DYCD Universal Participant Intake-Youth and Adult Form


Welcome to the Department of Youth and Community Development (DYCD)! DYCD is a New York City agency that funds programs for youth and families. These programs are operated by Community Based Organizations (CBOs).This form will allow you or your child to apply to a DYCD Comprehensive Afterschool System (COMPASS), Beacon, or Cornerstone youth or adult program. Please complete this form fully and return to the CBO that operates the program. One application will be accepted per person per site. Submission of an application does not guarantee enrollment in the program. Further paperwork and information may be required to determine program eligibility. If accepted, program will be at no cost to the participant. The following application items are collected for informational and program planning purposes only: Income, Gender, Race, Ethnicity, Language, Population Type, Household Information and Health Insurance Status. Responses to these questions will not impact your eligibility to receive services and will not be shared outside of DYCD without the applicant’s permission.

: Applicant Information For the purposes of this application, applicant refers to the person applying to receive services. Select one *
Applicant’s Gender (Select One) *
Applicant’s Race /Ethnicity (Select all that Apply): *

Contact Information Applicant’s Contact Information For youth without contact information, skip to the next section to provide parent/guardian contact information

Write down phone numbers for the applicant and circle the preferred method of contact *

Parent/Guardian Information This section is required for Applicants under 18

Write down all phone numbers and circle the best number to call in case of an emergency *

Emergency Contact Information At least one emergency contact must be identified

Emergency Contact #1 Name: Relationship to Participant: KW *
Emergency Contact #2 Name: Relationship to Participant *

This section is for parents/guardians enrolling their children Emergency contacts listed in Section II are authorized to pick up the child unless otherwise noted. The following additional people are authorized to pick up my child

The following people MAY NOT pick up my child

Applicant’s Education Status (Select One) *

***If applicant is a Part-Time Student or Full-Time Student: Select applicant’s current grade (Select One): ****If applicant is Not in School: Select the last grade completed by the applicant (Select One)

Applicant's Grade *
Applicant’s Current Work Status (Select One) *
Required for Full-Time Students Student ID/ OSIS: School Type *

Health Information Applicant's Health Information Please answer the questions below and provide additional details in the space provided. Many needs or health challenges can be accommodated and may not limit enrolment in the program

Does the applicant have any allergies? (food, medication, etc.) *
Does the applicant have asthma? *
Does the applicant have special health care needs? *
Does the applicant take medication for any condition or illness? *
Are there activities the applicant cannot participate in? *

Applicant’s Health Insurance Status

Does the applicant have health insurance? (Select One)
If yes, what kind of health insurance does the applicant have? (Check all that Apply)
If you do not have health insurance, do you want to be contacted by someone else with information about signing up for public health insurance? (Select One)
If you would like to be contacted about signing up for public health insurance, what is your preferred method of contact? (Select One):

Additional Applicant Information

How well does the applicant speak English? (Select One) *
Applicant’s Primary Language (Select One) *
Other Languages Spoken by Applicant (Select all that Apply) *
Would the applicant like to receive information/ be contacted about registering to vote?** (Select One) *

Applicant is eligible to vote in U.S. federal elections if: 1) You are a U.S. citizen; 2) You meet your state’s residency requirements; 3) You are 18 years old. Some states allow 17-year-olds to vote in primaries and/or register to vote if they will be 18 before the general election. Check your state’s voter registration age requirements.
Is the applicant any of the following:
If the applicant is an individual with a disability, please select disability type(s) (Select all that Apply)

Parent/Legal Guardian? *
Offender/Justice Involved? *
Foster Care Participant? *
Runaway Youth? *
Veteran? *
Active Military Personnel? *
An Individual with a Disability? *

: Household Information
For all the next set of questions, HOUSEHOLD is defined as any individual or group of individuals (family or non-family members) who are living together as one economic unit. INCOME is defined as the total annual gross income of all family and non-family members 18+years old living within the household.

