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SUMMER 2015
Program Dates 7.6.15 -7.30.15
Hours 9:00 AM- 4:00 PM
Orientation 6.26.15 @ 5:30 PM
Application due 6.15.15
th
Ages: 10-14(girls going into 6 grade, 7th, 8th or 9th grade)
Hand deliver, mail or e-mail applications to:
Girls Inc
283 Adams st
Brooklyn NY, 11201
CONTACT:
Program Coordinator
Corinne Santiago
718-260-2300 x 30421
[email protected]
Dear Families,
Please join us this summer in being strong, smart, bold, and active! Girls Inc. of NYC is hosting the Girls
Take the Lead! Summer Camp at The Urban Assembly Institute of Math and Science for Young
Women (UAI). Girls Inc. NYC staff facilitated the school’s summer camp last summer and it was a great
success. This summer is going to be even better!
Girls Incorporated of New York City delivers life-changing programs that inspire girls to be strong, smart,
and bold. Research-based curricula, delivered by trained professionals, equip girls to achieve
academically; lead healthy and physically active lives; manage money; navigate media messages; and
discover an interest in science, technology, engineering, and math. Girls Inc of NYC is an independent
affiliate of the national Girls Incorporated, the nation’s leading expert on issues affecting girls and young
women.
We are extremely excited to be offering this summer camp at UAI! We believe girls deserve
opportunities to grow in girl-friendly spaces that will support them to embark on their own journeys and
be leaders in any path they choose!
During Summer Camp, we will explore the theme: “Girls Take the Lead.” Girls will do this in a positive,
supportive, and safe environment. They will participate in core Girls Inc. activities that encompass
playing collaborative team sports, getting their hands dirty while gardening, creating art and music,
designing their own web sites, sharing a girl-friendly space with other girls, learning about positive body
image and self-esteem, learning about self-defense and becoming strong, smart and bold leaders!
For four days a week girls will be placed in fun activities and participate in weekly field trips, including
service learning projects. In order to participate in this free program the participant must be able to
attend program Monday - Thursday 9:00-4:00pm. The program begins on July 6th, 2015 and ends
on July 30th.
In order to be accepted into the program, you and your child must attend a Summer Camp Orientation
on Friday, June 26th from 5:30-7:00pm at Urban Assembly Institute of Math and Science. Girls
cannot join the program without a Parent/Guardian & girl attending this meeting. Enrollment in the
program is contingent upon attending the orientation and submission of complete paperwork. Part of the
application has questions for the parent/guardian and girl. Please answer the questions honestly so that
we can truly meet the needs and serve your girl to the best of our ability. Spaces will be filled on a first
come, first serve basis. The deadline to submit application is June 15th. Please mail or submit
paperwork at UAI campus (address is above).
We are truly looking forward to working with your family during the school year and hope that your family
is excited for this opportunity! Please feel free to call us if you have questions or concerns about the
program. Thank you and have a good day.
Sincerely,
Yeashea Braddock
Program Director - SONYC
Girls Inc. of NYC at Urban Assembly Institute of Math & Science for Young Women
tel. (718) 230-2600 EXT 30421
www.girlsincnyc.org
WELCOME!
