Wagner OST
/ Administrative Offices:
5548 Chestnut St
Philadelphia, PA 19139
Mailing Address:
Post Office Box 2061
Philadelphia, PA 19103 / Email:
Website: www.idaay.org
Welcome to IDAAY OST @ Wagner Middle School Afterschool Program 2016 – 2017!
IDAAY OST @ Wagner Middle Schoolis comprised of activities designed to provide youth with academic enrichment and improved literacy. Each activity is tailored to specific grade levels to increase comprehension and enhance academic performance.
Our program is committed to enriching youth through Project Based Learning (PBL). PBL activities are designed to provide practical opportunities for goal setting, personal accountability and opportunities to work with others to improve interaction with both peers and adults. All youth are encouraged to develop positive habits including: timely attendance, following directions, active listening and being courteous and respectful towards others.
IDAAY’s OST @ Wagner Middle School is aKeystone Stars Certifiedfacility.Keystone STARSPerformance Standards reflect research-based indicators to improve outcomes for children.A Keystone STARS designation informs families that the director and staff are committed to enhancing quality for the children and families in the program.
Priority is given to homework as the first major activity of the program day. When necessary, youth are given group or individual tutoring support. Our instructors communicate regularly with school teachers to give and receive feedback concerning homework help for program youth.
Over 76% of our youth consistently make Honor Roll.
We also provide:
· Healthy Snacks
· Engaging Academic Enrichment – Project Based Learning
· Sports, Music, Drama Clubs!
· Fun Trips… Some FREE with perfect attendance!
The program is free for all parents of youth in grades 6th through 8th. In this packet is an application that must be completed in full in order for your youth to attend the program. All information requested in the application is required to comply with state and PHMC guidelines. You are also required to provide health assessment completed within 30 days of enrollment: you may obtain the last one from your child’s physician. Lastly, the emergency contact form must be updated every 6 months.
We look forward to working with your youth and having a successful year. If you have any questions, please contact Assistant Director, SiddeeQah Jones, by phone at (215) 276-5354 or by email at .
http://idaay.org/our-programs/ost-at-wagner-middle-school/
APPLICATION CHECKLIST
Thank you for your interest in the IDAAY 2016-2017 OST After School Program @ Wagner To help you in the application process, we are providing this checklist so that we can make sure that you complete/provide all of the necessary forms for the first step in the application process.
Youth Name ______
Please check the following once it has been completed/provided:
□ Item 1 – Program Application /Please provide a copy of most recent report card
(Both Youth and Parent/Guardian Social Security Numbers are mandatory for funding purposes only)
□ Item 2 – Service Agreement
□ Item 3 – Informed Consent Form
□ Item 4 – Permissions Form (a)
□ Item 5 – Permissions Form (b)
□ Item 6 – IEP Information Sheet
□ Item 7 – Emergency Contact/Parental Consent Form
□ Item 8 – Youth Health Assessment Form/ Immunization Records
□ Item 9 – Parent Memorandum of Understanding
□ Item 10 – Student Contract
□ Item 11 - City of Philadelphia Consent to Release Information
□ Item 12 - PHMC Consent to Release Information
(Needs to be completed within 30 days by youth's Doctor or a copy of a recent health assessment dated no longer than a year, can be submitted.)
Institute for the Development of African-American Youth, Inc. (IDAAY)
IDAAY OST 2016
ENROLLMENT APPLICATIONProgram Name/Agency Name: IDAAY OST / Application Date:
Youth Name: / Age: / Date of Birth:
Social Security #: / Gender: ______Male
______Female / County Identifier
51
Race/Ethnicity: ____ African American/Black _____ Asian
____ Caribbean/African Immigrant _____ Hispanic/Latino
____ European American/White _____ Pacific Islander
____ Other (please specify):______
Special Needs: ____ Deaf/Hearing Impaired _____ Developmentally Delayed
____ ESL/ELL _____ Behavioral/Mental Health
____ Substance Abuse _____ Homeless
____ Other (please specify):______
School Name: / Grade:
Student ID # (located on school report card):
School Address: / Phone #:
Parent/Guardian Name: / Social Security # of person with whom youth is living:
Your Relationship to Youth (mother/father, grandparent, guardian, etc.): / Person with whom the youth is living:
Home Address: / Zip Code:
Home Phone#: / Cell Phone#: / Email Address
FUNDING SOURCE ELIGIBILITY STATUS (MUST BE COMPLETE)
Annual Household Income: $ / # of People in Household:
Means Test for “Services For Non-Placed Children”
1. Is the youth/family receiving TANF (Cash Assistance) SSI Food Stamps Medicaid None Case#:______
If services are being received, proceed to question 5 and answer “Yes.” If response is “None,” proceed to question 2.
