| Page 1 of 12
For Applicants Ages 13 and Younger | Updated July
2021
Questions? Call Community Connect:
1-800-246-4646 www.nyc.gov/dycd
Search for and apply to DYCD Programs Online!
https://discoverdycd.dycdconnect.nyc/home
Office Use Only
Date Application
Received:
Enrollment Start
Date:
Intake
Specialist/Staff:
Additional
Information:
DYCD Universal Participant Intake: Youth & Adult Application
Applicants Ages 13 & Younger
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.
Part I: Applicant Information
For the purposes of this application, applicant refers to the person applying to receive services. Select one:
☐ I am completing this application for myself
☐
I am a relative/non-relative, completing this application on behalf of the applicant
Applicant’s First Name:
Applicant’s Last Name:
MI:
Applicant’s Date of Birth (MM/DD/YEAR):
Applicant’s Primary Address (Number and Street):
Applicant’s Apt. Number:
Applicant’s City:
Zip Code:
Applicant’s Sex at Birth
(Select One):
☐ Female
☐ Male
☐ X (not female or male)
☐ Not sure
Applicant’s Race (Select all that Apply):
☐ American Indian and Alaskan Native
☐ Asian
☐ Black or African-American
☐ Middle Eastern/North African
☐ Native Hawaiian and Other Pacific Islander
☐ White or Caucasian
☐ Other ________________________
Applicant’s Ethnicity
(Select One):
☐ Hispanic or Latinx
☐ Not Hispanic or Latinx
☐ Applicant lives in a NYCHA Development (please provide name) _____________________________________
|Page 2 of 12
For Applicants Ages 13 and Younger | Updated July 2021
Questions? Call Community Connect:
1-800-246-4646 www.nyc.gov/dycd
Part II: Applicant’s (or Parent/Guardian’s) 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 check the preferred method of contact:
☐ Home __________________________
☐ Cell
___________________________________
☐ No Email
☐ Work _______________________________ ☐ Email _________________________________ ☐ US Mail
Parent/Guardian Information
This section is required for Applicants under 18
Parent/Guardian Name: ______________________________________________
Write down all phone numbers and check the best
number to call in case of an emergency:
☐
Home ______________________________
☐
Cell ___________________________________
☐ No Email
☐
Work _______________________________
☐
Email _________________________________
Address:
☐ Same as Applicant
City:
State:
Zip Code:
Emergency Contact Information
At least one emergency contact must be identified
Emergency Contact #1 Name:
Relationship to Participant:
☐ Emergency contact is parent/guardian of participant
Write down all phone numbers and check the best number to call in case of an emergency:
☐
Home ______________________________
☐
Cell
__________________________________
☐ No
Email
☐
Work
_______________________________
☐
Email
_________________________________
Address:
☐ Same as Applicant
City:
State:
Zip Code:
Emergency Contact #2 Name:
Relationship to Participant:
☐ Emergency contact is parent/guardian of participant
Write down all phone numbers and check the best
number to call in case of an emergency:
☐ Home ______________________________
☐ Cell
__________________________________
☐
No
Email
☐ Work
_______________________________
☐ Email
_________________________________
Address:
☐
Same as Applicant
City:
State:
Zip Code:
|Page 3 of 12
For Applicants Ages 13 and Younger | Updated July 2021
Questions? Call Community Connect:
1-800-246-4646 www.nyc.gov/dycd
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:
Name:
Phone #:
Relationship:
Name:
Phone #:
Relationship:
Name:
Phone #:
Relationship:
The following people MAY NOT pick up my child:
Name:
Name:
Name:
Part III: Applicant’s Education/Work Status
Applicant’s Education Status (Select One):
☐ Full-Time Student*** ☐ Part-Time Student*** ☐ Not in School****
***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):
Elementary School: ☐ Pre-K ☐ K ☐ 1
st
☐ 2
nd
☐ 3
rd
☐ 4
th
☐ 5
th
Middle School: ☐ 6th ☐ 7th ☐ 8
th
High School: ☐ 9
th
☐ 10
th
☐ 11
th
☐ 12
th
☐ Obtained High School Diploma
☐ Obtained High School Equivalency
4-Year College/University: ☐ Freshman ☐
Sophomore
☐ Junior ☐ Senior ☐ Obtained Bachelor’s Degree
Doctorate Degree:
☐ Some Doctorate degree credits, but no degree
attained
☐ Obtained Doctorate Degree
Other:
