NYCDOE Community School Empire State After School Program Student Enrollment Form School Year 2023-2024

Site Selection

To which borough would you like to search for a site?

To which site in the Bronx are you currently applying?

If no results are found in your search, please contact enrollment@newyorkedge.org.

To which site in Brooklyn are you applying?

If no results are found in your search, please contact enrollment@newyorkedge.org.

To which site in Long Island are you applying?

To which site in Manhattan are you currently applying?

If no results are found in your search, please contact enrollment@newyorkedge.org.

To which site in Queens are you applying?

If no results are found in your search, please contact enrollment@newyorkedge.org.

To which site in Staten Island are you applying?

If no results are found in your search, please contact enrollment@newyorkedge.org.

Student Information

Student's First Name:

Student's Last Name

Student OSIS (ID Number)

Gender

Grade

Date of Birth (MM/DD/YEAR)

Mailing Address

City

State

Zip Code

Home Phone

I give New York Edge permission to text my mobile number with special alerts, announcements and information about my program participation. You may opt out anytime, standard text messaging rates may apply as provided in your wireless plan.

I give New York Edge permission to call/robocall my mobile number with special alerts, announcements, and information about my program participation. You may opt-out anytime. Standard text messaging rates may apply as provided in your wireless plan.

Home Email

Racial Ethnic Group

If "Other" is selected, please specify

If Multi-Racial is selected, please specify

Language Spoken at Home

Math Teacher

English Teacher

Parent/Guardian Information

First Name of Primary Parent/Guardian 1

Last Name of Primary Parent/Guardian 1

Parent/Guardian 1 Title

If other title, please specify

Language Spoken

If Other language, please specify.

Parent/Guardian 1 Street Address

Parent/Guardian 1 City

Parent/Guardian 1 State

Parent/Guardian 1 Zip Code

Home Phone

Work Phone

Cell Phone

Does Parent/Guardian 1 have an email address?

Email

First Name of Parent/Guardian 2

Last Name of Parent Guardian 2

Parent/Guardian 2 Title

If other title, please specify

Language Spoken

If Other language, please specify.

Street Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Email

Empire After School Student Participation Release Form

I give my child

permission to enroll and participate in the Empire After School program at

Digital Signature (type in first and last name)

Today's Date

Release of Child at Dismissal

Child has permission to come home alone

If no, my child will be picked up after-school by me or one of the following individuals:

Authorized Person #1

Name

Relationship to Child

Home Phone

Cell Phone

Authorized Person #2

Name

Relationship to Child

Home Phone

Cell Phone

My child MAY NOT be picked up by the following individuals:

Name

Relationship to Child

Name

Relationship to Child

Name

Relationship to Child

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

First Name 1

Last Name 1

Relationship to Student

Home Phone

Cell Phone

First Name 2

Last Name 2

Relationship to Student

Home Phone

Cell Phone

Health Information

* To be completed by the parent/guardian. This confidential health information will only be used to ensure the safety of the children in this program.

Please provide your child’s medical history:

Any allergies to food?

Allergies Explanation

If allergies change at any time during the program year, please inform New York Edge staff.

Any behavioral/emotional history?

Behavioral/emotional history explanation

Any physical disabilities?

Physical disability explanation

Does your child use a corrective device?

Corrective device explanation

Does the applicant have asthma?

Does your child use an inhaler?

Allergies to Penicillin?

Allergy to plants?

Allergy to insect stings?

If allergies change at any time during the program year, please inform New York Edge staff.

Hay Fever?

Convulsions or seizures?

Does your child have diabetes?

Other pertinent information

Does your child have special health care needs?

Special healthcare need explanation

Does your child take medication for illness?

Medication explanation

Are there any activities your child cannot participate in?

Restricted activities explanation

By entering my digital signature below, I certify all health information listed above is complete and accurate.

Digital Signature (type in first and last name)

Date

If my child requires emergency medical care and I cannot be reached, I give my consent to the Empire After School program to obtain the necessary medical care for my child. I agree to pay all costs associated with the emergency medical care that my child receives. I understand that every effort will be made to contact me before and after medical care is provided. I understand that this consent will be in effect as of the date of my signing this form and will continue as long as my child is enrolled in this program.

Digital Signature (type in first and last name)

Date

Consent to Photograph, Film, or Videotape a Student for Non-Profit Use

(E.G., Educational, Public Service or Health Awareness Purposes)

Student Name

School

I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies or videotapes of the Student named above by the New York City Department of Education. I also grant to the New York City Department of Education 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 New York City Department of Education and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.

Consent for Photography/Videotaping

Digital Signature (type in first and last name)

Today's Date

Address of Parent Guardian

Parent Involvement

Parent First Name

Parent Last Name

Home Phone Number

Work Phone

Mobile Number

Email

I give New York Edge permission to email special alerts, announcements and student information. You may opt out at any time.

I give New York Edge permission to text my mobile number with special alerts, announcements and student information. You may opt out anytime, standard text messaging rates may apply as provided in your wireless plan.

I give New York Edge permission to call/robocall my mobile number with special alerts, announcements, and student information. You may opt-out anytime. Standard text messaging rates may apply as provided in your wireless plan.

What kind of work do you do?

What is your company affiliation (optional):

I would like to support New York Edge programs by becoming a volunteer in the following areas:

If other, please describe.

Certification Statement

I certify that all information on this form is true and correct. I understand that my statements are subject to verification. I agree and accept that I will abide by all applicable rules and regulations of this program. I consent to the enrollment and participation of the child listed above in this program.

