21st Century Afterschool Program Application

21st Century Program Application

“This project was funded in its entirety Under Title IV, Part B of the Every Student Succeeds Act (ESSA), 21st Century Community Learning Center (21st CCLC) grant funds through a grant agreement with the New Jersey Department of Education.”
Student Information

Please note must be a student at the chosen school in order to join the afterschool program.
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Grade Level*
T-Shirt Size*
Student Cell Phone Number
Please enter a valid phone number.
E-mail
example@example.com
Primary language spoken at home?*

EnglishSpanishCreoleOther
Would you like to add another child in the school to this afterschool application?*

YesNo

2nd Student Information

Please note must be a student at the chosen school in order to join the afterschool program.
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Grade Level*
T-Shirt Size*
Student Cell Phone Number
Please enter a valid phone number.
E-mail
example@example.com

First Aid & Medical Care
Child's Doctor/Clinic*
Doctor/Clinic Phone #*
Please enter a valid phone number.
Does your child have allergies, special diets, or medications?*

YesNo
If yes, please provide details:
Does your child have special limitations or concerns?*

YesNo
If yes, please provide details:
Does your child have any serious medical conditions?*

YesNo
If yes, please provide details:

Secondary Parent / Guardian
Secondary Parent Name*

First NameLast Name
Relationship to Student*

MotherFatherOther
Secondary Parent Email*
example@example.com
Cell Phone #*
Work Phone #
Home Phone #
Preferred Method of Contact*

CellHomeWorkE-mailText

Child Release Contacts

Please indicate any additional adults, other than the parents/guardians and emergency contact already listed, who are authorized to pick up your child from school. Additional names can be added on a separate sheet of paper.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.

PROGRAM PARTICIPATION CONSENTS
Consent for Emergency Medical Care
In case of an emergency, in the event that I or the Emergency Contact I’ve listed cannot be reached, I give permission to the medical personnel selected by United community Corporations' staff to provide medical treatment required by my child. To provide that medical treatment, I grant permission to release my child’s medical records.
To provide that medical treatment, I grant permission to release my child’s medical records.*

Yes, I give my permission.No, I do not give my permission.
Field Trips/Explorations
I give permission for my child to attend all trips associated with the program. This includes field trips that may involve walking and travel by public transportation and/or private bus. These trips may occur on non-program days. I understand that United Community Corporation will provide appropriate supervision. I will not hold the UCC or program employees responsible for accidents or injuries that may occur.
I give permission for the following information to be made available publicly, at the discretion of United Community Corporation:*

Yes, I give my permissionNo, I do not give my permission
Liability Waiver
I acknowledge that I have complete understanding of the potential risk associated with this activity, including injury and death, and I voluntarily agree to assume all such risk. I hereby release, discharge, indemnify, and agree to hold all agencies, its officers, agents, and employees, harmless from and against any and all liability, claims, actions, suits, damages, losses, or injuries of any kind, nature or description, including without limitation personal injuries and / or death, medical expenses, and economic damages arising or claimed as a result of any act or omission related to the program(s) offered by any affiliated program.
Signature*

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Media Release
Photographs/Video/Internet I hereby give permission for my child’s photograph to be taken and for him/her to be captured on video in connection with the activities of United Community Corporation and to be used in newspaper and magazine articles, on television and other presentations concerning the program, or on the internet. I understand that my child would only be identified by first name, if at all. I understand that my child, identified only by first name or as a member of a group, may also be included on video streams of events over the Internet that are organized and supervised by United Community Corporations’ staff.

I give permission for the following information to be made available publicly, at the discretion of United Community Corporation:
- My child’s first name and/or picture
- Video of students in a group
- My child’s intellectual property (such as artwork, poetry, essays, performances, etc.)
I consent to the above media release:*

YesNo
Signature*

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Purpose

United Community Corporation requests your permission to collect and use information about your child’s participation and performance in After-School programs as well as in school. United Community Corporation would like to use this information about your child to examine the influence of United Community Corporation’s programming on student achievement and engagement both during and after your child’s participation (e.g., middle school, high school and college).

This information will help United Community Corporation make improvements to its program to have an even greater impact on the students served.

Data Collected Directly by United Community Corporation
Information about your child will be collected by United Community Corporation directly or by evaluators or researchers contracted by United Community Corporation.

By proving your consent, the following information will be used for program evaluation:
▪ Information about your child’s background obtained from this enrollment form.
▪ Information collected by United Community Corporation about your child’s program attendance, his or her performance on academic skills assessments conducted during the After-School program, and his or her survey responses.

Data Obtained from External Sources
By providing your consent, electronic data, records, and/or documentation about your child will be shared with United Community Corporation by your child’s school, school district, state Department of Education, or the National Student Clearinghouse (a national database of students’ college enrollment and completion). This information describes your child’s demographics, school enrollment and attendance, program participation, in and out of school suspension records, and academic performance (including course grades and state test scores) starting in grade two (prior to your child’s enrollment in United Community Corporation) and enrollment in elementary school, middle school, high school and college. United Community Corporation will collect your child’s state assigned or locally assigned student identification number from your child’s school to be used to access these academic records.

How Information is Used
The only persons authorized to access your child’s information will be trained United Community Corporation staff, contractors, and/or trusted partner organizations who have agreed in writing to maintain the confidentiality of student information as required by the Family Educational Rights and Privacy Act (FERPA). United Community Corporation may use or disclose information in aggregate form to further the purpose discussed above. However, no child will be identifiable through information provided in any report or public document.

Consent to Release Data for Program Evaluation
Please indicate by checking a box below whether you agree to allow United Community Corporation to collect and use information about your child in connection with the purpose described above. Your child may participate in After-School programming whether or not you provide this consent. You may revoke your consent to share data for this evaluation at any time.

If you have any questions or if you would like to revoke consent for this program evaluation please contact Rhonda Battle, at (973) 642-0181, ext. 9957 or at rhonda.battle@uccnewark.org.
I consent to the above data release:*

Yes, I give my consent to UCC’s collection and use of information about my child for this purpose.No, I do not consent to United Community Corporations’ collection and use of information about my child for this purpose.
Signature*

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21st Century Program Application

Student Information

2nd Student Information

Demographic Data

First Aid & Medical Care

Transportation

Primary Parent/Guardian Information

Secondary Parent / Guardian

Emergency Contact Information

Child Release Contacts

PROGRAM PARTICIPATION CONSENTS

Liability Waiver

Media Release