Consent to Make Referrals and Share Information

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

Questions? Call Community Connect: 1-800-246-4646 dycd

Universal Participant Intake: Youth & Adult Application |Page 10 of 12 For Applicants Ages 13 and Younger | Updated April 2021

Minor, Participant Waiver, Release, Indemnification of All Claims &

Covenant Not to Sue

NOTICE: THIS IS A LEGALLY BINDING AGREEMENT. Read this document carefully and in entirety. By signing this agreement, you give up your right and the named minor's right to bring a court action to recover compensation or obtain any other remedy for any personal injury or property damage however caused arising out of the named minor's participation in United Activities Unlimited's afterschool, summer camp, night center, weekend programming, and/or workforce programming, and social services programming now or any time in the future.

Acknowledgment of Risk I, in my legal capacity as the parent/guardian of the minor camper/s named below, do hereby acknowledge and agree that participation in United Activities Unlimited's program activities comes with inherent risks. I have full knowledge and understanding of the inherent risks associated with United Activities Unlimited's program participation, including but in no way limited to: (1) slips, trips, and falls, (2) aquatic injuries, (3) athletic injuries, and (4) illness, including exposure to and infection with viruses or bacteria. I further acknowledge that the preceding list is not inclusive of all possible risks associated with United Activities Unlimited's program participation and that said list in no way limits the operation of this Agreement.

Coronavirus/COVID-19 Warning & Disclaimer Coronavirus, COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact. Federal and state authorities recommend social distancing as a means to prevent the spread of the virus. COVID-19 can lead to severe illness, personal injury, permanent disability, and death. Participating in United Activities Unlimited's programs or accessing United Activities Unlimited's buildings, offices, and/or facilities could increase the risk of contracting COVID-19. United Activities Unlimited in no way warrants that COVID- 19 infection will not occur through participation in United Activities Unlimited's programs or accessing United Activities Unlimited's buildings, offices, and/or facilities .

Waiver, Release, Indemnification & Covenant Not to Sue In consideration of my child's (children's) participation in United Activities Unlimited's programs, I, as the parent/guardian of the minor/s named below, agree to release and on behalf of myself and the minor/s named below, my heirs, representatives, executors, administrators, and assigns, HEREBY DO

United Activities Unlimited COVID-19 Camp Family Handbook v.7/2020 12

RELEASE United Activities Unlimited, Inc. and their officers, directors, employees, volunteers, agents, representatives and insurers ("Releasees") from any causes of action, claims, or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which I, the named minor, my heirs, representatives, executors, administrators and assigns may have, now or in the future, against the Releasees on account of personal injury, property damage, death or accident of any kind, arising out of or in any way related to the use of the Releasees programs and facilities including but not limited to United Activities Unlimited's programs, the camp grounds or any related facilities/equipment or participation in United Activities Unlimited's programs whether that participation is supervised or unsupervised, however the injury or damage occurs, including, but not limited to the negligence of Releasees.

In consideration of the named minor's participation in United Activities Unlimited's programs, I, the undersigned parent/guardian of the named minor, agree to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, or costs of any nature whatsoever arising out of or in any way related to the named minor's United Activities Unlimited's programs participation.

I hereby certify on behalf of myself and the named minor that I have full knowledge of the nature and extent of the risks inherent in United Activities Unlimited's programs participation and that I, on behalf of myself and the named minor, am voluntarily assuming said risks. I understand that I and the named minor will be solely responsible for any loss or damage, including personal injury, property damage, or death, the named minor sustains while participating in United Activities Unlimited's programs and that by signing this agreement I, on behalf of myself and the named minor, HEREBY RELEASE Releasees of all liability for such loss, damage, or death. I further certify that the named minor is in good health and has no conditions or impairments, which would preclude his/her/their safe participation in United Activities Unlimited's programs.

I further certify that I am therefore of lawful age (18 years or older) and otherwise legally competent to sign this agreement, and that I have legal capacity to act as the parent/guardian of the named minor. I further understand that the terms of this agreement are legally binding and certify that I am signing this agreement, after having carefully read it, of my own free will.