☐ Obtained Foreign Degree
☐ No Formal Schooling Attained
Community College: ☐ 1
st
year ☐ 2
nd
Year ☐ 3
rd
year
☐ 4
th
Year + ☐ Obtained Associate’s Degree
Master’s Degree:
☐ Some Master’s Degree credits, but no degree attained
☐ Obtained Master’s Degree
Professional Degree:
☐ Some Professional Degree credits (e.g. MD, DDS, DVM,
LLB, JD), but no degree attained
☐ Obtained Professional Degree (e.g. MD, DDS, DVM, LLB,
JD)
Vocational/Trade School:
☐ Some Vocational or Trade School credits, but no certificate
or degree attained
☐ Obtained a certificate or degree from a Vocational or
Trade school
Applicant’s Current Work Status (Select One):
☐ Employed Full-Time
☐ Employed Part-Time
☐ Retired
☐ Unemployed (Short-Term, 6 months or
less)
☐ Unemployed (Long-term, more
than 6 months)
☐ Unemployed (Not in labor force)
☐
Migrant Seasonal Farm Worker
☐ Not applicable (applicant is
under 14 years of age)
Required for Full-Time Students
Student ID/OSIS:
School Type:
☐ Public ☐ Charter ☐ Private ☐ Other ________________________________
|Page 4 of 12
For Applicants Ages 13 and Younger | Updated July 2021
Questions? Call Community Connect:
1-800-246-4646 www.nyc.gov/dycd
Part IV: 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 enrollment in the program.
Does the applicant have any allergies? (food, medication, etc.)
☐
No
☐
Yes ___________________________________________________________________________________
Does the applicant have asthma?
☐
No
☐
Yes
Does the applicant have special health care needs?
☐
No
☐
Yes ___________________________________________________________________________________
Does the applicant take medication for any condition or illness?
☐
No
☐
Yes ____________________________________________________________________________________
Are there activities the applicant cannot participate in?
☐ No ☐ Yes ___________________________________________________________________________________
Please provide any additional health information details:
☐
N/A
Please list any accommodation(s) you are requesting for yourself/the applicant:
☐
N/A
Applicant’s Health Insurance Status
Does the applicant have health
insurance? (Select One):
☐ Yes ☐ No
☐ Decline to Answer
If yes, what kind of health insurance does the applicant have?
(Check all that Apply):
☐ Medicaid ☐ Medicare
☐
State Children’s Health
Insurance Program
☐ Employment-Based ☐ Direct-Purchase
☐ State Children’s Health
Insurance for Adults
☐ Military Health Care ☐ Decline to Answer
School Name:
School Address:
City:
Zip Code:
|Page 5 of 12
For Applicants Ages 13 and Younger | Updated July 2021
Questions? Call Community Connect:
1-800-246-4646 www.nyc.gov/dycd
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):
☐ Yes
☐
No
☐
Decline to Answer
If you would like to be contacted about signing up for
public health insurance, what is your preferred method
of contact? (Select One):
☐ Email ☐ Phone ☐ US Mail
☐
Via provider ☐ Decline to Answer
Part V: Additional Applicant Information
How well does the applicant speak English?
(Select One):
☐ Fluent/Very well
☐ Well
☐ Not well
☐ Not well at all
Applicant’s Primary Language (Select One):
☐ English
☐ Albanian
☐ Arabic
☐ Bengali
☐ Chinese*
☐ French
☐ Fulani
☐ German
☐ Gujarati
☐ Haitian Creole
☐ Hebrew
☐ Hindi
☐ Hungarian
☐ Italian
☐ Japanese
☐ Korean
☐ Kru, Ibo, or Yoruba
☐ Mande
☐ Punjabi
☐ Persian
☐ Polish
☐ Portuguese
☐ Romanian
☐ Russian
☐ Spanish
☐ Tagalog
☐ Turkish
☐ Urdu
☐ Vietnamese
☐ Yiddish
☐ Other: __________________________________________
*including Cantonese and Mandarin
Other Languages Spoken by Applicant (Select all that Apply):
☐ English
☐ Albanian
☐ Arabic
☐ Bengali
☐ Chinese
☐ French
☐ Fulani
☐ German
☐ Gujarati
☐ Haitian Creole
☐ Hebrew
☐ Hindi
☐ Hungarian
☐ Italian
☐ Japanese
☐ Korean
☐ Kru, Ibo, or Yoruba
☐ Mande
☐ Punjabi
☐ Persian
☐ Polish
☐ Portuguese
☐ Romanian
☐ Russian
☐ Spanish
☐ Tagalog
☐ Turkish
☐ Urdu
☐ Vietnamese
☐ Yiddish
☐ Other: __________________________________________
☐ Not applicable (only one language spoken by applicant)
*including Cantonese and Mandarin
Would the applicant like to receive information/
be contacted about registering to vote?**
(Select One):
☐ Yes ☐ No
**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?
☐ Yes ☐ No
☐ Cognitive impairment
Offender/Justice Involved?
☐ Yes ☐ No
☐ Hearing-related
Foster Care Participant?
☐ Yes ☐ No
☐ Learning disability
Runaway Youth?
☐ Yes ☐ No
☐ Mental or Psychiatric
Veteran?
☐ Yes ☐ No
☐ Physical/Chronic Health Condition
Active Military Personnel?
☐ Yes ☐ No
☐ Physical/Mobility Impairment
An Individual with a Disability?
☐ Yes ☐ No ☐ Decline to answer
☐ Vision-related
☐ Other: _________________________
☐
Decline to Answer
|Page 6 of 12
For Applicants Ages 13 and Younger | Updated July 2021
Questions? Call Community Connect:
1-800-246-4646 www.nyc.gov/dycd
Part VI: 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):
☐ Single Parent - Female
☐ Single Parent - Male
☐ Single Person - No children
☐ Non-related adults with
children
☐ Two Adults – No Children
☐ Two Parent Household
☐ Multigenerational Household
☐ Other: __________________
☐ Own
☐ Shelter
☐ Rent
☐ Homeless
☐ NYCHA
☐ Other
Permanent
Housing
☐
Other: ____________________
Applicant’s Household Size
(Select One)
:
Total Household Income in the last 12 Months
(Select One):
☐ One
☐ Four
☐ Seven
☐ Ten
☐ Thirteen
☐ Sixteen
☐ Nineteen
☐ Two
☐ Five
☐ Eight
☐ Eleven
☐ Fourteen
☐
Seventeen
☐ Twenty or
more
☐ Three
☐ Six
☐ Nine
☐ Twelve
☐ Fifteen
☐ Eighteen
☐ $0
☐ $16,241 to $20,420
☐ $28,781 to $32,960
☐ $41,321 to $50,000
☐ $70,001 to $80,000
☐ $100,000+
☐ $1 to $12,060
☐ $20,421 to $24,600
☐ $32,961 to $37,140
☐ $50,001 to $60,000
☐ $80,001 to $90,000
☐ Decline to Answer
☐ $12,061 to $16,240
☐ $24,601 to $28,780
☐ $37,141 to $41,320
☐ $60,001 to $70,000
☐ $90,001 to $100,000
Sources of Applicant’s Household Income
(Select all that Apply)
:
☐
Employment Wages
☐ Childcare Voucher
☐ Housing Choice Voucher
☐ Permanent Supportive
Housing
☐ Retirement Income from
Social Security
☐ Temporary Assistance
for Needy Families (TANF)
☐ WIC
☐
Affordable Care Act Subsidy
☐ Earned Income Tax Credit
(EITC)
☐ HUD-VASH
☐ Private Disability Insurance
☐ Social Security Disability
Income (SSDI)
☐ Unemployment Insurance
☐ Worker’s Compensation
☐
Alimony or other Spousal
Support
☐ Employment Tax Credit
☐ LIEHEAP
☐ Public Housing
☐ Supplemental Security
Income (SSI)
☐ VA Non-Service
Connected Disability Pension
☐ Other: ______________
☐
Child Support
☐ General Assistance
☐ Pension
☐ Safety Net/Home
Relief
☐ Supplemental Nutrition
Assistance Program
(SNAP)
☐ VA Service-Connected
Disability Compensation
☐ Decline to Answer
|Page 7 of 12
For Applicants Ages 13 and Younger | Updated July 2021
Questions? Call Community Connect:
1-800-246-4646 www.nyc.gov/dycd
If participant is 18 and over:
I acknowledge that I am 18 years of age or older and am authorized to give consent.
☐ Yes ☐ No
Participant’s Signature
Participant: Print Name
Date
If participant is under 18 years old:
Parent/Guardian’s Signature
Parent/Guardian: Print Name
Date
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.
☐ Yes, I give my permission ☐ No, I do not give permission
Participant’s Signature
Participant: Print Name
Date
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.
☐ Yes, I give my permission ☐ No, I do not give permission
Parent/Guardian’s Signature
Parent/Guardian: Print Name
Date
Part VII: 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:
☐ Yes ☐ No
Consent to Participate
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.
|Page 8 of 12
For Applicants Ages 13 and Younger | Updated July 2021
Questions? Call Community Connect:
1-800-246-4646 www.nyc.gov/dycd
Consent for Photography/Videotaping and Use of Original Work
As a participant enrolled in a DYCD-funded program, please be aware that from time to time DYCD
and the City of New York, its contracted providers, authorized agents, third-party organizations with
which it collaborates, or other government, representatives (collectively, “Authorized Parties”) may
be present during program activities and special events associated with program services, both at
the usual program location and at off-site events. In some cases, they may photograph, videotape,
interview or otherwise record participants and their families and friends in these programs. The
resulting images, videos, and interviews may be used, with or without the participant’s name, in
printed and electronic media such as brochures, books, print and email newsletters, DVDs and
videos, websites, social media and blogs (collectively, “Media”).
I hereby authorize and permit the Authorized Parties, without compensation and without further
approval, to photograph and/or record my and my child’s image, name, likeness, and the sound of
my and my child’s voice during DYCD-funded program activities and special events, and I hereby
consent to the resulting images, videos and interviews being used, without compensation and
without further approval by the Authorized Parties solely for non-profit, non-commercial purposes
in any and all Media.
☐ Yes ☐ No
If, in the course of participating in DYCD-funded program activities and special events, any original
work such as art, music, choreography, poetry, or prose (collectively, “Original Work”) is created by
me or my child, I hereby consent to such Original Work being used by the Authorized Parties,
without compensation and without further approval, solely for non-profit, non-commercial purposes
in any and all Media.
☐ Yes ☐ No
If participant is 18 and over:
I acknowledge that I am 18 years of age or older and am authorized to give consent.
☐
Yes ☐ No
Full Name of Participant
Participant’s Signature
Date
If participant is under 18 years old:
Full Name of Participant
Parent/Guardian’s Signature
Date
|Page 9 of 12
For Applicants Ages 13 and Younger | Updated July 2021
Questions? Call Community Connect:
1-800-246-4646 www.nyc.gov/dycd
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 p
rovided.
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 c
hild’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 w
ill 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 ☐ No, I do not give my permission
Student/Applicant Name:
_________________________________________________________________________
Parent/Guardian Name:
_________________________________________________________________________
Parent/Guardian Signature:
_____________________________________________
Date:
_________________
Additional Parent/Guardian Name (optional):
_________________________________________________________
Additional Parent/Guardian Signature (optional):
_________________________________________________________
|Page 10 of 12
For Applicants Ages 13 and Younger | Updated July 2021
Questions? Call Community Connect:
1-800-246-4646 www.nyc.gov/dycd
Consent to Make Referrals and Share Information
The New York City Department of Youth and Community (DYCD) invests in programs and services to
help our communities and the people who live here. We want to make sure you know about them and
make it easy for you to apply.
Why we need your permission
With it, we can:
• send you information about DYCD-funded programs and services you can apply for, and
• share information from your DYCD Participant Application each time you apply.
What we share
We’ll only give information to show you qualify or help you enroll in DYCD-funded programs.
Who sees your information and how we protect it
Only authorized DYCD and funded program staff can see it. We don’t share it with others except to:
• decide if you’re eligible for services,
• enroll you in programs and services, and
• track the results of the services you receive
Please read below, check one of the boxes, and fill in the rest.
I understand why DYCD needs my consent to:
• send me information about programs and services I can apply for,
• refer me to DYCD-funded programs, and/or
• share information from my DYCD Participant Application with the programs I apply for
□ Yes, I give my permission □ No, I do not give my permission
___________________________________________________________________________
Full Name of Participant (please print)
_____________________________________________________________________________
Signature of Participant (or Parent/Guardian for participants under 18 years old)
___________________________
Date
|Page 11 of 12
For Applicants Ages 13 and Younger | Updated July 2021
Questions? Call Community Connect:
1-800-246-4646 www.nyc.gov/dycd
CONSENT FORM FOR COVID-19 TESTING
What is this form?
We are seeking your consent to test your child for COVID-19 infection. The New York City Department of Education
(NYC DOE) and New York City Department of Youth and Community Development (DYCD), working with NYC
Health + Hospitals and the New York City Department of Health and Mental Hygiene, have partnered with
laboratories and other providers to test Summer Rising participants, teachers, and staff members for COVID-19
infection.
How often would you test my child?
We are arranging for our laboratory and provider testing partners to come to every Summer Rising program
periodically to test some of the participants, teachers, and staff. If you consent, your child may be selected for
testing on one or more of these occasions in accordance with program guidelines. In addition, your child may
also be tested throughout the duration of the program (1) in accordance with state and city mandates, or (2) if
they exhibit one or more symptoms of COVID-19, or (3) if they are a close contact of a participant, teacher, or
staff person with COVID-19 infection.
What is the test?
If you consent, your child will receive a free diagnostic test for the COVID-19 virus. Collecting a specimen for testing
involves inserting a small swab, similar to a Q-Tip, into the front of the nose and/or collecting saliva (spit).
How will I know if my child tests positive?
If your child has a specimen collected for testing at Summer Rising, we will send information home with them to let
you know. COVID-19 test results will generally be provided within 48-72 hours.
What should I do when I receive my child’s test results?
If your child’s test results are positive, please contact your child’s doctor immediately to review the test results and
discuss what you should do next. You should keep your child at home and inform your child’s Summer Rising
program coordinator. If your child’s test results are negative, this means that the virus was not detected in your
child’s specimen. Tests sometimes produce incorrect negative results (called “false negatives”) in people who have
COVID-19. If your child tests negative but has symptoms of COVID-19, or if you have concerns about your child’s
exposure to COVID-19, you should call your child’s doctor. If you need help finding a doctor, call (844) NYC-4NYC.
TO BE COMPLETED BY PARENT, GUARDIAN OR ADULT PARTICIPANT
Parent/Guardian Information
Parent/Guardian
Print Name:
Parent/Guardian
Address:
Parent/Guardian
Tel./Mobile #:
Parent/Guardian
Email address:
Best way to
contact you
Child Information
Child
Print Name:
Child School
ID/OSIS # (if
known):
Child
Date of Birth:
Child Summer
Rising Program
Child Home
Address:
|Page 12 of 12
For Applicants Ages 13 and Younger | Updated July 2021
Questions? Call Community Connect:
1-800-246-4646 www.nyc.gov/dycd
NOTIFICATION OF INFORMATION SHARING
The law allows some information about your child to be shared with and among certain New York City and New York
State agencies and their contracted service providers, including those listed below. This information will be shared
only for public health purposes, which may include notifying close contacts of your child if they have been exposed
to COVID-19, and taking other steps to prevent the further spread of COVID-19 in your community. Information about
your child that may be shared with these agencies and service providers conducting COVID-19 Testing includes your
child’s name and COVID-19 test results, date of birth/age, gender, race/ethnicity, Summer Rising program name(s),
teacher(s), cohort/pod, enrollment and attendance history, and program participation, names of other family members
or guardians, address, telephone, mobile number, and email address. Sharing of information about your child will
only be done in accordance with applicable law and City policies protecting privacy and the security of your child’s
data.
• NYC Department of Education
• NYC Department of Youth and Community Development
• NYC Department of Health and Mental Hygiene
• NYC Health and Hospitals Corporation
• NYS Department of Health
• Contracted Service Providers for COVID-19 Testing
CONSENT
By signing below, I attest that:
• I have signed this form freely and voluntarily, and I am legally authorized to make decisions for the child named
above.
• I consent for my child to be tested for COVID-19 infection.
• I understand that my child may be tested at multiple times through September 1, 2021, and that testing may occur
(1) on days scheduled by the NYC DOE and/or DYCD in accordance with program guidelines or state and city
mandates, or (2) if they exhibit one or more symptoms of COVID-19, or (3) if they are a close contact of a
participant, teacher, or staff person with COVID-19 infection
.
• I understand that this consent form will be valid through September 1, 2021, unless I notify the designated contact
person from my child’s Summer Rising program in writing that I revoke my consent.
• I understand that if I revoke my consent or refuse to sign, my child may not be allowed to participate in Summer
Rising’s in-person programming.
• I understand that my child’s test results and other information may be disclosed as permitted by law.
• I understand that if I am a participant age 18 or older, or may otherwise legally consent for my own health care,
references to “my child” refer to me and I may sign this form on my own behalf.
Signature of Parent/
Guardian
(if child is under age 18)
Date
Signature of Participant
(if age 18 or over or
otherwise authorized to
consent)
Date