2018-2019 BCM After School Application Packet - Brooklyn Children's ...
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2018-2019 BCM After School
Application Packet
This is your BCM After School Program Application Packet.
This packet should contain:
A letter outlining guidelines for the registration process
(1 page)
A copy of the DYCD Application (4 pages)
A copy of the Parent/Guardian Participation Agreement
(1 page)Monday, August 6th, 2018
Dear Parents/Guardians:
We hope this letter finds you well and looking forward to the school year ahead. With generous support from the
Department of Youth and Community Development, the Brooklyn Children's Museum (BCM) is able to offer a tuition-free
after school program, Monday – Friday from 2:30pm to 5:45pm, September 17th 2018 to June 14th 2019 at P.S. 189 located
at 1100 East New York Avenue, Brooklyn, NY 11212. All participants will be provided a snack during the program. This
opportunity is available to children entering Grades K-5 in the 2018-2019 school year.
We are accepting applications from Monday, August 6th to Friday, September 7th, 2018. Placement notifications will be
sent during the week of September 10th 2018.
To enroll your child(ren):
STEP 1: Complete the Web Form
Fill out and submit the BCM 2018-2019 After School Web Form (available on August 6th 2018) at
https://www.brooklynkids.org/education/after-school-programs/
This form allows us to better communicate your child’s status during the registration process.
STEP 2: Download or Pick Up A Copy of The Application
Pick up a copy of the application for each child. Applications will be available at the following locations from August 6th
2018 – September 7th, 2018:
• Brooklyn Children’s Museum Admissions Desk- Hours: Tuesday-Sunday, 10:00am – 5:00pm (CLOSED MONDAYS)
• P.S. 189 – Main Office. Hours: Monday-Friday, 9:00am – 5:45pm (starting on September 6th)
• Online – https://www.brooklynkids.org/education/after-school-programs/
• Downloaded applications must be printed out, completed, and submitted manually.
STEP 3: Drop Off your Completed Application
Parents/guardians must submit the following documents for each child applying to the program:
• a completed DYCD application (even if the child has already participated in any of the museum's after school or
summer programs)
• a signed parent/guardian participation agreement
• a copy of the child’s birth certificate
A completed health form stamped by a doctor can be submitted AFTER you have received confirmation that your child
has been accepted into the program.
Completed applications should be returned to Brooklyn Children’s Museum’s admissions desk or to Uscis Douglass in the
Main Office at P.S. 189. Incomplete applications will not be accepted. Admission to the program is determined by a
lottery, which gives preference to families that attend our parent orientation and to siblings of selected applicants.
A Parent Orientation will be held at the Brooklyn Children’s Museum
(145 Brooklyn Avenue, Brooklyn, NY 11213) from 12pm-1pm on Saturday September 15th.
Please do not hesitate to contact After School Program Manager Kwame Brandt-Pierce if you have any questions –
kbpierce@brooklynkids.org (Please write “BCM After School” in the subject of the email), or at 646-301-2511.
Warmly,
Kwame Brandt-Pierce
After School Program ManagerUniversal Participant Intake
Welcome to DYCD! The following form will allow you or your child to apply to a DYCD program. One application will be accepted per person per site. Submission of an application does
not guarantee eligibility or 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: Gender, Race, Ethnicity, Language, Population Type, and Health
Insurance Status. Responses to these questions will not impact your status in receiving benefits or services and will not be shared without applicant’s permission outside of DYCD.
Income, Household Information, and Education/Work Status will only impact eligibility for select programs.
