23 West Chestnut Street
Hanover PA 17331
Phone (717) 637-2125
Fax
(717) 637-3516
www.ywcahanover.org
“Celebrating Oneself through Science, Mathematics, and Individual Creativity”
21st CENTURY COMMUNITY LEARNING CENTERS – After School Program
In collaboration with the Hanover Public and Spring Grove Area School Districts, and the YWCA Hanover
_______________________________________________________________________________________
REFERRAL FORM
Date: ______________ Student Name_________________ DOB: ____/____/____ Sex:
Current Grade: _______
M F
School: _____________________ Teacher: __________________
Parent/Guardian Name: _____________________________ Phone: (____)________________
Address: ______________________________________________________________________
Race:
 White  Black Hispanic  Asian  Native American  Multicultural  Other
Reason(s) why this student would benefit from the services of The C.O.S.M.I.C. Project:
(Provide a brief description)
Is the Parent/Legal Guardian an active participant at the school?
 Yes  No
Person making this report __________________________________ Date _________________
Signature _______________________________________________ Title _________________
*This is confidential information that will not be shared with parents or any other individual(s) not employed by
The C.O.S.M.I.C. Project
23 West Chestnut Street
Hanover PA 17331
Phone (717) 637-2125
Fax
(717) 637-3516
www.ywcahanover.org
“Celebrating Oneself through Science, Mathematics, and Individual Creativity”
21st CENTURY COMMUNITY LEARNING CENTERS – After School Program
In collaboration with the Hanover Public and Spring Grove Area School Districts, and the YWCA Hanover
_______________________________________________________________________________________
Starting Date:
/
REGISTRATION FORM
/
Date: ______________ Student Name_________________ DOB: ____/____/____ Sex:  M
F
Current Grade: _______ School: _____________________ Teacher: ___________________________
Parent/Guardian Name:
Phone: (
)
Address:
Race:
White  Black  Hispanic  Asian  Native American  Multicultural  Other
FAMILY INFORMATION:
1st Parent (Guardian)
Name: _________________________ Address: _________________________________ City: _____________ Zip: _______
Relationship to child ___ Mom ___ Dad Other ___________________ DOB ___/___/___ Email:_______________________
Place of Employment:_______________________________ Department: ___________________ Position: ________________
Address: ____________________________________________________________ City: ______________________________
Please number 1-3, 1 being priority contact number:
 (H) Phone: _______________________  (C) Phone ______________________  (W) Phone _____________________
2nd Parent (Guardian)
Name: _________________________ Address: _________________________________ City: _____________ Zip: __________
Relationship to child ___ Mom ___ Dad Other: ___________________ DOB: ___/___/___ Email:________________________
Place of Employment: _______________________________ Department: ___________________ Position: ________________
Address: ____________________________________________________________ City: _______________________________
Please number 1-3, 1 being priority contact number:
 (H) Phone: _______________________  (C) Phone ______________________  (W) Phone _____________________
List all family members living in your home: (Use reverse side of form, if needed)
NAME
DOB
____________________________________
SIGNATURE OF PARENT/ GUARDIAN
AGE
RELATIONSHIP TO APPLICANT
________________
DATE
23 West Chestnut Street
Hanover PA 17331
Phone (717) 637-2125
Fax
(717) 637-3516
www.ywcahanover.org
“Celebrating Oneself through Science, Mathematics, and Individual Creativity”
21st CENTURY COMMUNITY LEARNING CENTERS – After School Program
In collaboration with the Hanover Public and Spring Grove Area School Districts, and the YWCA Hanover
_______________________________________________________________________________________
CONSENT TO PARTICIPATE FORM
Family Name: ________________________________
Date: ___________
Through this document, I give consent for my son/daughter ____________________________ to
participate in the services provided by The C.O.S.M.I.C. Project offered through the YWCA of
Hanover.
I am aware that I can end my child’s participation in the after school program at any time by
providing a written notice to The C.O.S.M.I.C. Project. I am also aware if my child has a court order
enforcing participation, the YWCA of Hanover and or The C.O.S.M.I.C. Project will inform the Court
of the termination.
I am aware that The C.O.S.M.I.C. Project and the YWCA of Hanover will also provide client
information to the York County Court House and Children and Youth Services, if required. Student
information will also be released to the School District that my child attends or to the
individual/institute that referred for services.