DYCD OVERVIEW The Department of Youth and Community Development (DYCD) is a New York City agency that funds programs for youth and families. These programs are operated by community-­‐based organizations (CBOs). DYCD thanks you for enrolling yourself or your child in this program. ENROLLMENT PACKET OVERVIEW Please answer all the questions below to help us provide quality services. Those marked with an asterisk (*) are optional. If there is a question that you do not understand, please seek help. You can speak with a worker at the CBO that operates the program or call 311 and request the DYCD Youth Hotline. DYCD also has a website www.nyc.gov/dycd and can be followed on Facebook and Twitter for additional information on DYCD services. This enrollment packet will allow you or your child to be enrolled in this program. The information captured through this form will help the program plan to provide a safe and healthy environment, and provide appropriate services. Enrollment packet sections: n Welcome and Packet Overview (this page) n Signatures (pages 5, 6) n Participant Background (pages 2, 3) n Parent Consent Form n Participant Health and Safety (pages 3, 4) n Other PROGRAM OVERVIEW Out of School Time (OST): The OST initiative is the City’s public after-­‐school program and focuses on providing engaging academic, recreational, civic and cultural activities for students. The programs serve students in grades K-­‐ 8 after school, on many school holidays and during part of the summer, and are typically divided between elementary and middle school. Programs are operated by community based organizations and emphasize strong CBO and school partnerships, as well as family engagement. OST programs are primarily school based, and also operate from community based centers, public housing developments and city parks. OST Transition to High School: This initiative provides students entering the 9th Grade the support they need to adjust to the academic, social and emotional demands of high school. Counselor advocates foster peer bonding and parental involvement and ensure student access to critical support services with a goal of having participants promoted to 10th grade with the requisite number of credits and on the path to graduation and post-­‐secondary success. http://www.nyc.gov/html/dycd/html/afterschool/out_of_school_time.shtml OST PROGRAM
This program is operated by: Description of the Community-­‐Based Organization Name, short description, and contact information Please save this page for your records and future reference. Program Enrollment Packet | page
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PARTICIPANT
BACKGROUND
Name of the person completing this form: participant contact information Phone number: Last Name
First Name Home Address
Apartment Number City
State Zip Code
Borough Home Phone
Gender
Date of
Birth Ethnicity
Country of Origin
English Proficient
Student Status
School Type
School Name
Teacher/ Advisor
Cell Phone *SSN ¨ Birth Certificate ¨ Passport ¨ Driver’s License *Proof of ID ¨
Non-­‐Driver State ID ¨
Other ¨ Hispanic/Latino ¨ Not Hispanic/Latino ¨ No Response ¨ Female ¨ Male ¨ No Response
¨ American Indian or Alaskan Native ¨ Asi an ¨ Black/African American ite ¨ Other ¨ No Response
¨ Native Hawaiian/Pacific Islander ¨
Wh
Primary ¨ Yes ¨ No Is the participant a student: ¨
¨ No Yes Language
Additional Language(s) If yes:
¨ Full-­‐time ¨ Part-­‐time Student ID / OSIS #
¨Public ¨Charter ¨Private ¨Other School Address
Current Grade Level
¨ Grade K-­‐11; please list your last grade: If you are NOT a student, please provide ¨ HS Graduate ¨ HS Equivalency ¨ Some College the last school grade level completed: ¨ College Degree If you are NOT a student, are you: other Program Year ¨ Unemployed for weeks ¨ Employed Full-­‐time ¨ Employed Part-­‐time Please list anyone else in your household who is participating in this program. Provide first and last names. Program Enrollment Packet | page
OST PROGRAM
student or employment status Date
Race
Phone number (2): Email
demographics Who is enrolling in this program? ¨ Me ¨ My child To register yourself, you must be 18+ years old. 2
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PARTICIPANT
BACKGROUND
Section 1. Participant Background (continued) other family and household information The participant lives in housing that is: (Check all that apply) ¨ Rental ¨ Family Owned ¨ NYCHA housing OR The participant is: ¨ Homeless ¨ Other: Is or has the participant ever been in foster care: ¨ Yes ¨ No Has the participant been enrolled in programs operated by the Administration for ¨ Yes ¨ No Children’s Services (ACS)? Is the participant or any member of the household (0-­‐64 years old) covered by ¨ Yes ¨ No Medicaid, Child Health Plus, Family Health Plus, or private health insurance? If you answered no to the previous question, would you like to be contacted by ¨ Yes ¨ No someone for assistance with health insurance? Number of individuals in your household: * Is the participant or any member of your household receiving public assistance? ¨ Yes ¨ No * Is the participant or any member of your household receiving food stamps? ¨ Yes ¨ No * Gross Yearly Household Income: $ The participant lives in a household ¨ Self, Single, ¨ Single Female Parent no children ¨ Single Male Parent that is headed by: * Sources of household income: ¨ TANF ¨ Social Security ¨ Employment ¨ SSI ¨ General Assistance ¨ Pension 
¨ Unemployment Insurance ¨ Other PARTICIPANT SAFETY
EMERGENCY CONTACTS. If there is an emergency, please contact the following individuals: NAME Relationship to Participant: Pick Up ¨ This person may pick up my child. Address Apartment Contact Write down all numbers and circle the best number to call in case of an emergency: ¨ Home ¨ Cell ¨ Work ¨ Email Zip Code NAME Relationship to Participant: Write down all numbers and circle the best number to call in case of an emergency: ¨ Home Contact ¨ Cell City, State ¨ Work Zip Code ¨ Email Pick Up ¨ This person may pick up my child. Address Apartment Program Enrollment Packet | page
OST PROGRAM
City, State ¨ Two Parents ¨ Two Adults, no children 3
PARTICIPANT SAFETY
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Section 2. Participant Safety (continued) PARTICIPANT HEALTH INFORMATION. Please check any of the following that pertain to the participant. Many needs or health challenges can be accommodated and may not limit enrollment in the program. ¨ Allergies to food
¨ Behavioral/Emotional Issues
¨ Diabetes
¨ Obesity
¨ Allergies to medications
¨ Convulsions/Seizures
¨ Medication
¨ Physical Disabilities
¨ Asthma
¨ Congestive Illness (e.g., heart ¨ Corrective Devices (e.g., ¨ Pregnancy
murmur/disease, blood pressure)
crutches, hearing aid, eye glasses)
If you have checked any of the above OR there are other important health needs that may affect participation in the program, including activities that the participant MAY NOT do, please provide details: 
This section is only for parents enrolling their children. 
