Education United at Morse 24-25 - United Way of Westchester and Putnam

Student Information

Student's Full Name:(Required)

Student's Preferred Name:(Required)

Date of Birth:(Required)

Child's Photo (optional)

Max. file size: 100 MB.

Student's Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone:(Required)

Languages Spoken at Home:(Required)

Racial/Ethnic Group(Required)

If Other:

Student NYSED ID Number (completed by Program)

Student District ID Number (completed by Program)

Attending School:(Required)

Grade:(Required)

Student's Primary Teacher (required for grades 1-5, write N/A if not applicable)(Required)

How many days (Monday-Thursday) you interested in?(Required)

Four days a week.

Three days a week.

Two days a week.

I am open to what is available.

Please list the days that you want your child to attend the program.(Required)

Do you need free Lyft rides to pickup your child?(Required)

Yes

Name of Person Enrolling Student:(Required)

Relationship to Student(Required)

If other, please explain here.

Address of Person Enrolling Student (if different from student -fill in with N/A if not applicable)(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email of Person Enrolling Student:(Required)

Phone Number of Person Enrolling Student:(Required)

Emergency Contacts

First Emergency Contact Name:(Required)

Authorized to pick up?(Required)

Yes

Phone Number:(Required)

Email:(Required)

Second Emergency Contact Name:(Required)

Authorized to pick up?(Required)

Yes

Phone Number:(Required)

Email:(Required)

Release of Student at Dismissal

I give my child permission to walk alone at dismissal(Required)

yes

If no, my child can be picked up after school by me or the following individuals (use N/A if needed for required fields):

Name:(Required)

Phone Number:(Required)

Email:(Required)

Relationship to Student:(Required)

Name:(Required)

Phone Number:(Required)

Email:(Required)

Relationship to Student:(Required)

My child MAY NOT be picked up by the following individuals (type N/A if not applicable):

Name:

Relationship to Student:

Name:

Relationship to Student:

Name:

Relationship to Student:

Release of Student During Medical Emergencies:

If I am not available during emergencies, my child may be released to one of the following individuals:

Name:(Required)

Phone Number:(Required)

Email:(Required)

Relationship to Student:(Required)

Name:(Required)

Phone Number:(Required)

Email:(Required)

Relationship to Student:(Required)

Student Data Requirements and Surveys/Interviews Consent

I understand that my child’s academic, behavioral, attendance, and engagement information will be shared with the New York State Education Department and its lawful contractors, to measure and evaluate the quality and implementation of the local 21st Century Community Learning Center (21st CCLC) program as well as the effectiveness New York State’s program in supporting student growth, as required by Title IV, Part B of the Every Student Succeeds Act (ESSA) [see generally sections 4205 (b) and 4203 (14)]. I understand that my child and I may be asked to participate in surveys and/or interviews about and its effects.(Required)

I understand

Opt-out

Only check the following box if you would like to opt-out and not participate in surveys and/or interviews.

Education United Afterschool at Morse Interest Form

Education United Enrollment Form 24-25

Student Information

Emergency Contacts

Release of Student at Dismissal

If no, my child can be picked up after school by me or the following individuals (use N/A if needed for required fields):

My child MAY NOT be picked up by the following individuals (type N/A if not applicable):

Release of Student During Medical Emergencies:

Student Health Information:

Does your child have any of the following?

*Please note medications taken or administered at the program will need written parent/guardian consent and health care providerorder. Please check with program director/site coordinator for details.

Agreements

Student Data Requirements and Surveys/Interviews Consent

Signature of Consent

2025 Imagine Gala Donation

Imagine Gala Donation

Benefactor Information

Address

Card Payment

Finalize Donation