I am aware that if my child or I are under medical treatment, and information is needed from the
student/parent file(s), The C.O.S.M.I.C. Project and the YWCA of Hanover will provide the
necessary information, even without my consent.
I am aware that any incident of physical or sexual abuse, whether past or present, will be reported
to Childline. I have read this consent, it has been explained to me and I fully understand its
content.
___________________________________
Parent or Guardian’s Signature
____________________
Date
____________________________________
The C.O.S.M.I.C. Project Employee
____________________
Date
23 West Chestnut Street
Hanover PA 17331
Phone (717) 637-2125
Fax
(717) 637-3516
www.ywcahanover.org
“Celebrating Oneself through Science, Mathematics, and Individual Creativity”
21st CENTURY COMMUNITY LEARNING CENTERS – After School Program
In collaboration with the Hanover Public and Spring Grove Area School Districts, and the YWCA Hanover
_______________________________________________________________________________________
CONSENT FOR RELEASE OF INFORMATION
I (We) hereby authorize _____________________ School disclose / receive to / from The
C.O.S.M.I.C. Project and / or summer programs, the following information:
Psychological Evaluations _________
Psychiatric Evaluations _________
Educational Data Records __________
Physicians Reports _____________
Audiological Evaluations __________
Speech/Language Evaluations __________
Physical/Occupational Evaluations _________
Vision Evaluations_____________
PSSA results____________________
All the above ____________________
Regarding my child _____________________________________________________
for the purpose of intervention and after school programming.
I have read this carefully and understand what it means. This consent will expire one year from the
date of signature. I understand that I may revoke this consent at anytime by notifying The
C.O.S.M.I.C. Project in writing.
_________________________________
Parent / Guardian Signature
___________________
Date
_________________________________
Signature of COSMIC Program Employee
___________________
Date
TO RECEIVING AGENCY / INSTITUTION: This information has been disclosed to you from
records confidentiality protected by PA State Law and Department regulations. It is unlawful to
make disclosure of any or all of this information without prior written consent.
23 West Chestnut Street
Hanover PA 17331
Phone (717) 637-2125
Fax
(717) 637-3516
www.ywcahanover.org
“Celebrating Oneself through Science, Mathematics, and Individual Creativity”
21st CENTURY COMMUNITY LEARNING CENTERS – After School Program
In collaboration with the Hanover Public and Spring Grove Area School Districts, and the YWCA Hanover
_______________________________________________________________________________________
CONSENT TO TRANSPORT
Child’s Name: ________________________________
Grade: _______________
The C.O.S.M.I.C. Project offers transportation for all the students participating in the programs.
I __________________________________, give consent to The C.O.S.M.I.C. Project to provide
transportation for my child, for the purpose of participation in after school and summer programs as
well as activities and field trips. Please, mark and consent for the type of transportation you would
like your child to have at the dismissal of the program.
a) ______
I wish for my child to be transported by bus at the dismissal of the program.
He/She should be dropped off at the following address:
________________________________________________________________
b) _______ My child will be picked up after the program.
List all people authorized to pick up your child: (All those listed, must present a valid, photo ID, upon pick up)
Name
Relationship
____________________________
__________________________
____________________________
__________________________
____________________________
__________________________
____________________________
__________________________
______________________________________
Parent / Guardian Signature
_______________
Date
23 West Chestnut Street
Hanover PA 17331
Phone (717) 637-2125
Fax
(717) 637-3516
www.ywcahanover.org
“Celebrating Oneself through Science, Mathematics, and Individual Creativity”
21st CENTURY COMMUNITY LEARNING CENTERS – After School Program
In collaboration with the Hanover Public and Spring Grove Area School Districts, and the YWCA Hanover
_______________________________________________________________________________________
ACKNOWLEDGEMENT OF WARNING
We/I the parent(s) of _______________________________, hereby acknowledge that we/I
(Name of Student)
have been properly advised, cautioned, and warned by the proper personnel of The C.O.S.M.I.C.
Project, that by participating in a sport, community service, and/or field trip, our child may suffer
serious injury, including but not limited to sprains, fractures, and ligament/cartilage damage which
could result in a temporary or permanent, partial, or complete, impairment in the use of limbs, brain
damage, paralysis, or even death. Having been so cautioned and warned of the risk of serious
injury to my/our child, named above, I/we give my/our consent to The COSMIC Project Staff, for
my/our child to participate in the COSMIC Program.