Part I: Applicant Information
For the purposes of this application, applicant refers to the person applying to receive services. Please select one:
☐ I am completing this application for myself ☐ I am a parent or guardian completing this application for my child ☐ 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 Gender (Select One): Applicant’s Race (Select all that Apply): Applicant’s Ethnicity (Select One):
☐ Male ☐ American Indian and Alaskan Native ☐ Hispanic or Latino(a)
☐ Female ☐ Asian ☐ Not Hispanic or Latino(a)
☐ Gender Nonconforming ☐ Black or African- American
☐ Native Hawaiian and Other Pacific Islander
☐ White or Caucasian
☐ Other
Applicant’s Primary Address (Number and Street): Applicant’s Apt. Number:
Applicant’s City: Applicant’s Zip Code:
How well does the applicant Applicant’s Primary Language (Select One): Other Languages Spoken by Applicant (Select all that Apply):
speak English? (Select One):
☐ English ☐ Albanian ☐ Arabic ☐ English ☐ Albanian ☐ Arabic
☐ Fluent/Very well ☐ Bengali ☐ Chinese* ☐ French ☐ Bengali ☐ Chinese* ☐ French
☐ Well ☐ Fulani ☐ German ☐ Gujarati ☐ Fulani ☐ German ☐ Gujarati
☐ Not well ☐ Haitian Creole ☐ Hebrew ☐ Hindi ☐ Haitian Creole ☐ Hebrew ☐ Hindi
☐ Not well at all ☐ Hungarian ☐ Italian ☐ Japanese ☐ Hungarian ☐ Italian ☐ Japanese
☐ Korean ☐ Kru, Ibo, or Yoruba ☐ Mande ☐ Korean ☐ Kru, Ibo, or Yoruba ☐ Mande
☐ Punjabi ☐ Persian ☐ Polish ☐ Punjabi ☐ Persian ☐ Polish
☐ Portuguese ☐ Romanian ☐ Russian ☐ Portuguese ☐ Romanian ☐ Russian
☐ Spanish ☐ Tagalog ☐ Turkish ☐ Spanish ☐ Tagalog ☐ Turkish
☐ Urdu ☐ Vietnamese ☐ Yiddish ☐ Urdu ☐ Vietnamese ☐ Yiddish
☐ Other: _______________________________________________ ☐ Other: _______________________________________________
☐ Not applicable (only one language spoken by applicant)
*including Cantonese and Mandarin *including Cantonese and Mandarin
The New York City Department of Youth & Community Development invests in a network of community-based organizations and
programs to alleviate the effects of poverty and to provide opportunities for New Yorkers and communities to flourish.Universal Participant Intake
Would the applicant like to receive information/ be Is the applicant any of the following: If the applicant is an individual with a disability, please select
contacted about registering to vote?** (Select One): disability type(s) (Select all that Apply):
☐ Yes An Individual with a Disability? ☐ Yes ☐ No ☐ Decline to answer ☐ Cognitive impairment
☐ No Parent/Legal Guardian? ☐ Yes ☐ No ☐ Hearing-related
Offender/Justice Involved? ☐ Yes ☐ No ☐ Learning disability
Foster Care Participant? ☐ Yes ☐ No ☐ Mental or Psychiatric
*Applicant is eligible to vote in U.S. federal elections if: 1) You are a ☐ Physical/Chronic Health Condition
U.S. citizen; 2) You meet your state’s residency requirements; 3) You
Runaway Youth? ☐ Yes ☐ No
are 18 years old. Some states allow 17-year-olds to vote in primaries Veteran? ☐ Yes ☐ No ☐ Physical/Mobility Impairment
and/or register to vote if they will be 18 before the general election. Active Military Personnel? ☐ Yes ☐ No ☐ Vision-related
Check your state’s voter registration age requirements. ☐ Other: ____________________
☐ Decline to Answer
Part II: Applicant’s (or Parent/Guardian’s) Contact Information
☐ Contact information below is for the applicant ☐ Contact information below is for the parent/guardian
Phone Number #1 ☐ Home Phone Number #2 ☐ Home
☐ Cell ☐ Cell
☐ Work ☐ Work
Email Address: Preferred Method of Contact:
☐ Cell Phone ☐ Home Phone ☐ Email ☐ U.S. Mail
☐ No email address
Part III: Emergency Contact Information
Emergency Contact Name: Emergency Contact Primary Phone Number: ☐ Home
☐ Cell
☐ Work
Emergency Contact Email Address: Emergency Contact’s Relationship to Applicant:
☐ No email address ☐ Emergency contact is parent/guardian of applicant
