Southeast Bronx Neighborhood Centers, Inc.
Math/reading
Minds Unlimited Program SUMMER CAMP
....and theirs still more to come !!! Hours of Operation are Monday – Friday 8:00pm-6:00pm
JULY 5, 2016 – AUGUST 19, 2016 Fee: $450.00
To pick up an application stop by the Southeast Bronx Neighborhood Centers, Inc. 955 Tinton Avenue Bronx, New York 10456 (Located inside the Forest Community Center) Or call 718-542-2727 and ask for MICHELLE BEVERHOUDT at extension 136 Southeast Bronx Neighborhood Centers, Inc.
Participant Information
1. Last Name 2. First Name 3. Middle
4. Social Security Number 5. Gender 6. Birth Date
- - Male Female Month Day Year
7. Street Address (number and street) 8. Apt # 9. Zip Code
10. Borough Code 1. Bronx 2. Brooklyn 3. Manhattan 4. Queens 5. Staten Island
(Area code) (Area code) 11. Home Phone Number - - 12. Cell / Pager - -
13. Email Address:
14. Ethnicity 1. American Indian 2. Asian (Non-Hispanic) 3. Black (Non-Hispanic) 4. Hispanic/Latino 5. Pacific Islander 6. White (Non – Hispanic) 7. Other
Last Name First Name Emergency 15. Contact Name
(Area code) 17. Relationship 16. Home Phone Number - - to applicant
Last Name First Name Emergency 18. Contact 2 Name
(Area code) 20. Relationship 19. Home Phone Number - - to applicant
School Type: School 21. □ Public School □ Private School 22. Grade: Attending: □ Charter School
Public School 23. Student ID# (OSIS):
Primary Language 24. Spoken
25. English Proficient Yes No
Are you or any member of your household (0-64 years of age) covered by Medicaid, Child Health Plus, Family Health Plus or 26. private medical insurance? Yes No 27. If NO, do you want to be contacted with information about public health insurance programs? Yes No
If Yes, Are you or any member of your household receiving Public HRA 28. Assistance? Yes No Code #: New York City Department of Youth and Community Development
Please continue on the following page
29. Has the participant been enrolled in any of the following programs? 1. ACS 2. OST 3. TASC 4. Service Learning Do you have other children registered in this 30. program? Yes No If yes, please list additional children below:
Last Name First Name 31. Additional Child
Last Name First Name 32. Additional Child
Pick-Up Permissions
33. I give permission for my child to walk home alone at dismissal.
Child may be picked up by:
34. Last Name 35. First Name 36. Middle
(Area code) 38. Relationship to 37. Home Phone Number - - applicant
39. Last Name 40. First Name 41. Middle
(Area code) 43. Relationship to 42. Home Phone Number - - applicant
44. Last Name 45. First Name 46. Middle
(Area code) 48. Relationship to 47. Home Phone Number - - applicant
Child may not be picked up by: 49. Last Name 50. First Name 51. Middle
(Area code) 52. Relationship to applicant
52. Last Name 53. First Name 54. Middle
(Area code) 55. Relationship to applicant Parent / Guardian Information 56. Last Name 57. First Name 58. Middle
59. Street Address (number and street) 60. Apt # 61. Zip Code
63. Birth Date:
62. Borough Code 1. Bronx 2. Brooklyn 3. Manhattan 4. Queens 5. Staten Island Month Day Year
(Area code) (Area code) 64. Home Phone Number - - 65. Work Phone - -
66. Cell / Pager Number - -
67. Email Address:
68. Ethnicity 1. American Indian 2. Asian (Non-Hispanic) 3. Black (Non-Hispanic) 4. Hispanic/Latino 5. Pacific Islander 6. White (Non – Hispanic) 7. Other
69. Relationship to applicant
Primary Language 70. Spoken
71. English Proficient Yes No
Additional Parent / Guardian Information 72. Last Name 73. First Name 74. Middle
75. Street Address (number and street) 76. Apt # 77. Zip Code
79. Birth Date:
78. Borough Code 1. Bronx 2. Brooklyn 3. Manhattan 4. Queens 5. Staten Island Month Day Year
(Area code) (Area code) 80. Home Phone Number - - 81. Work Phone - -
82. Cell / Pager Number - -
83. Email Address:
84. Ethnicity 1. American Indian 2. Asian (Non-Hispanic) 3. Black (Non-Hispanic) 4. Hispanic/Latino 5. Pacific Islander 6. White (Non – Hispanic) 7. Other New York City Department of Youth and Community Development
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85. Relationship to applicant
Primary Language 86. Spoken
87. English Proficient Yes No
Intake Officer Signature Date New York City
Department of Youth and Community Development
HEALTH INFORMATION: Please indicate the following: ______Allergies (Please indicate allergies: ______) ______Asthma ______Seizures ______Medication (Indicate which and when administered)
FOOD: □ I give permission for my child ______to eat meals or snacks if provided. □ I do not give permission for my child to eat meals or snacks provided by the program. My child will bring his/her own snack/meal. □ Food Restrictions: ______
LIABILITY WAIVER I understand that if my child is injured at the program, it is not the responsibility of the Southeast Bronx Neighborhood Centers, Inc. Also, I have received the parent orientation packet and will be responsible for reading and adhering the guidelines outlined in this information, including instruction on behavior for my child.