PICK UP/DISMISSAL INFORMATION. My child has permission to walk home alone at dismissal. ¨ Yes ¨ No My child MAY NOT be picked up by: The following individuals are authorized to pick up my child: Relationship to Participant
NAME
Write down all phone numbers and circle the best number to call in case of an emergency: Phone
¨ Home ¨ Cell ¨ Work ¨ Other Email Address:
Write down all phone numbers and circle the best number to call in case of an emergency: Phone
¨ Home ¨ Cell ¨ Work ¨ Other Email Address:
Program Enrollment Packet | page
OST PROGRAM
Relationship to Participant
NAME
4
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PARTICIPANT INTERESTS. Interests/Activities Reading Math Media (digital art, photography, videography) Writing(poetry, short fiction, journaling) Art (painting, drawing, sculpturing) Performance (music, dance, drama) Science Technology Engineering Math/STEM Sports (team, individual) Video Games Board Games Cooking & Nutrition Gardening þ
Likes/Strengths
D Dislikes/Challenges
How we can be helpful to you/your child? Are there are other services or activities that would be interesting and or helpful to you/your child? Does your child have an Individualized Education Plan and/or Special Needs? ¨ Yes ¨ No Please use the space below or on the back of the page to provide details or list goals you would like to share with us. OTHER SERVICES. *Please check any other DYCD services you or your family might be interested in learning more about? Education/Literacy/High School
Housing Assistance
Senior Services
Equivalency Immigrant Services Summer Youth Employment Adolescent Literacy LGBTQ Support Services Young Adult Internships
Fatherhood Services
Runaway and Homeless Youth
Workshops/Fairs (College Prep, Financial Planning, Parenting, etc.) SIGNATURES. To the best of my knowledge the information above is true. I agree to its verification and understand that falsification may be grounds for termination of service. Information provided may be used by the City of New York to improve City services or to access additional funding. I have completed this application for my child. Parent/Guardian: (Print) I have completed this application for myself. Applicant: (18 and older) (Print)
Organization: Intake Specialist/Staff: (Sign)
(Date)
(Date)
(Sign)
Date: _ Program Enrollment Packet | page
OST PROGRAM
OTHER
5
Parent/Guardian Consent
The Department of Youth and Community Development (DYCD) provides funding for this
program as part of its mission to help you assist your child reach his or her full potential. Many
of our programs are run by community based organizations. We work to make sure the services
you and your children receive are of the highest quality. DYCD is requesting your permission to
allow us to collect information we need on your child, their participation and the quality of the
services provided.
Consent to Collect and Share Student Information
What information from your child’s student records is DYCD requesting?
We are requesting your permission for the NYC Department of Education (DOE) to share
personally identifiable information from your child’s student records with DYCD. The
information we would like to collect consists of biographical and enrollment information
(specifically consisting of your child’s name, address, date of birth, student identification
number, grade, school(s) attended and transfer, discharge, and graduation data about your child);
data concerning your child’s school attendance (including number of days attended and
absences); and academic performance data (including your child’s results on state and national
exams, credits earned, grades, promotion and retention status, and fitnessgram score); and data
related to any disciplinary actions taken against your child (including number and type of
suspensions).
