Summer Urban Program Camper Application 2020 
Summer Urban Program Solicitud de Campista 2020

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About the Application:
  • This application includes all information required to be considered for a spot at the camp you choose. The camp will contact you for more information within 2 weeks and there will be hard copy documents to submit in addition to this online form.
  • You must fill out all the information completely and accurately.
  • You must submit this form once for each child interested in the camps.
Information needed to complete this interest form:
  • Contact information for child, parent/guardian(s), and 3 emergency contact people
  • School information for child
  • Documentation of household income and assistance programs
  • Health and medication information, including insurance policy number
  • You can choose Digital or Paper options for attachments: Teacher/Counselor Questionnaire, Immunization Record, Medications & Doctor Signature. 
Thank you for your interest in PBHA's Summer Urban Program! If you have overall questions, contact sup@pbha.org. Please contact each camp directors for specifics about each program, and the Leaders program with questions about Junior Counselor staff positions for 15-21 year olds - youth can apply on the PBHA website. 

Program dates are from June 29th - August 13th, 2020 (subject to change due to Boston and Cambridge school district calendars). Deadline for returning campers is April 15, 2020. 

Sobre el proceso de solicitar:
  • Este formulario de interés expresa su deseo de solicitar a un campo. El campo le contactará para mas información dentro de 2 semanas y habrá un copio duro de documentos para entrar ademas de este formulario.
  • Tiene que completar todo la información completamente y precisamente.
  • Tiene que entrar este formulario para cada niño interesado en los campos.
Información necesario para completar este formulario de interes:
  • Información de contacto de nino, los padres/guardian(es), y 3 contactos de emergencia 
  • Información de la escuela para cada niño
  • Documentación de ingreso familiar y los programas de asistencia 

Gracias por su interés en el Summer Urban Program de PBHA! Si usted tiene algunas preguntas, no dude en contactar sup@pbha.org. Por favor contacte cada director del campo para los específicos de cada programa, y el programa de Leaders sobre las aberturas de posición personal de Junior Counselor, para los entre 14-21 de edad. Los jóvenes pueden postularse en www.pbha.org. 

Las fechas del programa son del 29 de junio al 13 de agosto de 2020 (sujeto a cambios debido a los calendarios del distrito escolar de Boston y Cambridge). La fecha límite para regresar a los campistas es el 15 de abril de 2020.

Please select a camp/Por favor escoja un campo:

Child information/Información de nino















School information/Información de escuela




Grade in school entering this Fall / Año que entrara este otoño



Parent/Guardian 1








This should be an email you check regularly. Confirmation of this application and follow up materials and notifications will be sent to this address./Debe ser un correo que compruebe con frecuencia. Confirmación de este formulario, materiales siguientes y notificaciones estarán mandado a este correo. 
Parent/Guardian 1 Address (information should also be the primary residence for the child/)/Dirección del Guardián 1 (la información también debe ser la residencia primaria del nino)





(e.g. on my home phone from 7pm-10pm Monday through Thursday)
Parent/Guardian 2












(e.g. on my home phone from 7pm-10pm Monday through Thursday)
Household Information/Información del Hogar




Sibling Information / Hermanos información

Please list their names and birth dates if they will be attending camp / Por favor escriba sus nombres y cumpleanos si atenderán):



Activities information / Información por actividades


Junior Leaders in Communities (JLinC) Specific Questions

Thank you for your interest in applying to Junior Leaders in Communities (JLinC)! Affiliated with the Phillips Brooks House Association at Harvard University, JLinC is a summer program committed to providing academic enrichment and leadership development for rising ninth graders in Boston and Cambridge. For six weeks during the summer, participants will attend classes, workshops, and field trips planned by directors. Participants will also complete service-learning projects and projects at the camps they have attended in previous summers. Participants will each receive a stipend of $450 upon the completion of the program. 
For youth participant:



For Parent/Guardian:


Emergency Information/Información de Emergencia

Youth Programs need references for safety/liability reasons, please provide 3 people they can contact to verify you./Programas juveniles necesitan contactos de referencia para razones de seguridad/responsabilidad civil. Proporcione tres nombres de contacto para verificarlo

Emergency 1 of 3




Emergency Contact 2 of 3




Emergency Contact 3 of 3




Summer Urban Program

 2020


Release Form 


I am the parent and/or legal guardian of _______________. I understand that the Phillips Brooks House Association professional staff and the staff of the Phillips Brooks House Association will maintain files containing academic, behavioral, and health related information about my child. I also understand that the aforementioned people may establish both written and verbal correspondence with my child’s teacher and/or guidance counselors in regard to my child’s progress and well-being. This correspondence may involve the sharing of behavioral reports and academic report cards. I grant the staff of the Phillips Brooks House Association permission to share with each other any information collected in my child’s file. Upon withdrawing my child from the program or upon my child’s completion of the program, I retain any right I may have to gain possession of copies of my child’s file, including any and all copies of the documents in that file which are in the possession of Phillips Brooks House professional staff or the staff of the Phillips Brooks House Association.

