Admission Application
2015-2016
GO Project Overview
The GO Project shapes the futures of New York City public school children by providing critical academic,
social and emotional support starting in the early elementary years. GO provides year-round educational
and family support services to children who are performing below grade level and equips them with the
confidence and skills needed to succeed at school, at home and in life. After completing GO Project,
students enter high school prepared for the academic challenges that lie ahead of them and confident
that they are able to succeed academically, socially and emotionally.
Requirements for Participation
A year-round & year-to-year commitment is required for participation in the GO Project. This includes
participation in GO Summer, a five-week full-day program and GO School, a seven-month, half-day
Saturday academic program during the school year.
Program Description
GO Summer
Our summer program is a summer of learning and fun for our students. The summer session will run
Monday through Friday, 8:45am-5:00pm, from July 6th to August 7th, 2015. The GO Project is hosted at
private schools in the surrounding neighborhood, offering access to beautiful and spacious facilities for
dynamic programming. The intensive academic curriculum focuses on reading, writing, and math
through interactive, hands-on activities. A social-emotional learning curriculum is also implemented in
each classroom, using high quality literature to explore themes of self-awareness, self-management,
social awareness, and relationship skills. With a 4:1 student to adult ratio in each classroom (Head
Teacher, Teaching Assistant, Student Teacher, High School Intern), our summer program ensures
individual attention is given to each student. All academic blocks during the summer take place from
9:00am-2:00pm. Between 2:00-5:00pm, students participate in enrichment classes such as martial arts,
soccer, music, dance, and theatre. Lunch is served daily, free of charge, and is nutritiously prepared each
morning by the kitchen staff from our partner private schools.
GO School
The GO Project academic program continues into the school year with programming from 9:30am12:30pm on Saturdays from October to April. All students who attend the summer program are
REQUIRED to participate in GO School. The objective is to build confidence and support the academic
needs of the students throughout the school year. Similar to the structure of the summer program, our
students benefit from small classroom instruction and individualized attention. A certified Head Teacher
and up to 4 volunteer tutors lead each classroom. GO School programming ensures that our students
maintain the gains made throughout the summer and that they remain successful and supported
throughout the academic year.
Family participation is a core value at the GO Project. During the year, the GO Project offers workshops
and individual support to our parents. This component of the GO Project is designed to empower
parents/guardians, to create a positive learning environment at home, and to address a variety of topics
that support the whole child. GO Project’s staff work directly with families to provide services in three
core areas: year-round counseling, family support services, and educational advocacy.
How to Apply to the GO Project
Enrollment Eligibility
ALL STUDENTS MUST MEET THE ENROLLMENT CRITERIA LISTED BELOW:
1. Students must be currently enrolled in Kindergarten- 3rd Grade.
2. Students must exhibit academic challenges in at least one core academic subject area (as
identified by the student’s public school teacher).
3. Strong preference is given to students who quality for free or reduced priced lunch.
4. Student must attend school within GO’s catchment area (see details below). A subset of these
schools will be given priority enrollment (details below).
5. Families must commit to the GO Project’s year-round & year-to-year programming, which
means consistent student attendance from July 2015 to April 2016 (no more than 3 absences
during program cycles, GO Summer or GO School).
*Sibling Enrollment: GO Project gives priority to siblings of students that already attend GO. In order for
siblings to attend, they must meet our enrollment criteria.
Priority Enrollment:
Students enrolled in public schools listed below will be given enrollment priority:
GO Avenues
259 Tenth Avenue,
between
th
25 and 26th Streets
GO GCS
86 Fourth Avenue,
between
th
10 and 11th Streets
GO LREI
272 Sixth Avenue,
at the corner of
Bleecker Street
Priority Public School
P.S. 3, P.S. 11, P.S. 33
Priority Public School
P.S. 15, P.S. 19 , P.S. 34,
P.S. 63, P.S. 64
Priority Public School
P.S. 20, P.S. 134, P.S.
137, P.S. 140, P.S. 142,
P.S. 188
*STUDENTS FROM NON-PRIORITY PUBLIC SCHOOLS: Students from our partner public schools
within the catchment area (In Manhattan south of 14th street and the Chelsea area) will be
considered based on school or parent recommendations as well as direct referrals from other
sources.