The New York City Department of Youth & Community Development invests in a network of community-based organizations and
programs to alleviate the effects of poverty and to provide opportunities for New Yorkers and communities to flourish.Universal Participant Intake
Part IV: Applicant’s Education/Work Status
Applicant’s School Type (Select One): ***If applicant is a Part-Time Student or Full-Time Student: Please select applicant’s current grade (Select One):
****If applicant is Not in School: Please select the last grade completed by the applicant (Select One):
☐ Full-Time Student***
☐ Part-Time Student*** Elementary School: ☐ Pre-K ☐ K ☐ 1st ☐ 2nd ☐ 3rd ☐ 4th ☐ 5th
☐ Not in School**** Middle School: ☐ 6th ☐ 7th ☐ 8th
High School: ☐ 9th ☐ 10th ☐ 11th ☐ 12th
Community College: ☐ 1st year ☐ 2nd Year ☐ 3rd year ☐4th Year ☐ 5th year ☐ 6th Year+
College/University: ☐ Freshmen ☐ Sophomore ☐ Junior ☐ Senior
Other: ☐ High School Equivalence (HSE) ☐ Vocational/Trade School ☐ Foreign Degree
Applicant’s current ☐ Employed Full-Time ☐ Employed Part-Time ☐ Retired
work status ☐ Unemployed (Short-Term, 6 months or less) ☐ Unemployed (Long-term, more than 6 months) ☐ Unemployed (Not in labor force)
(Select One): ☐ Migrant Seasonal Farm Worker ☐ Not applicable (applicant is under 14 years of age)
Part V: 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.
Applicant’s Housing Type (Select One):
The applicant lives in a household that is headed by (Select One):
☐ Single Parent - Female ☐ Two Adults – No Children ☐ Single Person - No children ☐ Own ☐ Rent ☐ NYCHA
☐ Single Parent - Male ☐ Two Parent Household ☐ Multigenerational Household ☐ Shelter ☐ Homeless ☐ Other Permanent Housing
☐ Non-related adults with children ☐ Other: ____________________________________________ ☐ Other: ____________________________________________
Applicant’s Household Size (Select One): Total Household Income in the last 12 Months (Select One):
☐ One ☐ Two ☐ Three ☐ Four
☐ Five ☐ Six ☐ Seven ☐ Eight ☐ $0 ☐ $1 to $12,060 ☐ $12,061 to $16,240 ☐ $16,241 to $20,420 ☐ Decline to Answer
☐ Nine ☐ Ten ☐ Eleven ☐ Twelve ☐ $20,421 to $24,600 ☐ $24,601 to $28,780 ☐ $28,781 to $32,960 ☐ $32,961 to $37,140
☐ Thirteen ☐ Fourteen ☐ Fifteen ☐ Sixteen ☐ $37,141 to $41,320 ☐ $41,321 to $50,000 ☐ $50,001 to $60,000 ☐ $60,001 to $70,000
☐ Seventeen ☐ Eighteen ☐ Nineteen ☐ Twenty+ ☐ $70,001 to $80,000 ☐ $80,001 to $90,000 ☐ $90,001 to $100,000 ☐ $100,000+
Sources of Applicant’s Household Income: (Select all that Apply):
☐ Affordable Care Act ☐ Alimony or other ☐ Earned Income Tax
☐ Employment Wages ☐ Child Support ☐ Childcare Voucher ☐ Employment Tax Credit
Subsidy Spousal Support Credit (EITC)
☐ Permanent Supportive ☐ Private Disability
☐ General Assistance ☐ Housing Choice Voucher ☐ HUD-VASH ☐ LIEHEAP ☐ Pension
Housing Insurance
☐ Supplemental Nutrition
☐ Retirement Income ☐ Social Security Disability ☐ Supplemental Security ☐ Temporary Assistance for
☐ Public Housing ☐ Safety Net/Home Relief Assistance Program
from Social Security Income (SSDI) Income (SSI) Needy Families (TANF)
(SNAP)
☐ Unemployment ☐ VA Non-Service Connected ☐ VA Service-Connected
☐ WIC ☐ Worker’s Compensation ☐ Other:________________ ☐ Decline to Answer
Insurance Disability Pension Disability Compensation
The New York City Department of Youth & Community Development invests in a network of community-based organizations and
programs to alleviate the effects of poverty and to provide opportunities for New Yorkers and communities to flourish.Universal Participant Intake
Part VI: 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):
☐ Medicaid ☐ Medicare ☐ State Children’s Health Insurance Program ☐ Military Health Care
☐ Yes ☐ No ☐ Decline to Answer
☐ Direct-Purchase ☐ Employment-Based ☐ State Children’s Health Insurance for Adults ☐ Decline to Answer