____________________________________
Parent Signature
________________________
Date
____________________________________
Signature of COSMIC Project Employee
________________________
Date
23 West Chestnut Street
Hanover PA 17331
Phone (717) 637-2125
Fax
(717) 637-3516
www.ywcahanover.org
“Celebrating Oneself through Science, Mathematics, and Individual Creativity”
21st CENTURY COMMUNITY LEARNING CENTERS – After School Program
In collaboration with the Hanover Public and Spring Grove Area School Districts, and the YWCA Hanover
_______________________________________________________________________________________
EMERGENCY CONTACT INFORMATION
Student’s Name__________________________
DOB________________
Age______
Release Statement:
I hereby give permission for the School District personnel and/or The C.O.S.M.I.C. Project
staff, to provide immediate emergency care to my child for injuries received while participating in
the after school and/or summer program activities.
Please check one
Yes
 No
I hereby give permission to have my child transported to and to receive emergency medical
treatment at the hospital nearest the accident scene for injuries received while participating in the
after school and/or summer programs.
Please check one
 Yes
 No
Parent Name______________________ Home Telephone #________________
Work Telephone #__________________Other #_________________________
Family Physician_________________________ Telephone #________________
Medical Insurance _________________________________________________
Please list at least two other persons to contact in case of an emergency
Name
____________________
____________________
____________________
Address / Phone Number
________________________
________________________
________________________
Relationship
__________
__________
__________
Does your child take any special medications? ___________________________
Does your child have any allergies?____________________________________
Does your child have a condition we should be aware of?___________________
NOTE: The following page requires a signature that corresponds with this emergency contact. Please provide any
additional information if applicable, and sign the bottom.
Cont. Emergency Contact Information
23 West Chestnut Street
Hanover PA 17331
Phone (717) 637-2125
Fax
(717) 637-3516
www.ywcahanover.org
“Celebrating Oneself through Science, Mathematics, and Individual Creativity”
21st CENTURY COMMUNITY LEARNING CENTERS – After School Program
In collaboration with the Hanover Public and Spring Grove Area School Districts, and the YWCA Hanover
_______________________________________________________________________________________
My child takes special medication _____________________________________
________________________________________________________________
________________________________________________________________
My child is under the care of a doctor___________________________________
________________________________________________________________
________________________________________________________________
My child has allergies_______________________________________________
________________________________________________________________
________________________________________________________________
My child has a condition you should be aware of__________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Other concerns about my child _______________________________________
________________________________________________________________
________________________________________________________________
________________________________________
Parent/Guardian Signature
_______________
Date
Emergency Contact Information/ Page 2
23 West Chestnut Street
Hanover PA 17331
Phone (717) 637-2125
Fax
(717) 637-3516
www.ywcahanover.org
“Celebrating Oneself through Science, Mathematics, and Individual Creativity”
21st CENTURY COMMUNITY LEARNING CENTERS – After School Program
In collaboration with the Hanover Public and Spring Grove Area School Districts, and the YWCA Hanover
_______________________________________________________________________________________
PICTURE/PHOTO RELEASE FORM
Student Name___________________________
Grade_______________
There are times when The C.O.S.M.I.C. Project will take pictures or videos of those,
including the children, involved in our program. Pictures may be used for promotional displays,
program brochures, for marketing purposes or just as a remembrance of an activity. These photos
are subject to appear in newspapers, flyers, newsletters, and the organization’s websites.
Because you have enrolled your child in the after school and/or summer program, we would like to
have your consent to take your child’s picture and or video to be used for public purpose.
I do________/I do not________ give permission for my child to be photographed or video taped by
The C.O.S.M.I.C. Project.
_________________________________
Parent/Guardian Signature
____________________
Date
23 West Chestnut Street
Hanover PA 17331
Phone (717) 637-2125
Fax
(717) 637-3516
www.ywcahanover.org
“Celebrating Oneself through Science, Mathematics, and Individual Creativity”
21st CENTURY COMMUNITY LEARNING CENTERS – After School Program
In collaboration with the Hanover Public and Spring Grove Area School Districts, and the YWCA Hanover
_______________________________________________________________________________________
Days of Attendance
The COSMIC Program is committed to practicing safe precautions while providing care to all
participants. For this reason we ask that parents let us know when your child will be attending the
program, so our staff is aware when to expect them. Please check the days that your child will be
attending the after-school program. .
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
(Multi-Cultural
Club)
NO
COSMIC
Additional Notes:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Parent or Guardian Signature: __________________________________ Date: ___________