English
Gardner Pilot Academy/YMCA
Summer Academy
2013
For more information regarding the summer program please call
Ari Fleisher @ (617) 635-8365
Summer Program Orientation
Wednesday June 12th, 6-6:30PM in the GPA Auditorium
CHILD INFORMATION
Child’s Name / NicknameDate of Birth / Gender / Age / Grade
Home Address / Phone
DESCRIPTION OF CHILD (Required by the MA Department of Early Education and Care)
Eye Color / Hair Color / Skin ColorPrimary Language / Ethnic Origin
Height / Weight / Identifying Marks
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name / Parent/Guardian NameRelationship to Child / Primary Language / Relationship to Child / Primary Language
Home Address
City Zip / Home Address
City Zip
Home Telephone Cell / Home Telephone Cell
Email Address / Email Address
Business Address
City Zip / Business Address
City Zip
Occupation / Occupation
Work Hours / Work Phone / Work Hours / Work Phone
SCHOOL INFORMATION
Child’s School / School AddressSchool Office Phone / Dismissal Time
Does your child have an I.E.P. (Individual Education Plan) or 504 Plan? _____ Yes _____ No
If yes, please provide a copy to the program.
Parent Signature: ______Date: ______
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CHILD’S MEDICAL INFORMATION
INSURANCE INFORMATION / MEDICAL HISTORYPlease write “NONE” if there are none.
Child’s Name / Date of Birth / Allergies / Reactions / Treatment
Medical Insurance Company / Policy Number / Special Disabilities / Needs /
Chronic Health Conditions / Current Medications:
Yes No
Home ______
School ______
Program ______
Other Coverage (Include Dental) / Emergency Medical/Dietary Information/Religious Restrictions
Child’s Physician / Phone / Address / Behavioral Issues
Child’s Dentist / Phone / Address / Other Emergency Health Concerns
Documentation of a physical examination, immunization record, and lead screening is on file at my child’s school ______
Parent Initials
MEDICAL TREATMENT CONSENT
I hereby authorize certified staff of the YMCA of Greater Boston to give First Aid and CPR to my child as needed. In the event of an emergency, I hereby authorize the program staff to have my child transported to the nearest medical facility or to ______and secure necessary medical treatment including, but not limited to: hospitalization, injections, anesthesia and/or surgery. In the event that I cannot be reached, I hereby give permission to the physician attending to my child to secure and administer treatment as necessary. I understand that the staff will make every effort to notify me of the emergency immediately.Child’s Name: ______
EMERGENCY CONTACTS*
Please list three additional individuals to be contacted in an emergency and non-emergency, if you cannot be reached. Please note that persons listed as “Emergency Contacts” are automatically authorized to pick up your child from the program.Name / Relationship / Address / Home Phone / Work Phone / Cellular Phone
Name / Relationship / Address / Home Phone / Work Phone / Cellular Phone
Name / Relationship / Address / Home Phone / Work Phone / Cellular Phone
PICK-UP AUTHORIZATION
Please list below individuals who are authorized to pick up your child from the program, but would not be contacted in case of emergency. (Example: coach, neighbor, etc.)Name / Relationship / Address / Home Phone / Work Phone / Cellular Phone
Name / Relationship / Address / Home Phone / Work Phone / Cellular Phone
*Biological parents and legal guardians listed on enrollment forms are automatically authorized to pick up your child unless the program is given a copy of a current court ordered custody agreement or restraining order. All individuals authorized to pick up your child from the program must be at least 16 years of age. A license or other positive proof of identification must be shown at pick-up time. If you wish to change, add, or delete any of these authorizations, you must do so in writing. Please note below any special instructions regarding these individuals.
Child’s Name:
Parent Signature: ______Date: ______
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Child’s Name: ______
PROMOTIONAL RELEASE
I hereby grant consent and authorize the use of photographs, slides, videotapes and film of my child participating in YMCA activities for commercial and art purposes in any medium of advertising, communication, publication or publicity that will promote YMCA programs and services, and/or recognition of participants. I understand that the YMCA is a non-profit organization.Parent/Guardian Signature: ______Date: ______
SUPPORT STAFF CONSENT
YMCA programs have support staff that consist of resource advisors, family support specialists, and social service staff. In addition, student interns and/or volunteers may work within the program. I give permission for my child to interact with these support staff.Parent/Guardian Signature: ______Date:______
OFF-SITE ACTIVITIES
I hereby grant consent for my child to (Check all that apply)__X__ utilize local YMCA facilities
__X__ take walks in local neighborhoods and to parks within a mile radius of the center
__X__ visit the following designated off-site activities/locations:
Smith Park Charles River Park Honan-Allston Library ______
(List of sites visited regularly by children within the program)
I understand that any other activity destinations or field trips will require my written permission.
