Program Application
S.T.E.A.M. 1 Week Program (Monday-Thursday)
Sign in to Google to save your progress. Learn more
Program Information
What session will you attend? (Please check ONE) *
Child Information
Child's Name *
Child Gender *
Child Date of Birth *
MM
/
DD
/
YYYY
Grade Child is currently in *
Child's Race *
Do you have other children in New Bedford Schools? *
Parent/Guardian Information
Name of Parent (First, Last) *
Relationship to Child *
Does the child live with this person? *
Address, City & Zip Code *
Home Phone
Cell Phone *
Email
Employer Name
Employer Address
Employer Phone
Best Time to Call *
Preferred Method of Contact *
Parent/ Guardian #2 Name
Relationship to Child
Does the child live with this person
Clear selection
Address, City & Zip
Home Phone
Cell Phone
Email
Employer Name
Employer Address
Employer Phone
Best Time to Call
Preferred Method of Contact
Clear selection
First Aid & Emergency Medical Care
Does your child have allergies? If yes, please specify in the other box. *
Does your child have a special diet? If yes, please specify in the other box. *
Does your child take any medications? If yes, please specify what medication, why they take it and the time taken. *
Does your child have any limitations or concerns? If yes, please specify. *
Does your child have any chronic health conditions? If yes, please specify. *
Identifying Information of your Child
What is your child's Eye Color? *
What is your child's skin color? *
What is your child's hair color? *
What is the height of your child? *
What is the weight of your child? *
Does your child have any identifying marks/features? *
I AGREE and authorize  staff and volunteers affiliated with PAACA’s Insight Youth Services Program to provide my child with first aid when needed. I understand that in the event of an emergency requiring medical attention for my child every effort will be made to contact me using the information I have provided. However, if I cannot be reached, I hereby authorize Emergency Response Personnel to transport my child to the nearest medical facility and to secure necessary medical treatment for my child. I will NOT hold PAACA’s organization, the INSIGHT program, and the school grounds, the City of New Bedford or any other program funders or facilitators responsible for any and all accidents or injuries that may occur. I agree to be responsible for any charges incurred in the rendering of care and treatment for my child. (By typing your name below, you are electronically signing your agreement to the above.) *
Additional Emergency Contacts (must be 18 or older)
In addition to you.
Name of Emergency Contact #1 (first and last) *
Address of Emergency Contact #1 *
Relationship of Emergency Contact #1 to your child *
Phone number of Emergency Contact #1 *
Name of Emergency Contact #2 (first and last)
Address of Emergency Contact #2
Relationship of Emergency Contact #2 to your child
Phone number of Emergency Contact #2
Transportation
Transportation *
Please indicate who is authorized to pick up your child from the INSIGHT after school program if different from Emergency contacts and parents/ guardians. Only listed people and parents / guardians listed above will be permitted to pick up your child. ALL persons are required to produce a picture ID upon pick up. For your safety and security, No exceptions will be made. (By typing your name below, you are electronically signing your agreement to the above.) *
Name (First, Last)
Home Address
Relationship to Child
Phone 1
Phone 2
Name #2 (First, Last)
Home Address
Relationship to Child
Phone 1
Phone 2
Participation in Activities
Field Trips/Explorations: I give permission for my child to attend all field trips associated with the INSIGHT summer S.T.E.A.M. program. This includes explorations, cooking, service projects and field trips that may involve walking and travel by public transportation and/or private bus. The INSIGHT staff will provide appropriate supervision.  By typing my name below, you are electronically signing, and you agree to not hold the program responsible for accidents or injuries that may occur during these excursions. Students will be provided with informational flyers on upcoming field trips with advance notice.  You may choose to not participate however there will be no program coverage for your child that day. Failure to communicate non-participation implies consent to attend the scheduled event / field trip. Please call at least 48 hours prior to any field trip with questions, concerns or special considerations. *
Photographs/Video/Internet: By typing you name below, you are electronically signing and you are giving permission for your child’s photograph to be taken in connection with the INSIGHT summer S.T.E.A.M. program and to be used in newspaper articles, website, television or other public presentations concerning the program. The best way to acknowledge youth doing great things is through the media. We realize there may be certain circumstances where this may not be appropriate for some participants. Please simply write NO PICTURES OR COMMENTS ALLOWED TO MEDIA in the parent signature line below. *