Parent/Guardian: ______Date:______
CONSENT FOR MEDICAL TREATMENT I give consent for the staff and volunteers of the Southeast Bronx Neighborhood Centers, Inc permission to seek medical assistance for my child if needed.
Parent/Guardian: ______Date:______
PHOTO RELEASE INFORMATION I hereby consent to and authorize the use of any information, quotes, photos, and images (Including media and television) that have or will be taken of my child for the purpose of Southeast Bronx Neighborhood Centers, Inc .publicity. I understand that neither my child nor their family will receive payment for allowing interviews, photos or videotaping. It is also agreed that the child’s name may accompany quotes, photos, or video when deemed appropriate by the staff of Southeast Bronx Neighborhood Centers, Inc.
Parent/Guardian: ______Date:______
PERMISION FOR FIELD TRIPS I give my child permission to participate in Southeast Bronx Neighborhood Centers, Inc. field trips. I understand that I will be notified in advance of field trips schedule throughout the year and will be asked to sign a permission slip for each trip. I understand the program is not responsible for any lost/stolen personal items such as beeper, cell phones, spending money, jewelry, etc., none of which the child is encouraged to bring to the program.
Parent/Guardian: ______Date:______
PERMISSION FOR SCHOOL TO RELEASE REPORT CARD INFORMATION: I hereby consent to and authorize my child’s school to release his/her report card or report card information, for all marking periods, which will indicate attendance, lateness, decorum, scores on standardized tests and marks, whether alpha or numeric for each subject class they attend.
Parent/Guardian: ______Date:______
PERMISSION FOR CHILD RESLEASE I give my child permission to walk home alone at dismissal. □Yes □No
My child will be picked up by myself or one of the following individuals:
Name: ______Relationship: ______Phone: ______
Name: ______Relationship: ______Phone: ______Name: ______Relationship: ______Phone: ______
Parent/Guardian: ______Date:______
Code of Conduct and Disciplinary Policies
The Southeast Bronx Neighborhood Centers, Inc. (SEBNC) is an organization dedicated to providing a safe, positive, and enriching experience for the youth population. In order to carry out our mission we have developed the following guidelines to serve as framework for disciplinary actions. This Code of Conduct and Disciplinary Policy will ensure that all children are provided with a safe and nurturing environment as well as provide each child with a fair opportunity for due process when applicable.
Levels of Infractions This policy is based upon three levels of infractions. As each level increases the severity of the infraction is paralleled. Level one being the least offensive and level three being the most offensive.
Exceptions All participants, parents, and/or guardians are entirely responsible for their personal conduct. Each infraction against our code of conduct will result in a form of action designated to the specific level of offense. It is imperative that all participants and guardians are aware that there will be no exceptions to the disciplinary policies unless designated by the Director of the Program. This policy is to ensure the overall wellness of the program.
Level One Infractions Level One Infractions include, but are not limited to all of the following offenses; 1. Non-compliance to rules and regulations regarding cleanliness and upkeep of SEBNC property and materials. 2. Non-compliance to rules and regulations regarding the use of inappropriate language including, but not limited to cursing, swearing, and racial slurs. 3. Non- Compliance to rules and regulations regarding the hours of operation of the program. 4. Non- compliance to rules and regulations regarding dress code. (i.e. doo rags, bandanas, tube tops, revealing of undergarments, shorts more than three inches above the knee, clothing containing inappropriate language, pants hanging down etc. 5. Non-compliance to rules and regulations regarding use of materials. 6. Possession of electronic devices that are not allowed. (CD players, walkmans, gameboys, PSPs, cell phones, etc.) 7. Non –compliance to rules and regulations regarding behavior and conduct within hallways, classrooms, gymnasium, and other areas within the building. 8. Non-compliance to rules and regulations regarding loitering on SEBNC property.
Level One Disciplinary Actions Committing any offense under level one will result in, but not limited to one or more of the following; 1. Verbal reprimand from SEBNC staff member. 2. Phone call to parent and/or guardian of participant. 3. Denial of privileges to one or more recreational activities. 4. Denied access to special events and/or field trips. 5. Confiscation of electronic devices. 6. Community service rendered to SEBNC facilities. 7. Any combination of the above disciplinary actions.
Level Two Infractions Level Two Infractions include, but are not limited to all of the following offenses; 1. Improper use of bathroom facilities. 2. Insubordination to staff member. 3. Any and all outright display of disrespect to fellow participants of SEBNC. 4. Forgery of any legal document i.e. permission slips, notes from parent or school. 5. Any habitual occurrence of a level one infraction.
