authorized Parties, without compensation and without further approval, solely for nonprofit, noncommercial purposes in any and all Media.
If, during participation 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 consent to such Original Work being used by the Authorized Parties, without compensation and without further approval, solely for nonprofit, noncommercial purposes in any and all Media
If the Participant Is 18 or Older

I acknowledge that I am 18 years of age or older and am authorized to give consent.
I acknowledge that I am 18 years of age or older and am authorized to give consent.
Participant's Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Participant’s Signature
If the Participant Is Under 18 Years Old
Participant Name

First NameLast Name
Parent/Guardian’s Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Consent to Collect and Share Student Information

The Department of Youth and Community Development (DYCD) provides funding for this program as part of its mission to help your child reach their 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 collect information about your child, their participation, and the quality of the services provided.
What information from your child’s student records is DYCD requesting?

We are requesting your permission for 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, including your child’s name, address, date of birth, student identification number, grade, schools attended, and transfer, discharge, and graduation data; school attendance data, including the number of days attended and absences; academic performance data, including state and national exam results, credits earned, grades, promotion and retention status, and FitnessGram score; and information related to disciplinary actions, including the number and type of suspensions.
We are requesting to collect the information listed above about your child on a past, present, and future (ongoing) basis.

We are also requesting your permission for DYCD to share information collected from you and/or your child on the enrollment form with NYCPS staff. This includes registration information, the student’s interests and challenges, the type of program enrolled in, and frequency of participation. This information will help the school and community organization work together to meet you and your child’s needs.
Who will see my child’s information, and how will it be safeguarded?

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 authorized to receive personal information is screened and extensively trained to follow strict confidentiality guidelines.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. It will not be shared with community-based organizations or their staff members. We will not use your name or your child’s name in any published report. Your responses to the requests below will not affect your child’s participation in DYCD-sponsored programs.
Please select Yes or No for each statement:
I understand why DYCD is asking for permission to access the information listed above from my child’s student records, and I give NYCPS permission to share that information with DYCD on an ongoing basis.
I understand why DYCD is asking for permission to share information about my child collected by DYCD with NYCPS staff, and I give DYCD permission to share that information with NYCPS on an ongoing basis.
Student/Applicant Name

First NameLast Name
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Additional Parent/Guardian Name (Optional)

First NameLast Name
Additional Parent/Guardian Signature (Optional)
Consent to Make Referrals and Share Information

The New York City Department of Youth and Community Development (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.
Why We Need Your Consent

With your consent, 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
What We Share

We will only provide information to show that you qualify or to help you enroll in DYCD-funded programs.
Who Sees Your Information and How We Protect It

Only authorized employees at DYCD and the programs funded by DYCD can see it.
Please read the statement below, select one option, and complete the remaining fields.

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
Consent (Select One):
Participant Name

First NameLast Name
Signature of Participant—or Parent/Guardian for Participants Under 18 Years Old
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Applicant Information

C4S After School Program P.S. 35q Application 2026–2027

Parent / Guardian Contacts

Emergency Contacts

Pick-Up and Dismissal Permissions

Participant Health Information

Consents and Signatures

Consent for emergency medical treatment

Consent Statement

Scholar Agreement

I have read and understood the Rules and Regulations and discussed them with my scholar. My signature and my scholar’s signature below indicate consent to these agreements.

GENERAL FIELD TRIP PERMISSION SLIP

PART I: APPLICANT INFORMATION

PART II: APPLICANT’S CONTACT INFORMATION

PARENT/GUARDIAN’S CONTACT INFORMATION

PART III: EMERGENCY CONTACT INFORMATION

This section is for parents/guardians enrolling their children

The following additional people are authorized to pick up my child:

The following people MAY NOT pick up my child:

PART IV: Applicant’s Education/Work Status

Required for Full-Time Students

PART V: Household Information

PART VI: Applicant’s Health Information

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.

PART VII: Consents and Signatures

Consent to Participate

If the Participant Is 18 or Older

If the Participant Is Under 18 Years Old

Consent for Emergency Medical Treatment

If the Participant Is 18 or Older

If the Participant Is Under 18 Years Old

Consent for Photography/Videotaping and Use of Original Work

If the Participant Is 18 or Older

If the Participant Is Under 18 Years Old

Parent/Guardian Consent to Collect and Share Student Information

What information from your child’s student records is DYCD requesting?

We are requesting to collect the information listed above about your child on a past, present, and future (ongoing) basis.

Who will see my child’s information, and how will it be safeguarded?

Please select Yes or No for each statement:

Consent to Make Referrals and Share Information

Why We Need Your Consent

What We Share

Who Sees Your Information and How We Protect It

Please read the statement below, select one option, and complete the remaining fields.