Scholar's Last Name

First Name

Middle Name

Street Address

Town

State

Zip Code

Scholar's Cell (if applicable)

Home Phone

Birthdate

Grade Entering in the Fall 2020

School

My Scholar will attend all sessions on weekdays from June 29- August 21, 2020 unless noted here:

Please check the program activities that interest your Scholar

ArtGuitarPianoDrumsMartial ArtsDanceRoboticsCreative WritingScienceReadingPuzzles and Games

Scholar’s Race/Ethnicity:

AsianBlack/African AmericanHispanicWhiteAmerican Indian/Alaska NativeNative Hawaiian/Other Pacific Islander

Scholar’s Gender:

FemaleMaleOther

T-Shirt Adult Size:

SmallMediumLargeXLarge

Parent/Legal Guardian #1

First Name

Last Name

Relationship

Cell Phone

Email

Address (if different from Scholar’s)

Parent/Legal Guardian #1

First Name

Last Name

Relationship

Cell Phone

Email

Address (if different from Scholar’s)

Emergency Contact #1 Name

Cell Phone

Emergency Contact #2 Name

Cell Phone

Parent Marital Status:

SingleMarriedCivil UnionLiving TogetherSeparatedDivorcedWidowed

Parent Primary Language: How well do you speak English?

Very wellWellNot wellNot at all

Do you speak a language other than English at home?

NoYes, it is:SpanishFrenchASLOther

Parent Work Status:

Employed Full-timeEmployed Part-timeUnemployedRetiredReceivingDisability

Family Housing:

We own homeRentPublic HousingSection 8Live with Family/FriendsHomelessShelter

Youth Housing:

Live with Parent/GuardianIn Foster CareGroup HomeLive with FriendsLive with Relatives

Please check below if your family is currently enrolled in one of the following programs.

SNAP (Supplemental Nutrition Assistance Program)WIC (Women, Infants, and Children Nutrition Program)Health Insurance Benefits (HUSKY, Medicaid, etc.)TANF (Temporary Assistance to Needy Families)EITC (Earned Income Tax Credit)

Certification and Consent:

I hereby certify that the information on this form is complete and correct to the best of my knowledge. I consent to have this information entered and saved into the LifeBridge Community Services confidential client database. I understand that client records are confidential and are not released or shared with anyone outside of LifeBridge Community Services without the parent/guardian’s written consent except as required by law.

I have read the Urban Scholars Program responsibilities and both my Scholar and I agree to meet those expectations.

I give my permission for my child to be photographed, recorded, and/or videotaped by LifeBridge Community Services during agency-sponsored activities. I also understand that these photos, audio, and/or videotapes may be used in future publications, as marketing material or as training material.

I understand that LifeBridge Community Services is operating the Urban Scholars Program with great care, but that COVID-19 is a transmittable disease and my child is only in LifeBridge’s care during the daytime program. I cannot hold LifeBridge Community Services liable if my child contracts COVID-19 or any other transmissible illness.

I give my permission for (Scholar’s name) to attend the Urban Scholars Summer Program at LifeBridge Community Services and to participate in all activities, subject to the authority of the Urban Scholars Program Director.

Parent/Guardian Signature

Date

Scholar's Last Name

First Name

Middle Name

Street Address

Town

State

Zip Code

Birthdate

Age as of June 29, 2020

Scholar’s Health Insurance Provider

Medicaid/HuskyMedicareNo InsuranceOther

If Other, please name

Insurance Policy Number:

Group ID

Health History Information:

Date of Last Tetanus Immunization:

Current Height

Current Weight

Primary Care Physician

Physician Phone

PERMISSION TO TREAT

Connecticut law states that except in the case of an emergency which threatens life or limb, parent or guardian must sign consent to treat for a patient under the age of 18. Please complete this section to allow your child to receive treatment for an accident, injury or illness at a medical facility.

• Scholar will be transported to Bridgeport Hospital

• Program staff will always notify parent/guardian of need for medical care.

• Scholar Health History and Registration Forms will be shared with the Medical Facility staff.

I request and authorize, Southwest Community Health Care Center or Bridgeport Hospital, or nearest medical center, and its personnel to deliver medical care to my child listed here: . I also authorize LifeBridge Community Services to share Scholar Health History with the Medical Provider. This authorization will expire one year from the date of signature unless otherwise stated.

This health history is correct so far as I know and the person herein described has permission to engage in all prescribed program activities except as noted. EMERGENCY AUTHORIZATION: I hereby give permission to the medical personnel selected by the Urban Scholar Director to order x-rays, routine tests and treatment for me(staff) or my child, and in the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Urban Scholar Director to hospitalize, secure treatment for and to order injection and/ or anesthesia and/or surgery for me(staff)/or my child as named above. This form may be photo-copied for use off property. I also give permission for the Urban Scholar Program to provide routine medical care for my child.

Parent/Guardian Signature

Date

Scholar Name

Age

My child has a food allergy(s) to:

My child has non-food allergy(s) to:

The plan of care is:

Strict AvoidanceMedication as required. Please attach medical provider’s order/ care plan.Other

Please Specify

My child requires medication for treatment of:

Please attach your medical provider’s order/ care plan.

My child has special dietary, dental or oral needs: The plan of care is:

My child is hearing or vision impaired

HearingVision

The plan of care is:

My child as a chronic illness or diagnosis of:

The plan of care is:

My child has cognitive, emotional and/or physical developmental needs related to the diagnosis of:

The best way to support my child with this is to:

My child has had a serious illness, hospitalization or accident in the last 12 months. Please explain:

My child has required psychiatric counseling/hospitalization

Any specific activities to be limited by physician’s advice. (Send with Physician’s orders)

If you would like to be contacted by Camp First Aider or Camp Director to further discuss and plan for the needs of your child. Please indicate best number or email for contact:

My child DOES NOT require any plan of care for special health needs:

Parent/Guardian Signature

Date