This Camp must comply with the regulations of the Massachusetts Department of Public Health and be licensed by the Cambridge Board of Health.
Cambridge Youth Enrichment Program
Jefferson Park • Newtowne Court • Roosevelt Towers
Phillips Brooks House •One Harvard Yard • Cambridge, MA 02138-6565
(617) 495-5526 • Fax (617) 496-2461
February 2016
Dear Parents,
The Cambridge Youth Enrichment Program (CYEP) is looking for campers for summer 2016! CYEP is one of the most affordable summer camps in theCambridge area and has operated in Cambridge for the past 33 years. This summer, camp will tentatively run fromMonday, June 27th through Friday, August 12th, 9am to 4pm, Monday throughFriday. The start and end dates of the camp are subject to change pending site negotiations. Each day of camp will include academic enrichment and fun and educational field trips. Our goal this summer, as always, is to provide a safe space in which campers can learn and grow both academically and personally. We hope that you and your children will join us for what promises to be an amazing summer with CYEP!
Please contact us at if you are interested in enrolling your child in camp this summer. We will send you applications for your children only after you have contacted us to say that you are interested, or you can go online and fill out an application at programs.pbha.org/sup/campers.These registration forms will be due back to us Friday, April 1st.Registration materials, once requested and received, can be returned in person or by mail to the Phillips Brooks House in Harvard Yard (mailing address: Phillips Brooks House, c/o CYEP), One North Harvard Yard, Cambridge, MA 02138). Registration materials must be completed in full, and to ensure that you return the appropriate materials by the deadline, a registration checklist is provided on the reverse of this sheet. Families who return incomplete registration materials will not be considered for Summer 2016.
If you would like to register multiple children, you must fill out a registration packet and submit immunization records for each participating child. Please note that in order to register with CYEP, your child must currently be in senior kindergarten through Grade 7. If your child is currently in junior kindergarten or grade 8, he or she is not eligible to participate in CYEP this summer.
The 2016 CYEP camper fee is $130 per camper for the first child in a family and $115 per camper for each additional child.This is one of the most affordable summer camps offered in Cambridge. Upon being admitted to the camp you will be asked to send a check or money order to CYEP for the amount owed. All camper fees must be submitted prior to the first day of camp.
Thank you for expressing interest in CYEP. Wehope to see your child at camp for Summer 2016!
Sincerely,
Catherine Nakato and Javion Rookard
Co-Directors, CYEP
Summer 2016 Registration Form
Name of child: ______
Date of birth: ______Age: _____ Sex (circle one):MF
Child’s race/ethnicity (optional): ______T-shirt size: ______
Number of years (if any) child has attended CYEP: ______Site(s) attended (if any): ______
Child’s school: ______Child’s current grade: ______
Teacher’s name: ______
Parent/Guardian #1
Name: ______Relation to child: ______
Address: ______
Street Apt. # City Zip
Mailing address(if different): ______
StreetApt. #CityZip
Home phone: ______Work phone: ______
Cell phone:______Email: ______
Best way/time to reach Parent/Guardian #1: ______
Parent/Guardian #2 (if applicable)
Name: ______Relation to child: ______
Address: ______
Street Apt. # City Zip
Mailing address(if different): ______
StreetApt. #CityZip
Home phone: ______Work phone: ______
Cell phone:______Email: ______
Best way/time to reach Parent/Guardian #2: ______
Does your family qualify for free or reduced lunch? (Circle one)YesNo
Does your family qualify for WIC, EBT, SSI, Section 8, Other Subsidized Housing or any other programs (please specify which ones you qualify for, if any)? ______
Does your child have an IEP (Individual Education Plan) or receive any special services at school (e.g. special education, ILP, Academic Support Services)? (Circle one) Y N
If yes, please describe your child’s IEP or other special services: ______
______
Please rank our sites in order of preference with “1” indicating your first choice. This year we will again divide the Newtowne Court and Roosevelt Towers sites by age rather than geographic location. Children currently in senior kindergarten through grade 4 may attend the Newtowne Court site and children currently in grades 4 through 7 may attend the Roosevelt Towers site. The Jefferson Park site will accommodate children currently in senior kindergarten through grade 7.
____ Jefferson Park (Tentatively at the Maria Baldwin School, North Cambridge)
____ Newtowne Court (Tentatively at the Kennedy-Longfellow School, East Cambridge)
____ Roosevelt Towers (Tentatively at the King Open School, East Cambridge)
Emergency Contact Information
Please list two emergency contacts with complete information. Emergency contacts should be different from the parent(s)/guardian(s) listed on page 1 of this packet.