Digital Signature (type in first and last name)

Today's Date

Parent Consent to Participate in the Evaluation of the After-School Program

Dear Parent/Guardian,

Your child,

, is enrolled in the

after school program at

. In order to monitor the effectiveness of the after school program and ensure its future success, New York Edge is conducting ongoing evaluations. It is the intention of the evaluations to learn how these services help students and how they can be improved in order to meet funding requirements.

after school program at

. In order to monitor the effectiveness of the after school program and ensure its future success, New York Edge is conducting ongoing evaluations. It is the intention of the evaluations to learn how these services help students and how they can be improved in order to meet funding requirements.

after school program at

. In order to monitor the effectiveness of the after school program and ensure its future success, New York Edge is conducting ongoing evaluations. It is the intention of the evaluations to learn how these services help students and how they can be improved in order to meet funding requirements.

after school program at

. In order to monitor the effectiveness of the after school program and ensure its future success, New York Edge is conducting ongoing evaluations. It is the intention of the evaluations to learn how these services help students and how they can be improved in order to meet funding requirements.

after school program at

. In order to monitor the effectiveness of the after school program and ensure its future success, New York Edge is conducting ongoing evaluations. It is the intention of the evaluations to learn how these services help students and how they can be improved in order to meet funding requirements.

Specifically we ask permission from parents to:

Talk to teachers and after-school staff about children’s progress and participation in the after-school program, and review program records on participation in the after-school program.
Survey and/or interview parents and children about the after-school program and its effects. There will be a survey distributed via text/email over the course of the year. The survey will take approximately 15 minutes. Group discussions may also be held, that would take up to 30 minutes.

Any information we collect will be used only to assess the after-school program and will not be made public. Participation in the evaluation is completely voluntary, and participants may withdraw at any time without consequence. Personal information will not be used for any purposes after the evaluation is complete.

Consent to Participate

Digital Signature (type in first and last name)

Today's Date

Parent/Guardian Data Release Consent Form

I. Information being requested.

New York Edge is requesting your permission to collect academic performance and enrollment data on your child. This information will be used for the purposes of establishing program outcomes and may be used in a combined, not individualized, format to help advocate for continued funding.

Contact their children’s school and obtain records showing their progress, including report cards, grades, citywide and statewide test scores, attendance, school choice, and any other reports pertaining to academic progress.
Biographical and enrollment information (specifically consisting of your child’s name, address, date of birth, student identification number, grade, school(s) attended and transfer, discharge, and graduation data about your child)
Data concerning your child’s school attendance (including number of days attended and absences)
Academic performance data (including your child’s results on state and national exams, credits earned, grades, promotion and retention status, and fitness gram score)
Data related to any disciplinary actions taken against your child (including number and type of suspensions)

II. How will your child’s data remain confidential?

We will not use your name or your child’s name in any published report. While we request your consent, your responses to the requests below will not affect your child’s participation in our programs.

Please check Yes or No to the following statement:
I understand why New York Edge is asking my permission to access the information listed above from my child’s student records, and I give permission to DOE to share that information with New York Edge on an ongoing basis.

Consent for DOE and NYE to Share Info

Student/Applicant Name

Digital Signature (type in first and last name)

Today's Date

Additional Parent/Guardian Name

Waivers and Consents

WAIVER OF LIABILITY: I recognize that activities to be engaged in by participants during New York Edge programs may result in personal injury or property damage. I hereby release and hold harmless New York Edge from any and all claims I or my child may have arising from, or in connection with, participation in the program. Such release includes, but is not limited to, any claims, demands or causes of action for injuries to my child, except where due to the negligence of New York Edge.

Waiver of Liability Consent

E-LEARNING CONSENT: I understand that at times my participant may have to engage in E-learning to participate in New York Edge programs. New York Edge will be facilitating any required E-learning, including in response to COVID-19 related closures, through the Google Classroom and Zoom platforms.

I provide consent for my child to participate in New York Edge E-learning opportunities using the Google Classroom platform and Zoom.

For additional information about E-Learning platforms, please visit:

Google Classroom

Zoom

E-Learning Consent

PHOTO/VIDEO CONSENT: I consent for my participant to be photographed or otherwise recorded during New York Edge events and activities, whether in school or away from school. I give my permission for any and all such photographs and/or recordings to be displayed by New York Edge in any lawful medium (books, newsletters, websites, social media, etc.) now or in the future, for which neither I or my participant shall receive ownership rights or monetary compensation.

Consent for Photography/Videotaping

INTERVIEW/SURVEY CONSENT: I understand that New York Edge holds events, both in-school and away from school, at which media representatives, television reporters, photographers or public-relations personnel may be present. In some cases they may interview, photograph or survey children who participate in these events, including my participant.

I understand that my participant may be asked questions concerning New York Edge activities and programs, and that the contents of that interview may be published or aired publicly. I understand that my child will be under the supervision of New York Edge personnel during at all times during any direct interview, photo or survey session. I understand my participant reserves the right to refuse to answer any questions or participate in any discussions, and that my child or the supervising New York Edge personnel may terminate the session at any time for any reason.

Interview/Survey Consent

PARTICIPATION CONSENT: I, the undersigned, certify that I am the parent or legal guardian of

, whose date of birth is

, that I have read the consents outlined above and give my participant permission to participate in the New York Edge program.

Digital Signature (type in first and last name)

Today's Date

After clicking submit, you will be prompted to enter a digital signature. This digital signature will apply to all consent forms and waivers in this application.