Level Two Disciplinary Actions Committing any offense under level two will result in, but are not limited to one or more of the following; 1. Verbal reprimand from staff member. 2. Phone call to parent and/or guardian. 3. Denial of privileges to one or more recreational activities. 4. Denied access to special events and/or field trips. 5. Community service rendered to SEBNC facilities. 6. Parent conference with SEBNC staff. 7. Suspension from a program and/or team. 8. Suspension for 1 to 3 operational days. 9. Any combination of the above disciplinary actions.
Level Three Infractions Level Three Infractions include but are not limited to all of the following offenses;
1. Any form of physical abuse rendered upon a SEBNC staff member, participant, or volunteer. 2. Disruption and failing to adhere to rules and regulations during field trips or any other off-site program. 3. Pulling or setting off fire alarms under false pretenses. 4. Committing any form of arson upon SEBNC property. 5. Vandalizing or stealing public property or of any SEBNC staff member. (i.e. automobiles, computers, purses etc.) 6. Possession of a weapon i.e. guns, knives, box cutters, matches etc. 7. Possession of a legal drug without permission or illegal substance. (alcohol, drugs, paint thinner, marijuana, cigars, etc.) 8. Any form of stealing. 9. Expression of any gang or gang affiliation. 10. Any form of bullying or harassment of fellow participants. 11. Any use of racial slurs toward staff member and/or participant. 12. Threatening any staff member or participant. 13. Disruption of any program. 14. Any habitual occurrence of a level two infraction.
Level Three Disciplinary Actions Committing any offense under level three will result in one or more of the following; 1. Verbal reprimand from staff member. 2. Phone call to parent and/or guardian participant. 3. Denial of privileges to one or more recreational activities. 4. Denied access to special events and/or field trips. 5. Confiscation of illegal items and / or substances. 6. Community service rendered to SEBNC facilities. 7. Parent conference with staff. 8. Suspension from a SEBNC program and/or team. 9. Suspension for 2 to 5 operational days . 10. Termination from SEBNC program and/or team. 11. Possible Arrest. 12. Any combination of the above disciplinary actions. Additional Policies 1. Two parent meetings may cause a level two suspension. 2. Three suspensions may cause an official expulsion from program. 3. Pulling a Fire Alarm will cause an official expulsion from program. 4. Harming other participants that may result in hospitalization or medical care will result in expulsion. Parents and/or guardians are required to conduct themselves in a respectful adult manner. Any parent or guardians that participate in unacceptable behavior will jeopardize their child’s membership to the Southeast Bronx Neighborhood Centers, Inc Programs. Rude and disrespectful comments and behavior made toward staff or any family member of a participant may result in a level three disciplinary action.
Note: All references to habitual occurrences consider three or more of the same offense.
Parent’s Signature
Participant’s Signature Health Record Information
Name of program: Southeast Bronx Neighborhood Centers Inc. (SEBNC) Name of child: / / M F Birthdate Sex Child’s address: Phone: ______Name of Parent/guardian: Phone: ______Place of Employment: Father (Guardian) Phone: ______Mother (Guardian) Phone: ______In case of emergency, notify: Phone: ______If parent or guardian are not available in an emergency, notify: 1. Phone: ______2. Phone: ______Important: Has this child been exposed to any communicable disease during the three weeks prior to beginning program? Yes No (If yes, state type of exposure: )
Health history: (Check, giving approximate dates) Allergies Diseases Ear Infections ______Hay Fever ______Chicken Pox ______Rheumatic Fever ______Ivy poisoning, etc. ______Measles______Convulsion ______Insect stings______German Measles ______Diabetes ______Penicillin______Mumps ______Behavior ______Other drugs ______Other contagious illnesses ______Asthma______
Other past illnesses______Operations of serious injuries (dates)______Hospitalization (dates)______Chronic or recurring illness ______Conditions that require activity to be restricted?______Appliance worn (glasses, contacts, etc.) ______Medication taken______Insurance Carrier: I.D.# / Medicaid #: ______
Providing this information will help us assist your child in the event of an emergency.
Consent for Emergency Medical Treatment I do hereby give authority to the Southeast Neighborhood Centers, Inc. staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible.
______Signature Date SOUTHEAST BRONX “We’re on the front lines” NEIGHBORHOOD CENTER, INC.
955 Tinton Avenue * Bronx, NY 10456 * Tel: 718-542-2727 * FAX: 718-589-2927 * www.sebnc.org
Social Media Form
Participants Name: ______Address: ______Telephone: ______E-mail: ______Facebook User ID: ______Twitter User ID: ______
Parent /Guardian: ______Address: ______Telephone: ______E-mail: ______Facebook User ID: ______Twitter User ID: ______
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Southeast Bronx Neighborhood Centers, Inc. Sponsors of the Forest and McKinley Community Centers