We are requesting to collect the information listed above about your child on a past, present and
future (i.e., ongoing) basis.
We are also requesting your permission for DYCD to share information we collect on the
enrollment form from you and/or your child with DOE staff. The information includes
registration information, student’s interests and challenges, type of program enrolled in and
frequency of participation. This information will be used to help the school and community
organization work together to meet you and your child’s need.
Who will see my child’s information and how will it be safeguarded?
The only people who will see your child’s individual information are DYCD and DOE staff who
manage the data systems and prepare research reports and program analyses. The limited number
of DYCD staff identified to receive personal information is screened, provided extensive training
to follow strict guidelines on protecting the confidentiality of information that would personally
identify you or your child. Personally identifiable information collected from student records will
only be shared electronically between DOE and DYCD and will be secured and protected in the
DYCD data base. Personally identifiable information will not be shared with any community
based organizations or their staff members.
We will not use your name or your child’s name in any published report. While we request your
consent, your responses to the below requests will not affect your child’s participation in DYCD
sponsored programs.
Please check Yes or No to each of the following statements:
• I understand why DYCD is asking my permission to access the information listed above
from my child’s student records, and I give permission to DOE to share that information
with DYCD on an ongoing basis.
Yes, I give my permission
•
No, I do not give my permission
I understand why DYCD is asking my permission to share information about my child
collected by DYCD with DOE staff and I give my permission to DYCD to share
information with DOE on an ongoing basis.
Yes, I give my permission
Student/Applicant Name:
Parent/Guardian Name: _
Parent/Guardian Signature:
Additional Parent/Guardian Name:
Additional Parent/Guardian Signature:(optional) _
No, I do not give my permission
Date:
Consent for Photo/Videotaping and Use of Youth Work
Please be aware that sometimes, staff, photographers, newspapers, television reporters, media
representatives and public relations personnel may be present during program activities and
special events, both in-school and away from school. In some cases, they may photograph,
interview or otherwise record children who participate in these events. The resulting images,
videos and interviews may be used solely for non-profit, non-commercial purposes of the
program to promote the programs in printed and electronic media published by our agency, such
as brochures, books, print and email newsletter, DVDs and videos, websites and blogs. These
images may also be used by DYCD in its publications for non-profit educational purposes.
• I understand my child may be photographed, interviewed or otherwise recorded during
program activities and special events and give permission for my child to be
photographed, interviewed or otherwise recorded solely for non-profit, non-commercial
purposes of the program.
Yes, I give my permission
No, you do not have permission
•
I understand that my child’s work may be used in materials that promote programs, solely
for non-profit, non-commercial purposes of the program.
Yes, I give my permission
No, you do not have permission
Consent for Emergency Medical Treatment
I give authority to the Program Agency’s staff to obtain necessary emergency medical treatment
for my child with the understanding that the family will be notified as soon as possible. I
understand that every effort will be made to contact me before and after medical care is
provided.
Yes, I give permission
No, I do not give permission
Consent Statement
I the undersigned, certify that I have reviewed all the above consent statements and indicated my
wishes. I understand that consent is voluntary and I can withdraw it in writing at any time.
Student/Applicant Name
Student Signature (if 18 or older)
Parent/Guardian Name
Parent/Guardian Signature
Additional Parent/Guardian Name (optional)
Additional Parent/Guardian Signature Date
Date
Agency:
School:
Parent Consent for Participation in Data Collection
Dear Parent:
Your child,
, is enrolled in a program at
which
is supported by the Department of Youth and Community Development (DYCD). In order to monitor
the effectiveness of this program and ensure its future success, DYCD is collecting information about
participants’ experiences in the program. This information will help DYCD learn how the program helps
students and how it can be improved. This project has been approved by the Department of Education.
Specifically we ask permission from parents to:
•
Survey children about the DYCD program.
Any information we collect will be used only to assess the DYCD program and will not be
made public. Participating in the evaluation will not affect your child in school, in the program, or
in any other way. We will not use your name or your child's name in any report. Participation is
completely voluntary and participants may withdraw at any time with no consequences.