     I also grant permission for my son/daughter/ward to be included in the documentation of the program, including photographs, video recordings, audio recordings, reproductions of academic work, and written quotations or descriptions of academic activities. I am aware that this documentation material may be edited as necessary. I also understand that the resulting material may be exhibited before the community, school, fundraisers, or other groups or individuals in video, audio, print, or other media formats.

I also give my child permission to participate in this program and all its activities, and to ride in PBHA vehicles.

I release, hold harmless and agree to indemnify the Phillips Brooks House Association (PBHA), Harvard University, and all Board of Trustees, officers, directors, faculty, staff, representatives, employees and agents, from and against any present or future claim, loss or liability for injury to person or property, related to my child's participation in this program (including periods of transit).

 

Yo soy el padre o el custadio legal de ___________________________. Yo entiendo que la administración de Phillips Brooks House Association, los directores, y los consejeros del Phillips Brooks House Association tendran un archivo con información sobre el comportamiento, la salud y el progreso escolar de mi nino. Yo también entiendo que la administración del Phillips Brooks House Association podra establecer correspondencia verbal y escrita con los maestros o con el consejero de la escuela con respecto al progreso del niño y de su bien-estar. Esta correspondencia puede envolver compartiendo información escolar y del comportamiento del niño.  Yo le doy permiso a la administración Phillips Brooks House Association para compartir esta información entre ellos mismos. Cuando mi hijo deja el programa, tengo el derecho a demandar el archivo sobre mi hijo y todas las copias.

     También le doy permiso a mi hijo/hija para participar en fotagrafías, grabaciones de video o de cintas de escuchar, y para que su trabajo escolar o citactiones sean publicada. Yo se que estas publicaciónes podran ser redactidas si es necesario. También entiendo que el material podra ser exhibido adalante de grupos de comunidades, de escuelas, y de contribuidores o otros grupos de individuales en formas audiovisual, audial, escritas o otros metados.

También, yo le doy permiso a mi hijo para participar en este programa, en todas sus actividades, y ser transportado en los vehículos de PBHA.

Yo, por este medio hago público, de liberar, y de comprometerme a no demandar y estoy de acuerdo a indemnizar y a no hacer responsible, a la Phillips Brooks House Association (PBHA), Harvard University, la Junta Directiva, los oficiales, los directores, la facultad, el personal, los representantes, los empleados y los agentes, de y en contra cualquier demanda en el presente o en el futuro, de demandas y reclamación de daños de cualquier clase, incluyendo lesiones y daños a propiedad, relacionada con la participación de mi niño(a) en este programa (incluyendo períodos de tránsito).

 

 

Parent’s Signature / Firma del padre: ______________________________ Date/Fecha: ___________

Sunscreen Policy

Department of Health Services

Dear Parents,

 

We are looking forward to having your child in camp this summer. To ensure the safety and health of your child this summer we encourage all children to wear sunblock. You should apply sunblock in the morning before your child leaves for camp. All children are encouraged to bring their own sunblock with them each day with their name clearly labeled on the container. All children will be reminded by counselors and senior staff members throughout the day to reapply sunblock to prevent any burns.  As a result, we recommend that parents send in sunblock that is in a spray bottle. If the sun block is provided in a spray bottle the staff is allowed to spray on the sunblock and the child will be asked to rub it in. Camps do have additional sunblock on site. If you would like your child to be able to use the camp sunblock, please sign the sunblock release form. 


Yours, 


Kate Johnsen, Deputy Director and Summer Program Group Officer 


PBHA Sunblock Release: 
To ensure the safety and health of your child this summer we encourage all children to wear sunblock. You should apply sunblock in the morning before your child leaves for camp. All children are encouraged to bring their own sunblock with them each day with their name clearly labeled on the container. All children will be reminded by counselors and senior staff members throughout the day to reapply sunblock to prevent any burns. As a result, we recommend that parents send in sunblock that is in a spray bottle. If the sun block is provided in a spray bottle the staff is allowed to spray on the sunblock and the child will be asked to rub it in.  Camps do have additional sunblock on site. If you would like your child to be able to use the camp sunblock, please initial the sunblock release form.