Application Process:
 The following documents must be submitted by the April 6th deadline in order for your child’s
application to be processed. Applications may be considered on a rolling basis so early
submissions are strongly encouraged.
 Completed Student Enrollment Form (ALL sections must be filled out).
 Student Evaluation Form from your child’s classroom teacher.
 Copy of Individual Education Plan (IEP) or Section 504 *if applicable. Only full IEPs will
be accepted.
 Copy of most recent report card and/or progress report.
 Copy of Promotion in Doubt (PID) letter from your child’s school *if applicable
 Parents must attend a program tour and an interview prior to being accepted into the program.
 Acceptance notifications will be mailed out by Monday, May 11th, 2015. Once accepted, GO
Project staff will contact families to schedule a comprehensive intake meeting.
Fees and Scholarships:
 There is a program fee of $80 for each student. The program fee can be paid by check or money
order and must be submitted during parent orientation.
 Scholarships are available for families that qualify.
 The Scholarship Application must be submitted with the Student Application Form.
 Scholarship availability is based on the financial needs of our families and the scholarship funds
available to the GO Project.
 If you have applied for a scholarship, but have not received paperwork by the parent orientation
date, please bring attend your assigned orientation and speak to a GO Project staff member.
May 11th, 2015
Important Dates
Attend program tour and interview. Interview date and time to be
confirmed with you by GO Project staff.
Completed Student Application Form 2015-2016, Report Card, GO
Project Student Evaluation Form, and Scholarship Application (optional)
are due.
Acceptance notifications will begin to be mailed out.
May/June (TBA)
Attend a Parent Orientation. Program Fee due.
May/June (TBA)
Intake Sessions for parent/guardian of accepted students
July 6th, 2015
First day of the summer session (8:45 AM-5:00 PM).
February 21st, 28th
March 7th, 14th, 21st, 28th
April 6th , 2015
For more information, please contact the GO Project office at 212-533-3744 or via email at
info@goprojectnyc.org
Internal Use Only
Date: ________________________
[ ] Accepted
[ ] Ineligible
[ ] Waitlisted
[ ] Referred
GO Project Student Application Form
2015-2016
Please make sure to complete all the sections and submit this form with all required documents to:
The GO Project at 50 Cooper Square, 3rd Floor, New York, NY 10003
COMPLETE APPLICATIONS ARE DUE by Monday, April 6th, 2015
Applications may be considered on a rolling basis so early submissions are strongly
encouraged.
PARENT TOUR & INTERVIEW: Prior to acceptance at the GO Project, the student’s
parent/guardian must attend a parent tour and interview. Both the parent tour and
interview will take place at Grace Church School (86 Fourth Avenue), LREI (272 Sixth Avenue),
or Avenues (259 10th Avenue).
Once we receive your Application Form and Student Evaluation, we will contact you to schedule
the mandatory tour and orientation between 10am-1pm on the following dates: February 21st,
February 28th, March 7th, March 14th, March 21st, March 28th, April 4th, April 11th.
Applicant Information:
Child’s First name __________________________ Last name: ______________________
Date of Birth (mm/dd/yyyy): _____/_____/______
Gender:
Male
Female
Home Address: _____________________________________________ Apt: ________
City: ______________________________
State: ________
Zip Code: ___________
Home Phone: ___________________________________________________________
Mailing Address (if different):________________________________________________
Present Grade: ______ Public School _____________________________
T-shirt Size ______
Is your child currently receiving free or reduced lunch in his/her public school?
Yes
NO
Parent/Caregiver Contact:
Mother/ Guardian’s Name: __________________________
Living with child
Financially supporting child
Mobile Phone: __________________________
Work Number: ____________________
Email Address: __________________________
Is this person an emergency contact?
Currently employed?
Yes
Yes
No
No Monthly salary: $____________________
Preferred Language for Communication (Check All that Apply)
English
Spanish
Mandarin
Cantonese
Other:______________________
Father/ Guardian’s Name: ____________________________
Living with child
Financially supporting child
Mobile Phone: __________________________
Work Number: ____________________
Email Address: __________________________
Is this person an emergency contact?
Currently employed?