Please select one of the options below.
You only need to complete and return this form if you select “No, I do not want my child to
participate.”
YES, I GIVE PERMISSION FOR MY CHILD TO PARTICIPATE. I have read the above information and
I give permission for my child to participate in the DYCD survey.
Signature
Date
NO, I DO NOT WANT MY CHILD TO PARTICIPATE. I have read the above information and I DO
NOT
give permission for my child to participate in the DYCD data collection activities.
Signature
Date
If you have any questions or concerns, please contact Lisa Gulick at DYCD at 212-676-8100.
New York City
Department of Youth and Community Development
http://www.nyc.gov/html/dycd/
Girls Inc. of New York City
PARENT PASSIVE CONSENT FORM
Dear Parent or Guardian,
Girls Inc. operates several types of programs all with the common purpose of enhancing the cognitive, emotional,
intellectual, and physical development of girls.
So that we may evaluate this program, your daughter will be asked to take a short, voluntary survey at the beginning
and end of the program. The survey will include questions regarding your daughter’s characteristics such as her age
and grade, her skills, and how she liked the program. Surveys for the older girls (grades 7-12) will also ask about
health behaviors, including substance use and sexual activity. We will also secure your daughter’s school record for
the year, in hopes that our program improves her school achievement.
The evaluation of Girls Inc. of New York City will be completed by Philliber Research Associates, an independent
research organization located in Accord, NY. Your child’s information will be kept confidential and no identifying
information will be shared outside of the research team.
If you have any questions about the evaluation study please contact Dr. Stacie Powers, the person in charge
of this study, at [email protected] or at #845-626-2126.
If you have any questions about the Girls Inc. program please contact Christina Benavides, the Director of
Operations at Girls Inc. of New York City, at [email protected] or #212-531-7620.
If you do NOT want your child to participate in the survey, you MUST return this form
Otherwise, you need not return the form and we welcome your daughter to our program.
q
I refuse to allow my child to participate in the Girls Inc. of New York City evaluation.
Child’s Name: ________________________________
Child’s Birthdate: _____/_____/______
(month / day / year)
___________________________________________________
Signature of Parent/Legal Guardian
____________________________________________________
Printed Name of Parent/Legal Guardian
Thank you,
Girls Inc. of New York City
Today’s Date: _____/_____/_______
(month / day / year)
Liability Release (REQUIRED)
I hereby authorize the participant to participate in Girls Incorporated of New York City programs,
including off-site trips. In consideration for this participation, I do hereby, for myself and my heirs and
assigns, release and agree to indemnify and hold harmless Girls Inc. of NYC, its employees, and
volunteers from all liability, loss, claim, demand, action or cause of action which arises or may arise or be
occasioned in any way by such participation. I also release and hold harmless Girls Inc. of New York
City, its employees and volunteers from all liability, loss, or claim which may occur in transporting the
participant for the purposes of participating in any Girls Inc. activity or off-site trip.
_______________________________________
Parent/Guardian Signature
Date
_______________________________________
Parent/Guardian Name (please print)
Girls Name: _______________________________
Grade: _____________
For Parent/Guardian: Please answer the following questions regarding participant. Answer questions
honestly, answers will NOT affect enrollment in camp. This survey will help us serve girls to the best of our
abilities.
Learning
Engagement-Activities
How does participant follow directions (for example:
needs repeated instruction)?
How active/passive is student; generally and in
activities, discussions, with peers, & in groups?
What motivates participant?
Please describe participant behavior/involvement at
home:
Describe participants focus/ability to stay on task
How does participant seek assistance when needed?
Please list activities in which participant has been
involved in:
Please list activities that you think would be best
suited for participant:
Social Support Needed
Peer to Peer Interaction
How can participant be helped to flourish socially?
Describe participant’s personality?
In general how does participant interact with peers &
adults?
In general, how does participant handle conflict?
Participant Name:______________________________
Grade: ___________
Diections: Participant – please answer all questions as completely as you can.
Describe yourself:
Write 3 reasons why you want to join Girls Inc. Summer Camp.:
1)
2)
3)
Write 3 things you would like to learn or accomplish during Summer Camp:
1)
2)
3)
What are your interests and hobbies?