Health Forms / Formularios de Salud


Medical Release

In case of emergency, I authorize the Summer Urban Program directors to seek any medical assistance that the above named child may require. I understand that if not fully covered by a medical insurance provider, I will be personally responsible for all costs incurred by the care provided. 

En caso de emergencia, doy permiso a los directores de este programa que encuentren el tratamiento necesario para mi hijo/hija. Entiendo que, si no tengo seguro medico, tendré la responsabilidad de pagar todos los cargos de este servicio médico.


Summer Data Consent Form

In the form below, for "Program in which your child is enrolling:", type "Phillips Brooks House Association - __________ (fill in camp name)". Languages other than English are available via email or hard copy.
logo

Dear Parent/Guardian,


This program is taking part in a city-wide program evaluation project (the “Measurement Project”) for all or part of the May 2020 - July 2021 year. This Measurement Project, managed by Boston After School & Beyond, Inc. (“BASB”), seeks to understand the quality of out-of-school and expanded learning time programming in Greater Boston and how programs support student skill development and learning. Several research organizations will help with the Measurement Project: the National Institute on Out-of-School Time (“NIOST”), the PEAR Institute (“PEAR”), the RAND Corporation, and ExpandED Schools (collectively, “Research Organizations”). By completing, signing, and returning this Consent Form, you acknowledge and agree to the following:

  1. BASB, Research Organizations, and Boston Public Schools (“BPS”) will have access to the following demographic and academic information about your child (obtained from this Program and/or BPS): student program attendance, school attended, race, gender, grade, age/date of birth, English learner (EL) status, home zip code, school-year attendance (days present, days tardy, rate), discipline records (total suspension incidents, days suspended, expulsions), test scores, State Assigned Student Identifier (SASID) and Boston Public Schools ID. These data are confidential and will be used only for evaluation to improve out-of-school time programming.
  2. Students in grades 4-12 may be asked to fill out a survey called NIOST Survey on Academic and Youth Outcomes (“SAYO Y”). The SAYO Y is a brief survey which asks students about their program experience and future plans. Participation in the survey is voluntary and students may stop at any time without penalty. Should you have any questions about this survey, use of these data, or your child’s participation, contact Dr. Georgia Hall at (781) 283-2530 or ghall@wellesley.edu, or Nancy L. Marshall at nmarshall@wellesley.edu.
  3. Students in grades 5-12 may be asked to fill out a survey called the Holistic Student Assessment (“HSA") and/or the Common Instrument survey (“CI”), developed by PEAR. The HSA is a tool that can deepen understanding of students’ social and emotional strengths and needs. Students complete a brief survey about themselves. The Program will use the HSA results to cultivate the strengths, abilities, and academic success of each student. The CI is a brief survey which assesses student interest in science, technology, engineering, and math. CI results will be used to improve program content and delivery. Participation in the survey(s) is voluntary and students may stop at any time without penalty. BASB, BPS, and Research Organizations will have access to HSA and CI data and results.  PEAR reserves the right to use all HSA and CI data for both research and educational purposes. Should you have any questions regarding HSA or CI, contact Jane Aibel at 617-484-0466 extension 204 or jaibel@mclean.harvard.edu.
  4. BASB and/or their partners/agents may videotape or take photos of your child’s participation in the program using video and/or digital photography.  These images may be taken before, during, or after programming.  These images may be used for the purpose of sharing your child’s participation and associated perspectives to a public audience.  Images may be published, posted, or played through a variety of communication channels, including but not limited to print, television, and/or online.

 

Confidentiality of Data Collected

Your child’s participation in the Measurement Project data collection helps us to better understand out-of-school time programming in Greater Boston. All data collected that may identify your child will be kept confidential.  In public reporting of research findings, only group data and/or de-identified data will be reported. At no time will a public report identify an individual student in any way. The only exception to confidentiality will be in the case of any information disclosed that indicates a child is in any danger.

 

Please complete, sign, and return.





