University Settlement Expanded Day Program Student Enrollment Form School Year 2021-2022

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

WELCOME,
It is with great pleasure that we welcome you to University Settlement Expanded Day Program at The Middle School for Media, Law and Fine Arts!

Email *

Student Information

Student Name *

First and last name

Email *

Date of Birth *

YYYY

What grade are you in?

6th Grade

7th Grade

8th Grade

Clear selection

Race/Ethnicity

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Asian

Black/African American

Hispanic/Latino

White

Middle Eastern

More than one race

Other

Clear selection

Gender *

Female

Male

Home Address *

Living Situation

Are you currently in foster care?

Yes

Clear selection

Have you ever been in foster care?

Yes

Clear selection

Are you currently homeless?

Yes

Clear selection

Have you ever been homeless?

Yes

Clear selection

Household size?

Citizenship

What is your country of birth?

Language(s) Spoken At Home

Are you a citizen of the United States?

Yes

Clear selection

Are you a permanent resident

Yes

Clear selection

Parent/Guardian Information

Name *

First and last name

Relationship to Student *

Phone number *

Email *

Speak English? *

Yes

Other:

Live in same home? *

Yes

Other:

Household Income and Family Background

Does anyone in your household receive public assistance?

Yes

I don't know

Clear selection

If YES, which types?

Food Stamps

Cash Assistance

SSI/SSDI

Medicaid

I don't know

Clear selection

The highest level of education my birth or adoptive mother received is:

Unknown

Less than high school

Completed high school

Completed 2 year college

Completed 4 year college

Completed graduate school

Clear selection

The highest level of education my birth or adoptive father received is:

Unknown

Less than high school

Completed high school

Completed 2 year college

Completed 4 year college

Completed graduate school

Clear selection

Please Provide Your Child’s Medical History

Medicaid Status - Do you have medicaid? *

If you selected "NO" in the previous question, would you like support with completing the Medicaid application? *

Yes

Allergies to food *

Yes

Other:

Behavioral/Emotional

Yes

Other:

Clear selection

Individualized Education Plan

Yes

Other:

Clear selection

Physical Disabilities

Yes

Other:

Clear selection

Corrective Device

Yes

Other:

Clear selection

Asthma *

Yes

Other:

Does your child use an inhaler? *

Yes

Allergies to Penicillin

Yes

Clear selection

Allergy to plants

Yes

Clear selection

Allergy to insect stings

Yes

Clear selection

Convulsions/Seizures

Yes

Clear selection

Hay Fever

Yes

Clear selection

Diabetes

Yes

Clear selection

Does your child have special health care needs that require treatment or medication? *

Yes

Other:

Does your child take medication for any condition or illness? *

Yes

Other:

Are there any activities your child cannot participate in? *

Yes

Other:

If my child requires emergency medical care and I cannot be reached, I give my consent to the University Settlement Expanded Day 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 accepting this form and will continue as long as my child is enrolled in this program.

PLEASE ACCEPT

I AGREE

I DISAGREE

Clear selection

Mental Health Screenings

University Settlement is excited to share with you that we are able to support your scholar with comprehensive mental health support for the 21-22 school year. This support includes mental health screenings for each scholar, 1:1 and group counseling for scholars, and family counseling services as well.

Do you consent to your child completing a mental health screening? Also, please share if you consent to your child receiving counseling services if needed. *

Student Participation Agreement

I give my child permission to participate in all expanded day program activities, including academic support, enrichment, social development, arts, sports, recreation, fitness and wellness. I understanding that all program activities will be supervised by University Settlement. I agree that University Settlement staff may meet my child’s attendance, achievement and progress with appropriate.

Yes

Clear selection

I give my child permission to walk home alone at dismissal.

Yes

Clear selection

My child will be picked up by me or one of the following individuals:

Please include: Name, relation to student, phone number

Consent and Release Agreement

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 University Settlement Society of New York. I also grant University Settlement Society of New York 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 University Settlement Society of New York and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.

I AGREE

I DISAGREE

Clear selection

I affirm that I am the legal parent/guardian for the child named on this form, and consent to their participation in the program *

I AGREE

I DISAGREE

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Middle School of Media, Law & Fine Arts. Report Abuse

Forms