Highview Afterschool 2024-25 - United Way of Westchester and Putnam

Step 1 of 10

10%

Student Information

Student's Full Name:(Required)

Student's Preferred Name:(Required)

Date of Birth:(Required)

MM slash DD slash YYYY

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 Health Information:

All information is confidential and is used by the program to ensure the safety of the students.

Does your child have any of the following?

Allergies(Required)

Yes

If yes, do they need/use an Epipen?(Required)

Yes

List allergies and which allergy the Epipen is for: (N/A if not applicable)(Required)

Asthma(Required)

Yes

If yes, do they use an inhaler/any other medicine for their asthma(Required)

Yes

Diabetes(Required)

Yes

If yes, does your child need medication or blood glucose monitoring?(Required)

Yes

If yes, does your child have a prescription for glucagon?(Required)

Yes

Seizure Disorder(Required)

Yes

If yes, does your child need medication for preventing or treating seizures?(Required)

Yes

Visual Condition(Required)

Yes

If yes, and your child needs aids at school other than wearing glasses or contacts, please describe:(N/A if not applicable)(Required)

Hearing Condition(Required)

Yes

If yes, and your child needs aids at school other than wearing a hearing aid, please describe: (N/A if not applicable)(Required)

Physical Limitations(Required)

Yes

Is your child able to participate in physical education class at school with no limitations?(Required)

Yes

If no, please list their activity limitations:(N/A if not applicable)(Required)

Other Medications(Required)

Yes

If yes, please list (N/A if not applicable)(Required)

Does your child have special diet needs, other health needs, or behavioral/emotional needs? If yes, please describe: (N/A if not applicable)(Required)

*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

I give my child permission to enroll and participate in the 21st CCLC Education United: Academic and Enrichment After-School Program.(Required)

Yes

I understand that following agreements and consents are not pre-conditions for approval to participate in the 21st CCLC Education United: Academic and Enrichment After-School Program.(Required)

Yes

I consent to emergency medical treatment for my child.(Required)

Yes

I consent for my child to participate in interviews, the use of quotes, and the taking of photographs, movies, or videotapes by the 21st CCLC Education United: Academic and Enrichment After-School Program. I also grant the 21st CCLC Education United: Academic and Enrichment After-School Program the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I also hereby release the 21st CCLC Education United: Academic and Enrichment After-School Program and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.(Required)

Yes

I consent for my child to take part in field trips, away from the program site, under supervision.(Required)

Yes

I understand the program may need additional permissions for situations such as transportation, medication, release of information, and field trips.(Required)

Yes

I provided information on my child’s special needs to the program to assist in the safety of my child.(Required)

Yes

I understand that information regarding my child’s special learning needs will be shared by my child’s school of enrollment with the 21st CCLC Education United: Academic and Enrichment After-School Program staff on a need-to-know basis for my child’s educational benefit.(Required)

Yes

I agree to review and update this information whenever a change occurs and at least once every year.(Required)

Yes

I agree to talk to the program staff about my child’s progress and participation in the 21st CCLC Education United: Academic and Enrichment After-School Program.(Required)

Yes

If at any time I change my mind about my child’s participation (any or all aspects), I will contact the site coordinator.(Required)

Yes

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.

Signature of Consent

By signing below, I certify that all information (above) is true and correct to the best of my knowledge.(Required)

I agree

Name/Signature of Parent/Guardian:(Required)

Date of Signature:(Required)