MM/DD/YYYY






By typing my name below, I am electronically signing this consent form. I agree to be bound by electronic signatures:


MM/DD/YYYY


En Español 

2020-2021 Formulario de Consentimiento – Por favor firme y devuelva 

Estimado(a) Padre/Madre/Guardián:                                                                                          

Este programa está participando en un proyecto de evaluación de toda la ciudad (el “Proyecto de Medición”) durante todo o parte del periodo comprendido entre mayo de 2020 a julio de 2021.  Este Proyecto de Medición, administrado por Boston After School & Beyond, Inc. (“BASB”, por sus siglas en inglés), pretende entender la calidad de la programación del tiempo de aprendizaje extendido y fuera del horario escolar en Greater Boston (el Gran Boston) y de qué manera los programas apoyan el desarrollo de habilidades y aprendizaje de los estudiantes.  Varias organizaciones de investigación ayudarán en el Proyecto de Medición: el Instituto Nacional de Tiempo fuera del Horario Escolar (“NIOST”, por sus siglas en inglés); el Instituto PEAR (“PEAR”); la Corporación RAND y Escuelas Extendidas (ExpandED Schools, llamadas colectivamente “Organizaciones de Investigación”). Al completar, firmar y devolver este Formulario de Consentimiento, usted reconoce y acepta lo siguiente:

 1.       BASB, las Organizaciones de Investigación y las Escuelas Públicas de Boston (“BPS”, por sus siglas en inglés) tendrán acceso a la siguiente información demográfica y académica sobre su hijo(a) (obtenidas de este programa y/o de PBPS): asistencia del (la) estudiante al programa, escuela a la que asiste, raza, sexo, nivel de grado, edad/fecha de nacimiento, condición de estudiante que aprende el idioma inglés (EL, por sus siglas en inglés), código postal de residencia, asistencia durante el curso escolar (días presente, días ausente, frecuencia), registros de disciplina (total de incidentes de suspensión, días suspendido(a), expulsiones), puntuación en pruebas, Identificación de Estudiante Estatal Asignada (SASID, por sus siglas en inglés) e identificación (ID) de Escuelas Públicas de Boston. Estos datos son confidenciales y serán usados solo para evaluación, con el fin de mejorar la programación del tiempo fuera del horario escolar. Estos datos son confidenciales y serán usados solamente para fines de evaluación con vista a mejorar la programación fuera del horario escolar.

 

2.       A los estudiantes en los grados 4 - 12 se les pedirá completar la encuesta de NIOST sobre Resultados Académicos de Jóvenes, (“SAYO Y”, por sus siglas en inglés) (NIOST Survey on Academic and Youth Outcomes (“SAYO Y”).   SAYO Y es un breve sondeo que se completará al menos una y como máximo dos veces, que pregunta a los estudiantes sobre sus experiencias en el programa y sus planes para el futuro. La participación en este sondeo es voluntaria y los estudiantes pueden interrumpirla en cualquier momento sin que se les apliquen sanciones.  Las respuestas individuales no serán compartidas con el programa. Si usted tuviera alguna pregunta acerca de este sondeo, contacte a la Dra. Georgia Hall, llamando al número (781) 283-2530 o a través del correo electrónico ghall@wellesley.edu, o escriba a Nancy L. Marshall a nmarshall@wellesley.edu.

 

3.      A los estudiantes de los grados 5 - 12 pudiera pedírseles completar una encuesta llamada Evaluación Holística del Estudiante (“HAS” por sus siglas en inglés) y/o la encuesta Instrumento Común (“CI”, por sus siglas en inglés), desarrolladas por PEAR. HSA es una herramienta que puede ayudar a profundizar en la comprensión de las necesidades y fortalezas emocionales y sociales de los estudiantes. Los estudiantes completan una breve encuesta acerca de sí mismos.  Los resultados de la HSA se emplearán para desarrollar las fortalezas, habilidades y lograr el éxito académico de cada estudiante. La CI es una encuesta breve que evalúa el interés de los estudiantes en las ciencias, tecnología, ingeniería y matemáticas. Los resultados de la CI serán usados para mejorar el contenido del programa y la forma en la que se imparte. La participación en la(s) encuesta(s) es voluntaria y los estudiantes pueden dejar de hacerla(s) en cualquier momento sin que se les apliquen sanciones. BASB, BPS, y las Organizaciones de Investigación tendrán acceso a los datos y resultados de HSA y CI. PEAR se reserva el derecho de usar todos los datos de HSA y CI para fines investigativos y educacionales. Si usted tuviera cualquier pregunta respecto a HSA o CI, contacte a Jane Aibel escribiendo a jaibel@mclean.harvard.edu.