2. Is the child a U.S. Citizen or qualified alien? Yes No; if yes, indicate source of citizenship information:
Birth Certificate INS Eligibility for TANF, SSI, Food Stamps, or Medicaid or Self-Declaration
3. Is the youth under 18 years of age? Yes No
4. In order to be eligible for “services for non-placed children,” a child’s/family’s gross income may not exceed 235% or400% of the Federal Poverty Level (FPL) for the family unit size. Using Table on the following page, provide a “YES” or “NO” in Column 4 in the corresponding row for the family size as to whether the youth/family’s income is less than the annual or monthly amount for the family size. (Family unit includes biological or adoptive parents, specified relatives, or non-relative court designated legal custodians and full, half, and/or adopted siblings living in the home under the age of 18 plus the TANF youth). This is a self-declared means test. No verification except the response of the family is required.
5. Is the child living in the home of a parent, other adult specified relative or a court designated legal custodian?
YES NO
6. Is the child/family receiving one of the benefits in question 1 or answers to questions 2, 3, 4 and 5 are ALL “YES?”
YES NO
If “YES,” the child is eligible for TANF funding for services for non-placed children.
MEANS Test Administered for: Month:______Year:______
7. Name of staff person administering this means test (Please type or print) Christian Bailey
8. Date this form was completed: ______
******FOR OFFICE USE ONLY*****
TANF Eligible: _____ Yes _____ No
If Yes, check all that apply: _____ Assistance Recipient _____At or below 400% of FPL
_____ At or below 235% of FPL (Federal Poverty Level)
_____ Other Status (please explain):______
______
*Staff must verify all required paperwork for eligibility status accompanies this form **
Application Reviewed by Staff: / Date:
Institute for the Development of African-American Youth, Inc. (IDAAY)
IDAAY OST 2016
PO Box 2061 ¨Philadelphia, PA 19103 ¨ Tel: (267) 602-6784 ¨ Fax: (215) 276-5357
SERVICE AGREEMENT
Please Sign ALL FIELDS where an X is indicated
55 PA CODE CHAPTERS 3270.123 & 181 (C); 3280.123 & 181 (c) ; 3290.123 & 181 (c)
name of childfee amount
N/A / per-day-week
N/A / day payment to be made:
N/A
Services to be provided as part of the day care fee (examples; transportation, care, meals, etc.)Please check all that apply
After School Program
Please check days that youth will be attending the program:
Monday
/ Tuesday
/ Wednesday
/ Thursday
/ Friday
child’s arrival time / child’s departure time / person(s) designated by parent to whom child may be released
Name Address Telephone #
late fee
N/A / per min-hr
N/A
Please answer the following questions:
How many people are in your household? / How many youth are you registering for the program?
What is your annual income? / Did you provide proof of income?
Did you include a Health Assessment form? / Did you provide a copy of your youths most recent report card?
I, the parent/guardian;
received complete written program information at the time of enrollment. (3270.121, 3280.121, 3290.121)
agree to update the emergency contact/parental consent form information whenever changes occur or every 6 months at a minimum. (3270.124, 3280.124, 3290.124)
______X______
signature-operator date signature-parent or guardian date
date of child’s admission / X
date of withdrawal / signature-parent or guardian date
Institute for the Development of African-American Youth, Inc. (IDAAY)
IDAAY 2016 OST
PO Box 2061 ¨Philadelphia, PA 19103 ¨ Tel: (267) 602-6784 ¨ Fax: (215) 276-5357
Informed Consent Form
By signing this form, I voluntarily consent to and give authorization for the following:
a. Allowing my youth to be supervised by IDAAY After School Program staff
b. Allowing my youth to answer questions about home, school, and/or the community
c. Allowing my youth’s school to provide records and information to IDAAY
I understand that Buckley Amendment to the Family Education Rights and Privacy Act of
1974 guarantees that my youth’s academic record will not be discussed with or disclosed to any third party without my written consent. I hereby authorize officials of the School District of Philadelphia or other school entities to release my child’s educational records only to IDAAY and to any corresponding partner agency which I/my youth may be referred.
I understand that this information will not be provided to any entity other than those indicated above. I also acknowledge that I have received information from IDAAY After School Program staff about parents and children’s rights and responsibilities. Furthermore, I agree not to hold the City of Philadelphia, the School District of Philadelphia and IDAAY responsible for injuries and/or damages to my child’s persona and /or property.
Youth Name:
Date of Birth: Social Security#:
School: Grade:
Time youth will arrive at the IDAAY OST Program: 3PM
Time youth will depart from the IDAAY OST Program: 6PM
This consent and authorization will remain valid indefinitely unless otherwise requested in writing.