Yes
Yes
No
No Monthly salary: $____________________
Preferred Language for Communication (Check All that Apply)
English
Spanish
Mandarin
Cantonese
Other:______________________
Authorization Pick-Up/Emergency Contact:
Please list three other emergency contacts (over the age of 16), that we can call if needed and who are able to
pick up your child from programming:
1)___________________________________________________________________________________________
Name
Relationship
Phone Number
2)___________________________________________________________________________________________
Name
Relationship
Phone Number
3)___________________________________________________________________________________________
Name
Relationship
Phone Number
1
The information below will not affect your child’s enrollment and is solely for statistical purposes.
_______________________________________________________________________________________
a) My child’s ethnicity/race:
White/Caucasian
Black/African American
Hispanic/Latino
Asian
Multi-racial
Other: ___________________________________
b) Language Spoken at home with my child:
English
Spanish
Mandarin
Cantonese
Other:__________________________
c) Annual Household income (required, documentation may be requested):
Less than $14,999
$15,000-$19,999
$20,000-$24,999
$25,000-$29,999
$30,000-$34,999
$35,000-$39,999
$40,000-$44,999
$45,000-$49,999
$50,000- $54,999
$55,000-$59,999
$60,000-$69,999
$70,000-$79,999
$80,000-$89,999
$90,000 +
d) Household Size:
Single Parent Household
Two-Parent Household
Number of people in the household (including you and your child): ___________
e) I heard of GO from:
GO staff
GO participants
Friends
Social Worker
School Teacher/Administer
Other: _____________________
**********************************************************************************
Applicant Medical/Behavioral Health Information:
1) Please mark if your child has any of the following medical/behavioral health conditions:
Vision
Hearing
Heart
Seizures
Allergy
Asthma
ADHD/ADD
Other: _______________
If Yes, Please specify: ___________________________________________________________________
2) Does the condition noted above require special medical/health assistance?
Yes
No
If Yes, Please specify: ___________________________________________________________________
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3) Does your child take medication?
Yes
No
If Yes, please name any medication your child takes: _________________________________________
4) Do any of the medications listed above require administration during the summer program hours (8:45am5:00pm)? Please note- we are unable to administer medication during our Saturday school-year program
(9:30-12:30pm).
Yes
No
Applicant Academic Information:
a) My child’s CURRENT classroom setting is :
General Education
ICT (Integrated Co-Teaching)
12:1
12:1:1
Other: ________________
b) My child receives special education services and has an Individualized Education Plan (IEP) or Section 504:
c)
IEP
Section 504
N/A
If applicable, please submit copy of your child’s full IEP or Section 504.
If applicable, my child receives:
SETTS
speech & language
physical therapy
counseling
occupational therapy
1:1 paraprofessional (behavior)
Behavioral Intervention Plan (BIP)
1:1 paraprofessional (health)
Other: _____________________
d) My child receives English as a Second Language (ESL) services at school:
Yes
No
a. If yes, your child’s current ESL Level:
Beginner
Intermediate
Advanced
If you are not sure, please obtain this information from your child’s teacher
e) My child has repeated a grade:
Yes
No
a. If Yes, what grade(s) and in what year(s) ______________
f)
My child is currently Promotion in Doubt (PID) for the current school year:
Yes
No
*If yes, please submit the PID notification letter from the school.
g) Did you meet with your child’s public school teacher for parent-teacher conferences?
Fall
Spring
Both
Neither
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h) Has your child been suspended this year?
Yes
No
If so, when_______________________________________________
I understand that GO Project is a year-round and year to year program. I am committed to my child’s
participation in GO’s year-round program for the 2015-2016 academic year. I am committed to my
child’s continued enrollment until he/she graduates from the program 8th grade.
Additionally, I understand that GO Project has a three absence policy and that my child cannot be
absent for more than 3 days during GO Summer 2015 and 3 days during GO School 2015-2016.
Child’s Name:_______________________________________
Parent/Guardian: ____________________________Signature_________________________________
____________________________________________________________________________________________
SCHOLARSHIP APPLICATION (Optional)
Are there current financial hardships that are affecting your ability to pay the Program Fee? If so, please briefly
explain and attach the appropriate documentation to support your response.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
You can request an amount from a full scholarship ($0) to $60 for financial aid to reduce the cost of the Program
Fee for your child.
Request Amount: $___________
Before you submit, please check the following documents are prepared:
Application Check List:
 Completed Student Enrollment Form (ALL sections must be filled out)
 Student Evaluation from your child’s public school teacher
 Copy of Individual Education Plan (IEP) and/or Section 504
*if applicable. Only full IEP will be accepted.
 Copy of most recent report card and/or progress report
 Copy of Promotion in Doubt (PID) letter from your child’s school
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ACADEMIC RELEASE FORM
The GO Project provides academic assistance to elementary and middle school students who are below grade level. This
form gives the GO Project permission to have access to any relevant academic information that will help us create
individualized academic plan for your child in our comprehensive year-round programming. Once enrolled in the GO
Project, this information can be accessed each year for the duration of the commitment to GO Project programming.
In order for the GO Project to provide the best services for your children it is important for us to have access your child’s
school records including information about enrollment, grades, test scores, OSIS numbers, Individualized Educational
Plans, and attendance information. Additionally, we ask on a yearly basis that your child’s public school teacher complete
a student evaluation form documenting their strengths and areas for development. Individualized Educational Plans,
student evaluations, and report cards will be shared with your child's GO Project teacher.
I hereby give the GO Project my permission to access my child’s school records by the professional staff at the GO Project.
This includes enrollment information, grades, test scores, OSIS numbers, Individualized Educational Plans, and attendance
information, as well as a completed Student Evaluation Form, and relevant academic information about my child for the
duration of their participation at the GO Project.
Child’s name _______________________________________________________________
Parent/Guardian Name _______________________________________________________
Parent’s signature __________________________________________
Date __________
_____________________________________________________________________________________________________________________
PERMISSION TO PUBLISH PHOTOGRAPHS & OTHER INFORMATION
I hereby authorize the GO Project to take and use black and white, color, slide, and/or video photographs of my child or
me for use in news media, newspaper, fundraising, and/ or additional materials for any purpose that the GO Project
deems appropriate.
I understand and agree that I will receive no financial compensation for publication of any photos and information. I
understand that this permission covers the entire time my child is enrolled in the GO Project.
Child’s name ______________________________________________________________
Parent/Guardian Name _______________________________________________________
Parent’s signature __________________________________________
Date ___________
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Summer Field Trip Permission Slip 2015-2016
My child ________________________ (first and last name) has my permission to attend GO Project field trips during GO Summer.
During these trips my child will:





Be supervised by GO Project Staff, Interns, and Volunteers.
Travel by subway, both ways.
Be expected to behave in a safe manner while traveling to and participating in all field trip activities.
Wear his/her GO Project t-shirt.
Adhere to all GO Project rules and regulations.
In the event of an emergency, I can generally be reached at the following contact numbers:
Home # ____________________ Cell #____________________Work #______________________
If I cannot be reached in the event of an emergency, the following person is authorized to act on my behalf:
1) Name___________________________________ Relationship_______________________________
Home # ______________________ Cell #_____________________Work #_______________________
2) Name____________________________________Relationship________________________________
Home # ______________________ Cell #_____________________Work #_______________________
Physician’s Name___________________________ Phone Number________________________________
Physician License Number _____________________ Physician’s Address_____________________________
Family Medical / Hospital Insurance ________________________________________________________
Insurance Company: ________________________Policy # _____________________________________
I give my permission for the adult in charge of the activity to take my son/daughter to a medical facility, if necessary. In case of
emergency, if none of the above can be contacted, I consent to treatment for my son/daughter under the supervision of and as
deemed necessary by a physician licensed under the Medical Practice Act. I agree to the release of any records necessary for
treatment, billing, or insurance purposes.
____________________________
Parent/Guardian Name
______________________________
Signature of Parent/Guardian
________________
Date
Dear Parent or Guardian,
8
We are working to ensure that the services we provide your child are making a difference in his or her life. As
part of this effort, we would like to collect some data that will enable us to track your child’s academic progress.
All of our research efforts are being overseen by researchers at an independent research firm called Glass Frog
Solutions. The researchers will use the information to learn more about our services and whether they promote
learning.
We are requesting access to your child’s OSIS number. We are also asking to talk to your child very briefly about
your child’s experiences in the program. We will ask very simple questions about what the child finds interesting
and what his/her favorite things about the program are. The interviews will be audio recorded; the recording will
only be used for research purposes and then destroyed. Finally, we are also asking to submit a very brief survey
to your child about whether he or she finds the program valuable.
We value your child’s privacy and would not ask for this information if we did not think it would improve the
quality of the programs we provide. We assure you that we will keep all of your child’s information strictly
confidential and will not share it with anyone outside of the immediate research team. We further assure you
that we are only interested in using this information for research and programming purposes.
By signing this consent form, you are not waiving any legal rights. You are giving The GO Project and the small
team of external researchers permission to access your child’s academic records and interview responses. All
information will be strictly confidential. Also, should you change your mind and decide that you do not want us
to access your child’s records, you may contact us and withdraw at any time. Your participation is entirely
voluntary. There are no risks to participating other than the risks your child may ordinarily encounter at school.
Please complete the second page of this consent form and send it back in with your child.
If you have any questions about how your child’s information will be used, please contact the lead investigator,
Dr. Rebecca Casciano (rebecca@glassfrog.us).
Respectfully Yours,
The GO Project Team
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The GO Project Parental Consent Form
CHILD’S NAME: ___________________________________________
CHILD’S date of birth: _________________________________
I give permission to The GO Project and Glass Frog to access my child’s school records and briefly interview and
survey my child. This information will be kept confidential and will be used to evaluate the effectiveness of the
program as it serves the learning needs of my child. I understand that no reports will ever be made in which my
child’s personal identity is revealed through name, gender, race, or other personal characteristics.
By signing below, I am agreeing to allow my child to participate voluntarily in the evaluation and certify that I
have read and understand the terms of my child’s participation.
Yes, I allow my child to participate.
__________________________________
Signature of Parent/Legal Guardian
No, I refuse for my child to participate.
__________________________________
Date
__________________________________
Printed Parent/Legal Guardian Name
I give permission to the Glass Frog research team to audio record my child’s interview. This information will be
kept confidential and will be used to evaluate the effectiveness of The GO Project in serving the learning needs of
my child.
By signing below, I am agreeing to allow my child’s interview to be audio recorded.
Yes, I allow my child’s interview to be recorded.
No, my child’s interview may not be recorded.
__________________________________
Signature of Parent/Legal Guardian
__________________________________
Date
__________________________________
Printed Parent/Legal Guardian Name
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Dear Parent or Guardian,
The following “Super Storm Sandy SSBG Eligibility/Consent for Services Form” is required for all families. The GO
Project received funding following Hurricane Sandy through which all students and families are provided with
additional services such as snacks during program time and additional GO Families parent workshops.
If you have any questions or concerns, please do not hesitate to contact the GO Project office at 212-533-3744 or
at info@goprojectnyc.org.
Respectfully Yours,
The GO Project Team
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Super Storm Sandy SSBG Eligibility/Consent for Services Form
Services are offered voluntarily and without cost under the Super Storm Sandy Supplemental Social Services Block Grant
funding. In order to receive these specific services you must be a victim of Super Storm Sandy, live in a Sandy–impacted
community or be directly impacted by Super Storm Sandy. The following policies and procedures are provided so that
individual’s rights are protected in accordance with Federal and State requirements:
The right to services that are considerate, safe, and respect one’s personal liberty.
The right to receive services without regard to race, color, gender, religion, age, handicap, marital status, national or
ethnic origin, or sexual orientation.
The right to ongoing participation in the planning of services to be provided and in the development and periodic revision
of the services plan.
The right to refuse service.
The right to give or refuse written signed consent if information is to be released.
The right to privacy and confidentiality of records except as otherwise provided by law or when a release of information is
signed. Your records may be reviewed by our state and/or federal funders for the purpose of determining adherence to
contractual obligations.
In the best interest of children and families, the Program is required to report suspected child abuse/neglect and may do
so without consent.
The right to referral, as appropriate, to other providers’ services at anytime, including upon discharge from program
I, ____________________________________, agree that I would like the services described above provided to me by the
staff of the Program or a designated subcontractor. I attest that I have met at least one of the eligibility requirements; 1.) I
am a victim of Super Storm Sandy, 2.) I live in a Sandy-impacted community, 3.) I’ve been directly impacted by Super
Storm Sandy.
Additional Program Specific Requirements:
_____________________________________________
Client/Participant Signature
_____________________________________________
Program Staff
____________________________
Date
____________________________
Date
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