*PAGES1*
Dear Parent/Guardian:
Please sign and forward this consent form along with the attached evaluation form to your child’s
teacher. Inform the teacher to return the form in the envelope provided to The Fresh Air Fund OR
fax to my attention at (212) 681-0158 OR email dasirifi@freshair.org within or by MAY 16TH 2016.
Thank you for your assistance regarding this matter. If you have any questions, please do not
hesitate to call me.
Sincerely,
Deborah Asirifi, MSW
Director of Support Services
: 212-897-8969
Community Outreach,
Partnerships and Support Services
PARENT PLEASE COMPLETE AND GIVE TO TEACHER
I,
give permission for
,
Parent/Guardian Name
Teacher’s Name
of
to
Teacher’s Title
School/Agency
provide information about my child,
to The Fresh Air Fund.
Child’s Name
Signature
Date: _____/_____/_____
Parent/Guardian
Day : _____-_____-_______
MM
DD
YYYY
Evening : _____-_____-_______
Parent/Guardian Name:
Address:
City:
State:
Zip:
In accordance with Federal law and U.S. Department of Agriculture policy, The Fresh Air Fund is prohibited from discrimination on the basis of race, color,
national origin, sex, age, or disability. To file a complaint, write to Secretary of Agriculture, Washington, D.C. 20250 or call 202-720-5964 (voice or TDD).
USDA is an equal opportunity provider and employer.
For Teacher Use Only
Child’s Name
Last
First
D.O.B
Dear Teacher:
The Fresh Air Fund is a not-for profit agency that provides free overnight summer experiences in the
country to New York City children through its Friendly Towns Program and Camping Program. In order
to assess whether our programs offer an appropriate setting for this child, we are requesting further
information. Please complete forms and return to The Fresh Air Fund in the envelope provided OR fax
to my attention at (212) 681-0158 OR email dasirifi@freshair.org. Please know that any information you
provide will be kept confidential. THIS CHILD’S APPLICATION IS NOT COMPLETE UNLESS THIS
FORM IS SUBMITTED.
We appreciate your help, and thank you in advance for completing this form. If you have any questions,
please do not hesitate to contact me at (212) 897-8969 or email me at dasirifi@freshair.org.
Name:
Title:
School/Institution:
Supervisor/Director:
Daytime Phone:
Email Address:
Best time to reach you:
How often do you see this child:
How long have you provided services for this child?
What type of services do you provide for this child? Please list special education classes or any
supportive services the child is receiving.
How does this child respond to authority? (Check one)
Responds well all of the time.
Responds well most of the time.
Does not respond well
For Teacher Use Only
How does this child respond to authority? (Check one)
Responds well all of the time.
Responds well most of the time.
Does not respond well
Please describe a situation in which this child had to respond to authority and how s/he reacted.
How does the child respond when called out for disruptive behavior? (Check one)
Responds well all of the time.
Responds well most of the time.
Does not respond well.
Please describe a situation in which this child was reprimanded and how s/he responded (i.e. listens and responds, withdraws, sulks, screams back, runs away, etc.).
How does this child socialize with other children and/or peers? (Check one)
Socializes well all of the time.
Socializes well most of the time.
Does not socialize well.
Please describe the common traits exhibited by this child while socializing (i.e. shares, cooperates, yells, hits, withdraws, etc.)
In what group activities does this child participate?
For Teacher Use Only
This child can best be described as (please check all that apply):
Athletic
Shy
Intellectual
Fearful
Quiet
Well-adjusted
Outgoing
Independent
Mature
Dependent
Immature
Angry
Bright
Slow
Moody
Cheerful
Sad
Happy
Please highlight any stressful events that have taken place in the child’s life that you know of.
Please discuss any behavioral problems exhibited by the child. If possible, include the cause or
precursor to the behavior and appropriate interventions which can be used to prevent or manage
the behavior.
Please share your positive experiences with the child and share child’s greatest strengths.
Please include any other information that you think would be helpful in considering this child for
a Fresh Air Camp or Friendly Towns experience.