Parent/Guardian Signature: Date:
Provider Witness Signature: Date:
Institute for the Development of African-American Youth, Inc. (IDAAY)
IDAAY 2016 OST
PO Box 2061 ¨Philadelphia, PA 19103 ¨ Tel: (267) 602-6784 ¨ Fax: (215) 276-5357
Permissions Form(a)
_____ School Records, Report Cards, Health Assessment Release
(initial)
I give permission for ______School to release to IDAAY
my youth’s school records, including report cards, health assessments, and other
pertinent information. I understand that these records will be used for evaluating my
child and tracking improvements in school throughout the duration of his/her program
enrollment. The documentation of my youth’s health history should be correct and
complete; however, if it is not, I will provide further information/documentation is
requested.
_____ Medical Assistance
initial)
In case of an emergency requiring medical attention, I, ______,
Parent/Guardian Name)
Parent/guardian of ______, give permission for IDAAY
(Print Youth Name)
After School Program staff to secure proper medical assistance for my youth. As I
realize program Staff cannot administer medication, in the event that I cannot be
reached during a medical emergency, I give permission to the Physician selected by IDAAY
program staff to secure and administer treatment, including Hospitalization, for my youth.
Please indicate any conditions/limitations we should be aware of (activities, behavior, medical, etc.):* Note: If the youth requires exclusively extensive special attention, he/she may be unable to attend the program.
_____ Photographic Release
(initial)
I give permission for my youth to fully participate in all IDAAY Summer Camp Program
activities and special events without restriction, unless otherwise stated. I further
give permission for my youth to be photographed while participating in program activities,
and for the resultant photographs to be appropriately used by IDAAY on its websites, as
well as in brochures, newsletters, presentations and other marketing materials developed
to promote interest in IDAAY programs/initiatives.
Institute for the Development of African-American Youth, Inc. (IDAAY)
IDAAY 2016 Summer Camps
PO Box 2061 ¨Philadelphia, PA 19103 ¨ Tel: (267) 602-6784 ¨ Fax: (215) 276-5357
Permissions Form(b)
By initialing each section, signing and dating this form, I acknowledge the foregoing permissions
For ______as applicable throughout the duration of my
(Print Youth Name)
Youth’s enrollment in IDAAY’s Summer Camp Program. I also understand this form will
be photocopied and used for field trips, special activities/events, etc.
Parent/Guardian Signature: ______Date:______
Home Phone: ______Cell Phone: ______
Provider Witness Signature: ______Date: ______
Provider Agency Name: Institute for the Development of African American Youth
Institute for the Development of African-American Youth, Inc. (IDAAY)
IDAAY 2016 Summer Camps
PO Box 2061 ¨Philadelphia, PA 19103 ¨ Tel: (267) 602-6784 ¨ Fax: (215) 276-5357
INDIVIDUALIZED EDUCATION PLANS (IEP) &
INDIVIDUALIZED FAMILY SERVICE PLANS (IFSP)
INFORMATION SHEET
Because of the diverse set of needs of the youth in our program, it is important to gather as much information about the best ways to assist each youth. IEP’s and IFSP’s are created by service providers working with youth with special needs and include this information. The Keystone STARS Performance Standards therefore require each provider to request copies of IEP’s and IFSP’s for the youth in their care.
The information found on an IEP/IFSP is protected by privacy laws including the Health Insurance Portability and Accountability Act (HIPAA). Releases of information may also be required to speak to members of a child’s treatment team. Professional development regarding privacy issues, and HIPAA in particular, is highly recommended.
Parent/Guardian Sign – off Sheet
Youth’s Name: ______
Your youth’s growth and development is measured with developmental assessments. If your youth currently has an IEP/IFSP, it would be beneficial to share a copy of this plan with us so we can work together to ensure that the guidelines are put into practice. You do not have to provide this information if you do not wish to do so.
□ I am providing a copy of my youth’s IEP or IFSP.
□ I am not providing a copy of my youth’s IEP or IFSP and/ or this is
not applicable to my youth.
Signature: ______Date: ______
Printed Name: ______
EMERGENCY CONTACT/PARENTAL CONSENT FORM
55 PA CODE CHAPTERS 3270.124(a)(b), 3270.181 & 182: 3280 124 (a)(b), 3290.181 & 182
Please Sign ALL FIELDS where an X is indicated
Youth’s name / Date of Birthaddress
mother’s name/Legal Guardian / home telephone number
address
business name / business telephone number
address
emergency contact person(S): Name Address Telephone # when child is in care
person(S) to whom child may be released: Name Address Telephone # when child is in care
name of youth’s physician/medical care provider / telephone number
address
special disabilities (if any) / allergies (including medication reaction)
medical or dietary information necessary in an emergency situation / medication, special conditions
additional information on special needs of child
health insurance coverage for child or medical assistance benefits / policy number (required)
parent’s signature is required for each item below to indicate parental consent
obtaining emergency medical care
X / admin. of minor first – aid procedures
X
walks and trips
X / swimming
X
transportation by the facility
X / wading
X
PERIOD REVIEW