OST 2025-2026 Application Template

Student First Name

Student Last Name

Student Grade

School Location?

I would like my student to be considered for: (NOTE* Juniata Park, Tanner Duckrey, & Edward Gideon are the ONLY sites that offer Morning Care*)

After Care ProgrammingMorning Care Programming

Are you interested in enrolling your student in Spring and/or Winter Break Camp?

Spring BreakWinter BreakBothNo thank you

Program Offerings

Please read the Handbook in it's entirety, the Handbook can be found here: GPY Handbook

Your child's application status and start date will be confirmed by the Site Director in writing, along with written program information. Your child may not begin until their start date has been confirmed.

I attest that I have received all program information at the time of enrollment and agree to the above terms and conditions.

Student (First and Last Name)

Parent/Guardian (First and Last Name)

Caregiver Information

Name of Parent #1

Relationship to Student

Parent #1 Phone Number

Parent #1 Email

Same Address as Student?

Street Address

City

State

Zip Code

Parent #1 Workplace

Parent #1 Work Phone

Parent #1 Work Address

Name of Parent #2

Relationship to Student

Parent #2 Phone Number

Parent #2 Email

Same Address as Student?

Street Address

City

State

Zip Code

Parent #2 Workplace

Parent #2 Work Phone

Parent #2 Work Address

Custody Agreements

Is anyone specifically NOT allowed to pick up this child, or is there a custody arrangement on pick up times or days?

YesNo(In case of divorce/separation, we will need a copy of divorce decree/custody court order)

Person's Name

Relationship to Student

Description of the Individual

Copy of the Court Order

Emergency Contacts

Emergency Contacts are individuals (other than parents) PERMITTED TO PICK UP your children from program. Program staff will never release a child to a person not on the Emergency Contact. Addresses are used to verify identification.

PLEASE INCLUDE ANYONE YOU WOULD LIKE TO PICK UP YOUR CHILD.

Do not write your own name.

Emergency Contact 1

Emergency Contact (First and Last Name)

Relationship to Student

Street Address

City

State

Zip Code

Phone Number

Permissions

Call in Case of EmergencyPermission to Pick Up

Emergency Contact 2

Emergency Contact (First and Last Name)

Relationship to Student

Street Address

City

State

Zip Code

Phone Number

Permissions

Call in Case of EmergencyPermission to Pick Up

Emergency Contact 3

Emergency Contact (First and Last Name)

Relationship to Student

Street Address

City

State

Zip Code

Phone Number

Permissions

Call in Case of EmergencyPermission to Pick Up

Emergency Contact 4

Emergency Contact (First and Last Name)

Relationship to Student

Street Address

City

State

Zip Code

Phone Number

Permissions

Call in Case of EmergencyPermission to Pick Up

Heath Information - REQUIRED BY STATE LAW

Insurance Company Name

Name of Person Subscribed to Insurance

Insurance Policy Number

Insurance Phone Number

Primary Care Physician Name

Primary Care Physician Phone Number

Primary Care Physician Address

Hospital of Choice

Is the Student Diabetic?

YesNo

Please list any medications your child routinely takes, when they take it, what they take it for and who administers it. If NONE, enter NONE.

Please list ALL of your child's allergies, the severity of the reactions and what should be done if exposed to the allergen(s). IF NONE, enter "None"

Please describe, in detail any dietary restrictions that participant has (religious, gluten intolerance, vegan, vegetarian, etc). IF NONE, enter "None"

Please explain in detail your child's medical conditions and any considerations/accommodations needed by the Greater Philadelphia YMCA. IF NONE, enter "None"

Health Assessment

Program Consents

Child's Name (First and Last Name)

Child's Date of Birth

Child's Address

Purpose: The City of Philadelphia (the City) funds after school programs, also called "Out of School Time" (OST) through various city agencies and departments; other OST programs are funded and run by independent providers (collectively "OST programs"). When you enroll your child in an afterschool program, the City will collect information from you and your child and from the OST programs and the School District of Philadelphia and store it in a secure centralized system, where it may be shared with other OST programs in order to help manage the programs, provide academic assistance, publicize the programs, identify unused participant public benefits, as well as improve programming, services, and participant safety.

Process:

When you sign up an afterschool program, you will be asked to provide information about your child, including but not limited to his or her name, age, address, and other demographic information.
OST program staff may also visit the program and talk to your child about being at that program and may also ask your child to complete short surveys about the program to learn more about the experience; these visits are a part of afterschool programs for every child and every afterschool site.
Additional information may be added to your child's file, including from the School District (if you agree) and other OST programs your child has attended including but not limited to: date of birth, gender, race, ethnicity, phone, ID, school name, grade, and attendance.

Information Privacy and Sharing of Information

The information that is collected about your child will be shared with staff at the afterschool program.
In addition, the information about your child will be shared with approved City and OST program and administrative staff, including providers or independent contractors.
If the City ever allows the information to be used for research or evaluation purposes, no identifying information about your child or your family will be shared.
All of the information will be stored in a database that complies with requirements for managing student education records set forth in the Family Educations Rights and Privacy Act (FERPA).
Furthermore, the system is guarded by layered security protocols that prevents unauthorized persons form accessing the system. You also have the right to inspect and review documents collected and maintained in that system.

By checking and signing below, I acknowledge that I have read and understand this OST Data Sharing Consent Form and agreement to have my child's information shared as described above.

I give permission to the City Out of School Time program to collect, store, and share the information I provide on my child for use in the OST program as outlined above and for my child and/or me to complete programmatic surveys that may be shared with other OST programs.

YesNo

I give permission for the OST program to provide the School District of Philadelphia with information about my child’s attendance in the OST program for the purposes of programming for my child and overall program evaluation.

YesNo

I give permission for the OST program to provide the School District of Philadelphia with information about my child’s attendance in the OST program for the purposes of programming for my child and overall program evaluation.

YesNo

I give permission for the OST program to photograph, digitally record, videotape, or audio tape my child while s/he is participating in the OST program. I further agree that any material may be used in publications, promotional literature, or in other similar ways, and that such use shall be without payment of fees. I understand that any photographs, videotapes, or audio tapes shall remain the property of the City and that I do not have the right to prior approval of their use. I release and hold harmless the City of Philadelphia, the City OST program, OST providers and their officers, employees, and agents from all claims and causes of action that I or my child may have as a result of the use of my child’s photograph, videotape, or audio tape in connection with the program.

YesNo

Parent/Guardian (First and Last Name)

I understand that I may revoke this consent upon providing written notice to the OST program that my child attends. I further understand that until revocation is made, this consent shall remain in effect and my educational records will continue to be provided to the OST program for the reasons described above.