The applicant lives in a household that is headed by (Select One) *
Applicant’s Housing Type (Select One) *
Applicant’s Household Size (Select One) *
Total Household Income in the last 12 Months (Select One) *
Sources of Applicant’s Household Income (Select all that Apply) *
Consents and Signatures Pick-up/Dismissal Information This question must be answered for parents/guardians enrolling their children My child has permission to travel home alone at dismissal *

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 and access to those services, and to access additional funding.
If participant is 18 and over

I acknowledge that I am 18 years of age or older and am authorized to give consent. *

If participant is under 18 years old

Consent for Emergency Medical Treatment If participant is 18 and over I am enrolled as a participant in a DYCD-funded program. In the event of a medical emergency, I hereby give consent for necessary emergency medical treatment to be obtained on my behalf. I further authorize the emergency contact(s) listed to be contacted
If participant is under 18 years old: My child is enrolled as a participant in a DYCD-funded program. In the event of a medical emergency, I hereby give consent for necessary emergency medical treatment for my child to be obtained, with the understanding that I will be notified as soon as possible. I understand that every effort will be made to contact me, or, if I am unavailable, the emergency contact(s) listed, before and after medical care is provided.

Parent/Guardian Consent to Collect and Share Student Information
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.
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 needs.
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, and 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 *

Parent Consent for Participation in Afterschool Evaluation Data Collection
(SONYC and COMPASS High Participants Only)
Dear Parent:
Your child is enrolled in an afterschool program that is supported by the Department of Youth and Community Development (DYCD). American Institutes for Research (AIR) is doing a study of the afterschool programs that are part of COMPASS. In order to monitor the effectiveness of these programs and ensure their future success, DYCD, and its evaluation partner AIR, are collecting information about participants and their experiences in the afterschool program, specifically around youth leadership development. This project has been approved by the Department of Education (DOE). AIR will visit some of the afterschool programs and survey its staff as well as youth and their families to learn more about DYCD afterschool programs and how they can be improved.
We ask permission from parents to conduct the following study activities:
• Administer 10-minute surveys to children asking about the DYCD afterschool program in which they participate and their perceptions of youth leadership development in the afterschool program
• Invite children to attend 45-minute focus group and/or interview about the DYCD afterschool program in which they participate, focused on their experience in the afterschool program and their perceptions of youth leadership development
AIR may also collect and analyze of your child’s school records from New York City Department of Education, including demographic data, school day attendance, disciplinary referrals, grade promotion, and academic performance data (e.g., test scores and grades). These data are anonymous and completely confidential. The data will be combined to the school-level and we will not be able to link this school information to individual children or their families.
Any information we collect will be used only to assess the DYCD afterschool program and will not be made public. The only people who will have access to this information are members of the AIR evaluation team. Choosing not to participate in the evaluation will not affect your child in school, in the afterschool program, or in any other way. We will not use your name or your child's name in any report. There are no known risks to participating in this study. Participation is voluntary and participants may withdraw at any time. Please contact Jessica Newman by phone (312-588-7341) or email (jnewman@air.org) with questions about the study.
If you have concerns or questions about your child’s rights as a participant, please contact AIR’s Institutional Review Board (which is responsible for the protection of project participants) at IRB@air.org, toll free at 1- 800-634-0797, or c/o IRB, 1000 Thomas Jefferson St. NW, Washington, DC 20007.

Parent Consent for Participation in Afterschool Evaluation Data Collection

Please select from the options below

Consent for Audio Recording

If you gave your child permission to participate in focus groups and interviews, AIR researchers may record the student focus group and interviews for note‐taking purposes. If you allow AIR to record the focus group and interviews, please sign below. No one outside of the research team will hear the recording, and the recording will be deleted when the study is concluded. Students can request to have the recorder turned off at any point

If you have any questions or concerns about the evaluation, please contact Jessica Newman, the project manager at AIR, at (312) 588-7341 or by email at jnewman@air.org. If you have questions about DYCD afterschool programs, visit DYCD Youth Connect Youth Page or call by phone at 1-800-246-4646.
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