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”
21 st CENTURY COMMUNITY LEARNING CENTERS – After School Program
In collaboration with the Spring Grove Area School District and the YWCA Hanover
_______________________________________________________________________________________
REFERRAL FORM
Date:__________ Student Name:________________________ Current Grade: _______
Parent/Guardian Name: _____________________________ Phone: (____)________________
Address: ______________________________________________________________________
** Reason(s) why this student would benefit from the services of The C.O.S.M.I.C. Project:
(Provide a brief description ) ( Required field ) **
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”
21 st CENTURY COMMUNITY LEARNING CENTERS – After School Program
In collaboration with the Spring Grove Area School District 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:
1 st
Parent (Guardian)
Name: _________________________ Address: _________________________________ City: _____________ Zip: _______
Relationship to child: ___ Mother___ Father ___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 _____________________
2 nd
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 AGE RELATIONSHIP TO APPLICANT
____________________________________
SIGNATURE OF PARENT/ GUARDIAN
________________
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”
21 st CENTURY COMMUNITY LEARNING CENTERS – After School Program
In collaboration with the Spring Grove Area School District and the YWCA Hanover
_______________________________________________________________________________________
CONSENT TO PARTICIPATE FORM
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
Hanover.
I am aware that I can end my child’s participation in the program at any time by providing a written notice to The C.O.S.M.I.C. Program staff. I am also aware if my child has a court order enforcing participation, the YWCA Hanover and or The C.O.S.M.I.C. Program will inform the Court of the termination.
I am aware that The C.O.S.M.I.C. Program and the YWCA 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. Program and the YWCA 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”
21 st CENTURY COMMUNITY LEARNING CENTERS – After School Program
In collaboration with the Spring Grove Area School District and the YWCA Hanover
_______________________________________________________________________________________
CONSENT FOR RELEASE OF INFORMATION
I (We) hereby authorize Spring Grove Area School District to disclose / receive to / from The
C.O.S.M.I.C. Program and / or summer programs, the following information:
Psychological Evaluations _________
*Educational Data Records __________
Audiological Evaluations __________
Physical/Occupational Evaluations _________
Psychiatric Evaluations _________
Physicians Reports _____________
Speech/Language Evaluations __________
Vision Evaluations_____________
*PSSA results____________________
All the above ____________________
Regarding my child ______________________________________ for the purpose of intervention and after school programming.
I have read this form 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 any time by notifying The
C.O.S.M.I.C. Program in writing.
_________________________________
Parent / Guardian Signature
_________________________________
Signature of COSMIC Program Employee
___________________
Date
___________________
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”
21 st CENTURY COMMUNITY LEARNING CENTERS – After School Program
In collaboration with the Spring Grove Area School District 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”
21 st CENTURY COMMUNITY LEARNING CENTERS – After School Program
In collaboration with the Spring Grove Area School District and the YWCA Hanover
_______________________________________________________________________________________
ACKNOWLEDGEMENT OF WARNING
I, the parent of _______________________________, hereby acknowledge that I have been properly advised, cautioned, and warned by the proper personnel of The C.O.S.M.I.C. After School
Program, that by participating in a sport, community service, and/or field trip, my 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, with full knowledge and understanding of the risk or serious injury, it is my desire to give consent for participation in the
COSMIC After School Program.
____________________________________
Parent Signature
____________________________________
Signature of COSMIC Project Employee
________________________
Date
________________________
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”
21 st CENTURY COMMUNITY LEARNING CENTERS – After School Program
In collaboration with the Spring Grove Area School District 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? ___Yes
(If yes, please specify on the back of this form)
Does your child have any allergies? ___ Yes
(If yes, please specify on the back of this form)
Does your child have a condition we should be aware of? ___ Yes
(If yes, please specify on the back of this form)
___No
___ No
___No
NOTE: The following page requires a signature that corresponds with this emergency contact. Please provide any additional information if applicable. A signature at the bottom is required to complete this form.

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”
21 st CENTURY COMMUNITY LEARNING CENTERS – After School Program
In collaboration with the Spring Grove Area School District and the YWCA Hanover
_______________________________________________________________________________________
Medications:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Allergies:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Special Conditions:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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”
21 st CENTURY COMMUNITY LEARNING CENTERS – After School Program
In collaboration with the Spring Grove Area School District and the YWCA Hanover
_______________________________________________________________________________________
PICTURE/PHOTO RELEASE FORM
Student Name___________________________ Grade_______________
There are times when The C.O.S.M.I.C. Program will take pictures or videos of those, including the children, involved in our program. Pictures may be used for promotional displays, program brochures, 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 videotaped by
The C.O.S.M.I.C. After School Program.
_________________________________
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”
21 st CENTURY COMMUNITY LEARNING CENTERS – After School Program
In collaboration with the Spring Grove Area School District and the YWCA Hanover
_______________________________________________________________________________________
The COSMIC Program is committed and required to practice safe precautions while providing care to all participants. For this reason we ask that parents tell us what days your child will be participating in the after school program, as well as if they will be participating in the Saturday
Multi-Culture Club.
* Please note that it is our responsibility as an after school care provider, to make sure that your child attends the program on the days they are scheduled. If for any reason, your child will absent from the program, we ask that you please contact the COSMIC Staff directly, (NOT THE SCHOOL), before 2:00pm to make us aware of this change. Without prior notice from a parent and/or guardian, we are required to keep students after school on the days they are scheduled.
I have been made aware and fully understand that my child must attend the after school program on the days I have selected, unless otherwise authorized by me, the parent. If I have any questions regarding this policy, I am aware that I can refer to my student/parent handbook or contact the COSMIC Staff directly.
Parent or Guardian Signature: __________________________________ Date: ___________