Parent/Guardian Signature: ______Date: ______
WADING/SWIMMING CONSENT
My child’s swim level is _____ non-swimmer _____ beginner ____ intermediate (may use deep end after testing) ____ advanced (may use deep end after testing)I hereby grant consent for my child to participate in wading/swimming activities in life guarded locations, including at the YMCA. My child may also engage in sprinkler play under YMCA staff supervision.
Parent/Guardian Signature: ______Date: ______
PERSONAL SAFETY CURRICULUM
Our teachers are trained to use the Talking About Touching: A Personal Safety Curriculum in our programs. This curriculum teaches children skills that will help keep them safe from dangerous or abusive situations. Children also learn to ask for help when they need it. If you have questions or concerns about the program please speak with your Site Director.I hereby grant consent for my child to participate in the Personal Safety Curriculum.
ARRIVAL
/DEPARTURE
My child will arrive at the YMCA program by:_____ Public Transportation
Describe: ______
____ Walking (check one)
____ Supervised
____ Unsupervised
___X__ Parent/Authorized Release Drop-Off
_____ Other
Please Specify: ______
_____ N/A / My child will depart the YMCA program by:
_____ Walking (check one)
_____ Supervised
_____ Unsupervised
___X__ Parent/Authorized Release Pick-Up
_____ Other
Please Specify: ______
_____ N/A
Arrival Time: 8:00 / Departure Time: 5:30 pm
Child’s Name:
I give permission for my child to use the specific hand sanitizer checked below. I understand that they will still be required to wash hands with soap and water before eating, after using the bathroom, and if they sneeze into their hands, and they will not be required to use hand sanitizer at the program.
Parent Signature: ______Date: ______
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_____Purell
_____Germ-X
_____Soft Soap
_____Sany Hands
Parent Signature: ______Date: ______
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_____ Any Brand
_____ Other
____I do not give my child permission to use any hand sanitizer when at the YMCA. I understand that s/he will be required to use hand sanitizer if s/he is away from the building where there is no access to soap and water, unless both parent and physician note a medical reason to avoid usage.
I understand that by signing below, I absolve the YMCA of Greater Boston of any responsibility, should a reaction occur from said product. I also understand that I will need to provide the above product, in its original container/box for use on my child.
Parent Signature: ______Date: ______
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I give permission for the staff at the Gardner YMCA to apply the following OTC (over the counter) topical treatments/ointment to my child:
Parent Signature: ______Date: ______
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_____ Sunscreen
_____ Bug Spray
_____ Petroleum jelly
_____ Aquaphor
_____ Lotion – Brand:______
_____ Other:______
Parent Signature: ______Date: ______
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_____ All of the above
Application Instructions:
Child’s name:
I hereby authorize the staff from Gardner Pilot Academy and the staff professionals of the Huntington Avenue YMCA to release and share information on my child, including, but not limited to attendance, report cards, IEPs, progress reports and behavior charts. It is my understanding that the content of all records will remain confidential and will be used to enhance my child’s academic performance and overall afterschool/summer experience. No school records may be released to any other person or agency without by full permission.
Also, I will have the option of inviting afterschool staff members to attend in-school conferences and to meet with school teachers and/or staff members to discuss my student’s progress per my request.
Child’s Name:
CONSENT FOR CHILD TO LEAVE
THE GARDNER PILOT ACADMY AFTER SCHOOL PROGRAM
102 CMR 7.09(3)(b)
My child has permission to arrive late or to leave the Gardner YMCA Afterschool Program for the following reasons/activities:
à To work with or receive extra help/tutoring from Gardner teachers or staff as needed Monday through Friday.
à To participate in school-run clubs and activities with Gardner teachers, staff, volunteers and community partners such as chess club, drama, music, art, etc. on the days that they are offered.
à Stay after school with classroom teachers or Gardner staff any time/day to “help” with special projects and activities.
à Other Activity/Supervisor/Location (include start/end dates and times:______
______
______
______
All of the above activities will take place within the school building or outside on school property.
I understand that it is the responsibility of the Gardner Staff, classroom teachers, or specific activity coordinators, to sign my child in and/or out of the after school program when participating in the above activities
I recognize that YMCA staff will not be supervising my child while s/he is participating in the above activities.
I understand that the YMCA is not responsible for my child when s/he is participating in the above activities.
This permission is in effect for the Summer 2013.
Child’s Name:
Parent Signature: ______Date: ______
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