_____________________________________________________ Parent/Guardian Signature

_____________________________________________________ Parent/Guardian Full Name

_____________________________________________________ Participant/Child Full Name

______________ Date

________________________ Name of UAU Camp Location

United Activities Unlimited COVID-19 Camp Family Handbook v.7/2020 13

CHILD & ADOLESCENT HEALTH EXAMINATION FORM Please

NYC DEPARTMENT OF HEALTH & MENTAL HYGIENE -- DEPARTMENT OF EDUCATION

Print Clearly

NYC ID (OSIS)

TO BE COMPLETED BY THE PARENT OR GUARDIAN

Child's Last Name

First Name

Child's Address

City/Borough

State

Zip Code

Middle Name

Hispanic/Latino? Yes No School/Center/Camp Name

Sex Female Date of Birth (Month/Day/Year ) Male ___ ___ / ___ ___ / ___ ___ ___ ___

Race (Check ALL that apply) American Indian Asian Black White

Native Hawaiian/Pacific Islander Other _____________________________

District __ __ Phone Numbers Number __ __ __ Home ___________________

Health insurance Yes Parent/Guardian Last Name (including Medicaid)? No Foster Parent

First Name

Email

Cell _________ Work

TO BE COMPLETED BY THE HEALTH CARE PRACTITIONER

Birth history (age 0-6 yrs)

Does the child/adolescent have a past or present medical history of the following?

Uncomplicated Premature: ______ weeks gestation

Asthma (check severity and attach MAF): Intermittent

Mild Persistent

If persistent, check all current medication(s): Quick Relief Medication Inhaled Corticosteroid

Moderate Persistent

Severe Persistent

Oral Steroid Other Controller None

Complicated by _________________________________ Asthma Control Status

Well-controlled

Poorly Controlled or Not Controlled

Allergies None Epi pen prescribed

Anaphylaxis Behavioral/mental health disorder

Congenital or acquired heart disorder Drugs (list) __________________________________________ Developmental/learning problem

Foods (list) __________________________________________

Diabetes (attach MAF) Orthopedic injury/disability

Other (list) __________________________________________ Explain all checked items above.

Seizure disorder Speech, hearing, or visual impairment Tuberculosis (latent infection or disease) Hospitalization Surgery Other (specify) Addendum attached.

Medications (attach MAF if in-school medication needed)

None

Yes (list below)

Attach MAF if in-school medications needed

PHYSICAL EXAM

Date of Exam: ___ /___ /___ General Appearance:

Height _____________ cm

( ___ ___ %ile) Nl Abnl

Physical Exam WNL Nl Abnl

Weight _____________ kg

( ___ ___ %ile) Psychosocial Development HEENT

BMI _____________ kg/m2

( ___ ___ %ile) Language

Behavioral Head Circumference (age 2 yrs) _______ cm ( ___ ___ %ile) Describe abnormalities:

Dental Neck

Nl Abnl Lymph nodes Lungs Cardiovascular

Nl Abnl Abdomen Genitourinary Extremities

Nl Abnl Skin Neurological Back/spine

Blood Pressure (age 3 yrs) _________ / _________

DEVELOPMENTAL (age 0-6 yrs)

Nutrition

Hearing

Date Done

Results

Validated Screening Tool Used?

Date Screened < 1 year Breastfed Formula Both

Yes No Screening Results: WNL

____/____/____

1 year Well-balanced Needs guidance Counseled Referred Dietary Restrictions None Yes (list below)

Delay or Concern Suspected/Confirmed (specify area(s) below):

Cognitive/Problem Solving

Adaptive/Self-Help

SCREENING TESTS

Date Done

Results

Communication/Language

Social-Emotional or Personal-Social

Gross Motor/Fine Motor Other Area of Concern: __________________________

Blood Lead Level (BLL) (required at age 1 yr and 2 yrs and for those at risk)

____ /____ /____ _________ ?g/dL ____ /____ /____ _________ ?g/dL

< 4 years: gross hearing

____/____/____ Nl Abnl Referred

OAE

____/____/____ Nl Abnl Referred

4 yrs: pure tone audiometry ____/____/____ Nl Abnl Referred

Vision

Date Done

Results

................
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