If you do not have health insurance, do you want to be contacted by someone else with If you would like to be contacted about signing up for public health insurance, what is your
information about signing up for public health insurance? (Select One): preferred method of contact? (Select One):
☐ Yes ☐ No ☐ Decline to Answer ☐ Email ☐ Phone ☐ US Mail ☐ Via provider ☐ Decline to Answer
The New York City Department of Youth & Community Development invests in a network of community-based organizations and
programs to alleviate the effects of poverty and to provide opportunities for New Yorkers and communities to flourish.Parent/Guardian Name:______________________________________________________________________________________
Parent/Guardian Contact Number:______________________________________________________________________________
Parent/Guardian Email:_______________________________________________________________________________________
Child/ren’s Name(s):_________________________________________________________________________________________
Child/ren’s Age(s): __________________________________________________________________________________________
2018-2019 After School Parent/Guardian Participation Agreement
Attendance Policy: If your child is selected for the program, daily participation is expected. Only 1 unexcused absence
per 30 day period will be permitted for the duration of the program. More than 3 unexcused absences in a 3 month
period may result in your child being removed from the program. An unexcused absence is defined as any absence not
communicated in advance to the After School Program Manager. Absences due to illness must be accompanied by a
note from a doctor.
Changes to a Child’s Regular Dismissal Routine: Parents must communicate any changes to a child’s regular dismissal
routine directly to the BCM After School Program Manager prior to dismissal time. Changes to a child’s regular
dismissal routine must be communicated in writing via signed letter, email, or text. Texts must come from a phone
number listed on the BCM authorized contact list. Emails must come from an email address listed on the authorized
contact list.
Early Pickup Policy: If your child is selected for the program, he/she is expected to participate each day for the entire
day. Only 2 early pickups per month will be permitted for the duration of the program. More than 2 early pickups per
month may result in your child being excused from the program. An early pickup is defined as any pickup occurring
before the program’s regular dismissal time of 5:45pm.
Late Pickup Policy: The program ends at 5:45pm, Monday through Friday. If your child is selected for the program, you
are expected to pickup your child promptly at 5:45pm. Failure to pickup your child on time may result in your child
being excused from the program. Only an adult that is listed on our approved guardian list may pickup a child. If you
need to make arrangements for an unlisted adult to pickup your child, those must be communicated in writing to the
After School Program Manager in advance via letter, text, or email to kbpierce@brooklynkids.org.
Emergency Contact Policy: In the event of an emergency, it is important that program staff have a working contact
number for parents/guardians. If your child is selected for the program, you are expected to maintain a working
contact number for emergencies. If this number should change for any reason, you must communicate this change in
writing to the After School Program Manager at kbpierce@brooklynkids.org or 646 301 2511.
If you agree to the above-mentioned terms and policies, please sign and date this form below.
Signature___________________________________________ Date___________________________________You can also read
