THE POINT - Circus Program
TEEN & YOUNG ADULT INFORMATION
Primary language spoken at home
Street Address Line 2
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Cell Phone Number
How many years have you been coming to THE POINT?
Total number of people living in the household:
Place of Employment
Work Phone Number
Place of Employment
Work Phone Number
Name of school attended in 2011-2012
Dean or Main Advisor Name
Have you ever been retained?
What type of education programming are you enrolled in?
English as a Second Language
If you are enrolled in Special Education please specify what type (i.e. inclusion, out of support)
If yes, state reason:
What are your favorite subjects?
Physical must be less than 1 calendar year - nothing before July 9th 2011 will be accepted
Family Clinic or Hospital
Name of Physician
Medication currently being taken by participant:
Allergies of participant
Other Medical Condition:
Medical Insurance Policy#
Three people who will be responsible for the child if the parent or guardian is not available
Please select your T-shirt, Pants and Sneaker sizes
(Please fill out with your child)
1. A strength is something you’re good at and enjoy doing. Can you list one or two of your strengths?
2. A challenge is something you haven’t done yet because it is not something you can easily do. What are some things that are difficult or challenging for you?
3. If you could receive help in getting better in any subject, sport, activity or skill what would you like to be coached or mentored in?
4. A goal is something you want to achieve. It can be a physical, academic, emotional or social goal. What are some of your goals for this school year?
5. What types of books do you enjoy reading and why? What are the names and/or author names?
6. Do you have access to a computer at home? If so, what do you mainly use it for and how many hours a week are you on it?
7. What is your favorite movie or television program and why?
8. What games or activities do you like to do for fun?
9. If you were in charge & could change one thing in your community, what would it be and why?
10. What are your favorite foods and why?
Parent & Participant 18+ Agreement Form
In order for THE POINT CDC After School Program to better serve you or your child, we ask that you carefully review the following guidelines for participation. By signing the consent form below, you are accepting the terms of participation and making a commitment to the overall success of the program. I also agree that failure to comply can result in expulsion!
I understand that THE POINT CDC will be hosting SYEP participants from 9-4PM Monday through Thursday, based on individual schedules.
I agree to maintain consistent attendance record during the program year. Chronic unexcused absences will result in immediate program expulsion. I agree to inform the program of any other activities that would interfere with my child attending no less then three days per week consistently. Consistent attendance is critical to keeping our doors open.
I agree to attend community outreach meetings at THE POINT CDC during the course of the summer. By signing this I am also agreeing to make myself available for individual parent conferences as needed. At least one custodial parent must be in attendance for the orientation and you must be responsible for sharing this information with all relevant family members/parties. If it becomes evident that a parent is not aware of their obligations may result in expulsion.
Report Card/School Contract:
I agree to provide copy of the final report card June 2010. Final report cards from previous school year must be handed in order to enroll into our program. Report cards must be handed in before start of summer program. I also give permission to THE POINT CDC staff to contact my child’s teachers/school administrators for educational and behavioral purposes (including parent teacher conferences). I also give permission to THE POINT CDC to get copies of all report cards (including final quarter) directly from the school. I also give THE POINT CDC permission to share relevant information with teachers/school administrators and for the them to do likewise.
In case of medical or dental emergency, I give permission to THE POINT CDC, to obtain necessary and immediate medical treatment for my child, with the understanding that a family member or I will be notified as soon as possible. I also promise to inform THE POINT CDC of any condition or injury that would effect his ability to participate or in anyway harm another program participant. I also promise to provide THE POINT CDC with doctors notes if my child misses program due to illness. Letter will be due upon the date of the child’s return. Failure to share such information is again grounds for expulsion.
I give consent for my child to participate in activities which consists of walks and exploration of the Hunts Point Area. I am aware that my child needs to have the appropriate attire in other to participate in the class.
I agree to inform THE POINT CDC of any physical injury or illness as well as any emotional trauma that might interfere with THE POINT CDC’s ability to maintain a safe space for the children in our care. I understand that failure to do so can result in the expulsion of my child from the program with no refund of admission costs.
I give permission to THE POINT CDC to use photographs video footage, and audio recordings in which my child may appear to publicize and support THE POINT CDC Programs. These images and sounds are property of THE POINT CDC’s and can be used to publicize our programming indefinitely even after my child’s graduation.
I agree that it is my sole responsibility as guardian to make sure that my child’s application is up to date. Especially emergency contact numbers and authorized pick up contacts. THE POINT CDC will not responsible for any incident caused by inability to contact parent due to a changed or out of service number or for not relinquishing a child to person not on the authorized pick list.
In signing this I understand that THE POINT CDC requires all participants to follow three key rules in order to guarantee all participants safety. One, that kids will listen to instructions and feedback from staff and instructors in a timely fashion. Second, participants will not harm using either words or fists. Third, if anyone makes them feel unsafe physically or emotionally that they will promptly tell a staff member and the youth programs coordinator. Failure to comply with these rules can result in a suspension of up to five days. Parents are responsible for going over these expectations with their child. Repeated occurrences can result in expulsion from program with no refund of camp fees.
Student (if over 18)/Parent/ Guardian Signature
Should be Empty: