GO MIDDLE
Re-Enrollment Form 2015-2016
(Current 5th-7th Grade Students)
Requirements for Participation
A year-round & year-to-year commitment is required for participation in the GO Project. This includes
participation in GO Summer, our five-week full day program and GO School, our seven-month half-day
Saturday academic program during the school year.
Important Dates
March 28th 2015
May/June (TBA)
Student Re-Enrollment Form 2015-2016, Report Card, GO Project
Student Evaluation Form, Updated IEP (if applicable) and Scholarship
Application (optional) are DUE.
Attend a Parent Orientation. Program Fees due.
July 6th, 2015
First day of the summer session (8:45 AM-5:00 PM).
July 10th to July 12th, 2015
Current 6th/Rising 7th Grade Leadership Camp -RAMAPO for Children
August 7th, 2015
LAST DAY OF GO SUMMER (*Half-Day: Dismissal at 12:30pm)
Re-Enrollment Process:
 The following documents must be submitted by the March 28th deadline in order for your reenrollment to be completed.
 Completed Student Re-Enrollment Form (ALL sections must be filled out).
 Student Evaluation Form from your child’s classroom teacher (5th grade students only)
 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.
Fees and Scholarships:
 There is an annual 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 who 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.
Key Highlights of GO Middle Programming:
Teen Talk: Offered for all GO Middle students weekly. Teen talk provides an opportunity for our
students to work on social skills and character development. Through their participation, they will
develop greater self-awareness, self-confidence and healthier interpersonal relationships.
Topics include, but are not limited to:
 Peer Relationships
 Conflict Resolution
 Sexuality/Puberty
 Personal Hygiene
 Time management Decision Making
 Self-Esteem
* Topics will be discussed and explored with the students in a safe, age-appropriate, and educational
space.
GO Bridges: GO Bridges provides a unique opportunity for our students to prepare for a successful
transition to middle school and high school. Students will have the opportunity to discuss and express
their excitement, anxieties, and concerns regarding the upcoming transition to middle/high school.
They will participate in skills-based activities that focus on building self-confidence and readiness for this
next phase of their academic careers. Parents/guardians will also participate in concurrent workshops
to ensure comfort and familiarity with the choice process.
Leadership Camp (7th Grade Only): The Leadership Camp is a two-night, three day overnight camp. This
camp will be facilitated in partnership with Ramapo for Children. Ramapo provides adventure-based,
experiential learning experiences that promote positive character values, build social and learning
competencies, and enhance self-esteem. The program is directed by highly experienced Ramapo
facilitators and certified GO Teachers. The Leadership Camp will be held from July 10th to July 12th
(Friday to Sunday). The Leadership Camp is mandatory for all rising 7th graders participating in GO
Middle Summer Program. There is a mandatory GO Summer-Middle orientation for all parents. The
orientation will provide information on GO Summer-Middle and the leadership camp.
For more information, please contact the GO Project office at 212-533-3744 or via email at
info@goprojectnyc.org
Internal Use Only
Date: ________________________
[ ] Complete
[ ] Incomplete
GO Project Re-Enrollment 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
Submission Due: Saturday, March 28th , 2015
Applicant Information:
Child’s First name __________________________
Last name: ____________________
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?
Yes
No
Currently employed?
Yes
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?
Yes
No
Currently employed?
Yes
No
Monthly salary: $________
Preferred Language for Communication (Check All that Apply)
English
Spanish
Mandarin
Cantonese
Other:______________________
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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 +
Household Size:
Single Parent Household
Two-Parent Household
Number of people in the household (including you and your child): ___________
**********************************************************************************
The GO Middle Program allows your child to report to and be dismissed from the program site on
their own. In order to ensure your child’s safety, please complete the following questions.
1) Is your child reporting to the program on his/her own?
Yes
No
IF Yes, please complete the authorization form included in this re-enrollment form.
2) Do you allow your child to go home on his/her own during GO Summer?
Yes
No
3) IF APPLICABLE, do you authorize your GO Middle child to pick up his/her younger sibling also
enrolled at GO?
4)
Yes
No
Authorization Pick-Up/Emergency Contact:
Please list three other emergency contacts (over the age of 16), who 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
2
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: ___________________________________________________________________
3) Does your child take any 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
(9:30am-12:30pm).
Yes
No
Applicant Academic Information:
a) My child’s CURRENT classroom setting is :
General Education
ICT (Integrated Co-Teaching)
15:1
12:1
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 unsure, please obtain this information from your child’s teacher
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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 this 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
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 the program in 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.
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Request Amount: $___________
Before you submit this form, please check that 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 (5th grade/rising 6th grade only).
 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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GO Middle Student Independent Arrival/ Dismissal
Authorization Form
Student Name: ________________________
Date of Birth: _________________
Parent Name: __________________________
Parent/Guardian Authorization:
I give permission for my child to arrive to the program on his/her own and to be
dismissed without me or an authorized picker upper present. He/she is responsible for
leaving the program site independently at dismissal.
My GO Middle Child is authorized to arrive to the program and pick up his/her
sibling(s)______________________________ without me or an authorized picker upper
present. He/she is responsible for leaving the program site with his/her sibling (s)
independently at dismissal.
Student Independent Travel Agreement
As a responsible GO Middle student, I hold myself accountable to the following:
1) I will report directly to/from home to GO Project Programming
2) I will arrive on time and sign myself out with my teacher at dismissal.
3) I understand that GO staff will communicate any tardiness and/or absences with
my parent/guardian daily.
4) I will not engage in any unsafe behavior during my travels to/from GO Project.
____________________________________________
Parent/Guardian Signature
_________________________
Date
____________________________________________
Student Signature
_________________________
Date
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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
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Dear Parent or Guardian,
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 simply giving The GO Project and the
small team of external researchers permission to access his/her 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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GO Middle Summer Leadership Camp 2015
Participation Information and Consent Form
(6th Grade/Rising 7th Grade Only)
PLEASE NOTE: Each participant must provide the GO Project with the following information in order to participate
in the Leadership Camp in partnership with Ramapo for Children. Please write any limitation(s) and/or health
related issues that we should be aware of in question #4
I _____________________________________, give permission for my child, _____________________
to participate in the overnight Leadership Camp in partnership with RAMAPO for Children from July 10th
to July 12th. I understand that this is a mandatory camp for all rising 7th graders attending the GO
Summer 2014 program. I also understand I must attend the GO Summer orientation and prepare
necessary materials for my child to attend this camp. I agree to drop-off and pick-up my child at Grace
Church School located on 86 Fourth Avenue, between 10 th and 11th Streets.
_____________________________________
Student Information:
_______________________
Parent/Guardian Signature
Date
Name: ____________________________________ Date Of Birth: ________________________
Address: ________________________________________________________________
Telephone#: __________________________________
Parent/Guardian Emergency Contact Information:
Name: ________________________________________________________________________
Address: ___________________________________________________________
Home Telephone: ___________________
Work Telephone: ______________
Cell Phone: _______________________
Email: ________________________________
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Health/ Medical Information:
1) Your Child’s Insurance Carrier: ___________________________________________
2) Policy Number: ________________________________________________
3) Does your child have any limiting, temporary or permanent injuries, illnesses conditions or disabilities that
may interfere with his/her participation in a physically active, outdoor adventure program that may include
warm-up games, initiatives, low and high ropes course activities, swimming, boating, and hiking?
Yes
No
If yes, please identify and explain:
________________________________________________________________________
________________________________________________________________________
4) Please add any additional and pertinent information about your child, which may be helpful for Program
Staff:
________________________________________________________________________
________________________________________________________________________
The health information noted above is correct and I give consent for my child to engage in all camp
activities except as noted on this form.
Permission to Provide Necessary Emergency Care: I give my permission for the adults in charge of the
activity to take my child to a medical facility, if necessary. In the event of an emergency, if none of the
above can be contacted, I consent to treatment for my child 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
___________________________
Date
__________________________________
Signature
I give s.
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