Behavior: By typing your name below, you are electronically signing. I understand that the INSIGHT after school program is responsible for maintaining a safe educational environment and if my child’s behavior is disruptive or in violation of the INSIGHT summer S.T.E.A.M. program rules for student behavior he/she may be dismissed/expelled from the program.   I am aware that my child has signed a behavioral management contract stipulating the rules for conduct and behavior.  I also am aware that I can obtain a copy of that agreement upon request.I understand that program suspensions may require a parental meeting to resume participation; however some conduct / behavioral issues are grounds for immediate expulsion. I understand that physical and other types of violence and/or possession of illegal materials of any kind will result in an automatic expulsion from the program. Other behaviors may also result in suspension / expulsion upon review of the facts as decided among INSIGHT staff and personnel. *
Snacks, Cooking and Food Allergies: As part of the each day of the INSIGHT summer S.T.E.A.M. program, a snack will be provided. There will also be an opportunity for participants to learn basic cooking skills and different cultural recipes through our cooking lessons within the program.  I give permission for my child to have the daily snack and participate in any food related / cooking activities.  If you do not wish for your child to participate in ANYTHING pertaining to snacks, cooking or food please write "NO SNACKS, COOKING OR FOOD." *
Participation in Evaluations
External/ Internal Evaluation
I understand that an evaluation of the INSIGHT after school program is being conducted to learn the effects of after school services on students and families and to find ways to improve the INSIGHT after school program. INSIGHT staff will collect evaluation data and conduct random informational sessions with students to gather information intended to help promote future enhancements to the program model and academic success.
I understand that, as part of the evaluation, information about my child’s enrollment, attendance, and school report cards may be obtained from my child’s school and school district. I also understand that information about my child’s participation and progress in the INSIGHT after school program may be obtained, and that my child and I may be asked to complete a survey and/or participate in a group interview about experiences with this program. The INSIGHT program is funded in part by the City of New Bedford Invest In Kids Initiative. I agree to participate in a short survey about my experience and that of my child at the end of each session. I acknowledge that I will receive this survey from the City and that I will complete it in a timely manner to additionally assist with program enhancements, modifications and additional future funding. I understand that any information collected about my child and me will be known only to those responsible for collecting and analyzing evaluation data and that our names will not be used in any report. By signing this I am allowing the NBPS to release my child’s report card and attendance records for the school year they are involved in the program.

(By typing your name below, you are electronically signing your agreement to the above.) *
Social Emotional Health
Do you know who to contact at school if you need to talk to someone? *
Are you involved in any other activities/ groups? If yes, please type in other. *
COVID-19 Response Protocal
- Please call the office at 508-979-1580 morning of program if your child is sick and will not be attending.
- If your child has a pending COVID test or is getting tested, please contact us and do not bring them to program while quarantined.
-We are following all local and state guidelines.
- All surfaces have been disinfected and disinfected with each use.
- Hand sanitizer and frequent hand washing will be part of our routine.
- There will be no groups larger than 15 (that includes staff)
- Van transports will be done with no more than 15 people (including the driver) in the van per transport.

Please call 508-979-1580 or email tswanbell77@gmail.com with any concerns or questions.  
We ask that you inform us of any medical concerns and instill in your youth the importance of staying safe and healthy.  

Please electronically sign on the next page to signify that you have read the protocol and agree to follow the requirements.

Please electronically sign (by typing your name) below to signify that you have read the protocol and agree to follow the requirements. *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms