Last Name First Name City State Zip Code Borough Home Phone Email Gender Response Date of Birth Ethnicity Hispanic/Latino Hispanic/Latino No Response Race American Indian or Alaskan Native American Native Hawaiian/Pacific Islander Response Country of Origin Primary Language English Proficient Yes Additional Language(s) Student Status Interested in half-day programming? Yes or no: Yes Student ID / OSIS # Name School Address Teacher/ Advisor Current Grade Level No No No Female Male Other
Section 1. Participant Background (continued) other family and household information The participant lives in housing that is: (Check all that apply) Owned housing OR The participant is: Is or has the participant ever been in foster care: Yes Has the participant been enrolled in programs operated by the Administration for Children’s Services (ACS)? Yes Is the participant or any member of the household (0-64 years old) covered by Medicaid, Child Health Plus, Family Health Plus, or private health insurance? Yes If you answered no to the previous question, would you like to be contacted by someone for assistance with health insurance? Yes 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 that is headed by: Self, Single, no children Single Parent Single Parent Two Parents Two Adults, no children * Sources of household income: Employment Pension TANF SSI Social Security General Assistance Unemployment Insurance PARTICIPANT SAFETYPlease place parent info in the emergency contact boxes if applicable. EMERGENCY CONTACTS. If there is an emergency, please contact the following individuals:
Henry Street Settlement After-School and Camp Services HENRY STREET SETTLEMENT Division of Youth Services 301 Henry Street New York, NY 10002 (P) 212-254-3100 (F) 212-777-1445 Additional Pick-up/Emergency Contacts List (not required) Participants Name: _____________________________________________ Date of Birth: _______________ Name: Relationship: Phone Number: ( ) - Type: □ □ Work □ Cellphone □ Phone Number: ( ) - Type: □ Home □ Work □ Cellphone □ Is this person an Emergency Contact: □ YES □ NO Is this person authorized to pick up: □ YES □ NO Email Address: Language Spoken: □ English □ Spanish □ Mandarin □ Cantonese □ Other - Please Specify: ________________ Name: Relationship: Phone Number: ( ) - Type: □ Home □ Work □ Cellphone □ Other Phone Number: ( ) - Type: □ Home □ Work □ Cellphone □ Other Is this person an Emergency Contact: □ YES □ NO Is this person authorized to pick up: □ YES □ NO Email Address: Language Spoken: □ English □ Spanish □ Mandarin □ Cantonese □ Other - Please Specify: ________________ Name: Relationship: Phone Number: ( ) - Type: □ Home □ Work □ Cellphone □ Other Phone Number: ( ) - Type: □ Home □ Work □ Cellphone □ Other Is this person an Emergency Contact: □ YES □ NO Is this person authorized to pick up: □ YES □ NO Email Address: Language Spoken: □ English □ Spanish □ Mandarin □ Cantonese □ Other - Please Specify: ________________ CHILD MAY NOT BE PICKED UP BY RELATIONSHIP OF THE PERSON NOT ALLOWED Program Enrollment Packet page 6