Emergency Contact #1
Name: ______Relation to child: ______
Address: ______
StreetApt #CityZip
Home phone: ______Work phone: ______Cell phone: ______
Emergency Contact #2
Name: ______Relation to child: ______
Address: ______
StreetApt #CityZip
Home phone: ______Work phone: ______Cell phone: ______
Drop-off / Pick-Up Form
Camp begins at 9am and ends at 4pm Monday through Friday.It is important to arrive on time for drop-off and pick-up out of consideration for the staff of CYEP and the custodial staff of the schools that house our sites. Please note that children are not allowed to be in the school facilities where camp is held before or after camp hours without adult supervision. Because spots in CYEP are always in high demand, it is expected that CYEP campers should be attending camp each day. If campers are to miss more than four days due to vacation, CYEP reserves the right not to admit that applicant.
How will your child get home from camp?
My child will walk home from camp alone.
(Please note that we will not allow children under the age of 10 to walk home alone.)
My child has permission to walk home with the following campers:
Name: Relation to child:
______
______
______
I will pick my child up after camp.
The following people have permission to pick my child up from camp:
Name: Relation to child:
______
______
______
Other arrangements (please specify):
Summer 2016 Release Form
I am the parent and/or legal guardian of ______(child’s name). I understand that the Phillips Brooks House Association’s professional staff and the staff of the Cambridge Youth Enrichment Program (CYEP) will maintain files containing academic, behavioral, and health related information about my child. I also understand that the aforementioned people may establish both written and verbal correspondence with my child’s teacher and/or guidance counselors in regard to my child’s progress and well-being. This correspondence may involve the sharing of behavioral reports and academic report cards. I grant the staff of CYEP permission to share with each other any information collected in my child’s file. Upon withdrawing my child from the program or upon my child’s completion of the program, I retain any right I may have to gain possession of copies of my child’s file, including any and all copies of the documents in that file which are in the possession of Phillips Brooks House Association professional staff or the staff of CYEP.
I also grant permission for my son/daughter/ward to be included in the documentation of the program, including photographs, video recordings, audio recordings, reproductions of academic work, and written quotations or descriptions of academic activities. I am aware that this documentation material may be edited as necessary. I also understand that the resulting material may be exhibited before the community, school, fundraisers, or other groups or individuals in video, audio, print, or other media formats.
I also give my child permission to participate in this program and all its activities, and to ride in PBHA vehicles.
I release, hold harmless, and agree to indemnify the Phillips Brooks House Association (PBHA), Harvard University, and all Board of Trustees, officers, directors, faculty, staff, representatives, employees, and agents, from and against any present or future claim, loss, or liability for injury to person or property related to my child’s participation in this program.
______
Parent/Guardian’s Name (printed)
______
Parent/Guardian’s SignatureDate
Student’s Name______
Program Name ______
CONSENT TO RELEASE DATA FOR PHILLIPS BROOKS HOUSE ASSOCIATION EVALUATION
Purpose
PBHA requests your permission to use and disseminate information about your child’s participation and performance in PBHA programs as well as in school. PBHA would like to use this information about your child to examine the influence of PBHA’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 PBHA make improvements to its programs to have an even greater impact on the students served.
Data Collected Directly by PBHA
Information about your child will be collected by PBHA directly or by evaluators or researchers contracted by PBHA. The following information will be used for program evaluation and stored in a secure database at PBHA. You consent to this information being used by enrolling in the program:
●Information about your child obtained from their application/registration form(s)
●Information collected by PBHA about your child’s program attendance, his or her performance on academic skills assessments collected as an activity during the PBHA program, and his or her survey responses. Information connected to your child will only be reported externally in aggregate.
Two research organizations – National Institute on Out-of-School Time (NIOST), and Programs in Education, Afterschool, and Resiliency (PEAR) – will have access through what you allow PBHA to access or directly collect of your child’s school information and demographic data like age, race, and gender. These data are confidential and will be used for research only with your consent.
•Researchers and specialists will observe some summer classrooms and activities.
•Assessments such as the Survey of Afterschool Youth Outcomes including Teacher, Staff, and Youth versions of the assessment and the Assessment of Afterschool Program Practices Tool will be used during programming. Students will be asked to fill out a survey called NIOST Survey on Afterschool Youth Outcomes (SAYO-Y). The SAYO-Y is a 10 minute paper or online survey which asks students questions about their program experiences, sense of competence, and future plans. Students will complete the survey once during the last week of the program. Participation in the survey is voluntary and may stop at any time without penalty. A study researcher will train the students on how to participate in the survey. Individual survey responses will not be shared with afterschool program staff, partner organizations, or any other organization or individual. Should you have any questions about this survey, use of these data, or questions about your rights or your child’s rights as a participant in this study, feel free to contact Dr. Georgia Hall at (781) 283-2530 or or Nancy L. Marshall at or (781) 283-2551.
•Some students may be asked to fill out a survey called the Holistic Student Assessment (HSA), which was developed by PEAR (Program in Education, Afterschool and Resiliency). The HSA is a tool that can deepen understanding of students’ social and emotional strengths and needs. Students complete a brief survey about themselves, at least once and as many as two times. Student completion of the HSA is voluntary and students may stop the survey at any time without penalty. Teachers, educators, and support staff will use information from the survey to cultivate the strengths, abilities, and academic success of each student. Teacher, educators, and support staff will keep information from the HSA confidential to protect participants. PEAR reserves the right to use all HSA data for both research and educational purposes.
We will protect your child’s confidentiality
All data collected will be kept confidential. Only group data will be reported publically. The only exception to confidentiality will be in the case of any information disclosed that indicates a child is in any danger. Should that occur, protocols for such disclosure are in place for protection of participants.
Data Obtained from External Sources
By providing your consent, electronic data, records, and/or documentation about your child will be shared with PBHA by your child’s school. School district, state Department of Education, or the National Student Clearinghouse (a database of students’ college enrollment and completion). This information describes your child’s demographics, school enrollment and attendance, program participation, suspension records, and academic performance (including course grades and state test scores) starting in grade Kindergarten (prior to your child’s enrollment in PBHA) and enrollment in middle school, high school and college. Giving your permission allows PBHA to collect and/or use your child’s state or locally assigned student identification number for access to student records.
How Information is Used
The only persons authorized to access your child’s information will be trained PBHA 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). PBHA 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 documentation.
Consent
Please indicate by signing below whether you agree to allow PBHA to collect and use information about your child in connection with the purposes described above during and after participation in PBHA programs. Your child may participate in PBHA and information collected in registration and program activities will be used whether or not you provide this consent. If you have any questions or if you would like to revoke consent for this program evaluation please contact Jesse Leavitt, Coordinator of Training, Reflection and Evaluation, at (617) 495-5526 or a .
PARENT/GUARDIAN SIGNATURE (REQUIRED)
By signing this form below, I acknowledge that I have read, understand, and consent to the above. I understand that I can revoke consent at any time by contacting PBHA.
(If you do not consent to PBHA’s use of information about your child for the purposes described above, do not sign below and discuss your concerns, comments and questions with a PBHA program director or Director of Programs.)
Parent/Guardian Signature (to consent): ______
Parent/Guardian Name (please print):______
Date:______
Summer Swimming and ActivitiesForm
This summer, CYEP will be using MDC pools throughout Cambridge as our primary swimming facilities. Although campers generally go swimming once a week, theyshould bring a swim suit and towel to camp every day.
All pools are staffed by professional lifeguards. Additionally, CYEP staff trained as American Red Cross lifeguards will always be present on field trips to MDC pools and waterfront areas. On the first day of swimming, each child will be evaluated for his or her swimming ability and monitored accordingly. If you have any special concerns or questions regarding your child’s swimming ability, please make note of them at the bottom of this form.
Swimming Waiver
I, ______(parent/guardian’s name), allow my child, ______(child’s name), to participate in swimming activities with the Cambridge Youth Enrichment Program. I have indicated below any restrictions or necessary information concerning my child and his or her swimming ability.
______
Parent/Guardian’s SignatureDate
Can your child swim? (circle one)YesNo
Swimming level (circle one): Beginner Intermediate Advanced
Notes on child’s swimming ability:
Please list any activities that you do NOT want your child to participate in this summer:
Health Information Form
Name of child: ______
Name of parent(s)/guardian(s): ______
Do you have medical insurance? (circle one)YesNo
Name of medical insurance company: ______
Policy number: ______Name of policy holder: ______
Child’s primary care physician: ______
Hospital/health clinic: ______
Telephone number: ______
Address: ______
StreetCityZip
Does your child have any allergies? ______
Is your child being treated for any condition we should know about? ______
______
Health Insurance and Emergency Care Waiver
I am the parent/guardian of ______(child’s name). In case of emergency, I authorize Cambridge Youth Enrichment Program staff to seek any medical assistance that the above named child may require. I understand that, in the case of a medical emergency, my child will be brought to the closest medical facility to receive care. I understand that, if not fully covered by a medical insurance provider, I will be personally responsible for all costs incurred by the care provided.
______
Parent/Guardian Name (printed)
______
Parent/Guardian’s SignatureDate
Medication Form
Is your child on any medication? (Circle one)Yes No
If yes, please list below (attach separate sheet with list of medications if necessary):
______
Name of Medicine Reason for use Dosage per day
______
Name of Medicine Reason for use Dosage per day
If your child needs to take medication during camp hours (between 9am and 4pm), please fill out the following information:
Medication #1: ______Prescription/Non-prescription (circle one)
Dosage: ______Time(s) to be given: ______
Medication #2: ______Prescription/Non-prescription (circle one)
Dosage: ______Time(s) to be given: ______
I give permission to the counselors, directors, and volunteers of CYEP to dispense the medication(s) listed above to ______(child’s name).
______
Parent/Guardian’s Signature Date
______
Doctor’s Signature Date
Camper Information and Parent Input Form