4.       BASB y sus asociados/agentes pueden tomar fotos o grabar en video la participación de su hijo(a) en el Programa, usando video y/o fotografía digital. Estas imágenes pueden ser tomadas antes, durante o después de la programación.  Estas imágenes pueden ser usadas para compartir con una audiencia pública la participación de su hijo(a) y las perspectivas asociadas a dicha participación. Las imágenes pueden ser publicadas, expuestas o pasadas a través de una serie de canales de comunicación, incluyendo pero no limitadas a impresión, televisión y/u online.

Confidencialidad de los Datos Recopilados

La participación de su hijo(a) en la recopilación de datos del Proyecto de Medición nos ayuda a entender mejor la programación del tiempo fuera del horario escolar en el Gran Boston. Todos los datos recogidos que pudieran identificar a su hijo(a) se mantendrán confidenciales. Cuando se informe en público acerca de los resultados de la investigación, se reportará solamente datos de grupo y/o datos sin identificación. En ningún momento un reporte público identificará a un estudiante individualmente de ninguna forma. La única excepción a la confidencialidad será en el caso de que cualquier información revelada indicase que un menor está en algún peligro

Por favor, complete, firme y devuelva.

Required Documents - Digital or Paper Option

The following pages contain document requirements. You may choose to upload them once complete, or download and submit them on paper after completing this online form. Your application will not be complete without them, we offer option of digital or hard copy for your convenience. 

If you choose Digital" below

If you choose "Hard copy" for any of the below, download the respective required form now before proceeding from this page to the next.
Teacher Questionnaire

Immunization

Medication

Pick-up/Walker Policy

Teacher/Counselor Questionnaire Completion

You may complete the fields below that will automatically contact the teacher/counselor you name; 

OR

send this link to a questionnaire to a teacher/counselor of your choice who can contribute to how SUP can support your child: https://www.tfaforms.com/4809257

OR

download and print this form to give to a teacher of your choice who can contribute to how SUP can support your child.




Immunization Records

Certificate of Immunization shall mean either:

(1) any form or letter signed and dated by a physician or designee, or
(2) a dated report from the Massachusetts Immunization Information System; 

provided that either document specifies the month and year of administration and the type/name of the vaccines(s) administered to the camper or staff person, or alternative evidence of immunity.

If you have questions about exemptions or other details, please read the full regulations at the link below, then contact sup@pbha.org: 
https://www.mass.gov/doc/105-cmr-430-minimum-standards-for-recreational-camps-for-children-state-sanitary-code-chapter/download

Medication / Medicamento

Download, print, and bring this form to your doctor to complete the application requirement for for administering medicines on site needing instructions and permission to be administered for your child: https://docs.google.com/document/d/1rw3kC7X6nWsPidz5HQDw5-4e_JwZwIt4n1YagDUnLJs/edit

Walker Policy

My child will walk home with the following people./ Mi hijo/a caminará con las siguentes personas

Please list any individuals authorized to pick up your child. Note: If an individual is not on this list, we cannot allow them to pick up your child unless we receive notice in due time.


Liste por favor a cualquier individuo autorizó a recoger su niño. La nota: si un individuo no está en esta lista, nosotros no los podemos permitir recoger a su niño a menos que recibamos nota con el tiempo.

Responsible Person 1 of  3
Responsible Person 2 of 3
Responsible Person 3of 3

Optional - Send a message about SUP to other families!

Emails you type above will be sent the message below. Feel free to reach out to them as well!






Subject: <<parent/guardian 1>> wants you to know about the Summer Urban Program!

Email body: 

Hi <<Name>>,

Someone you know is interested in the Summer Urban Program and would like you to learn more! 
<<Parent/guardian 1>> referred you as someone who may want more information about SUP. See the description below and check out http://pbha.org/programs/sup/ to read about this award-winning summer program for youth and children. You may download the application or fill it out online through that site.

We will be glad to follow up with you if you need further information, please email directly the program that you're interested in located in/near your neighborhood, listed below. 

Yours,

Summer Urban Program Staff
Phillips Brooks House Association

What is the Summer Urban Program

SUP builds positive relationships with youth, families, and community partners to ensure that young people in Boston and Cambridge can build the social, emotional, and academic skills needed to define, access, and achieve their own success in and beyond our programs. PBHA’s youth programs strive to meet the following long-term outcomes:

  1. Youth take advantage of opportunities toward established goals and make plans that show hope and determination.
  2. Youth access resources and support through positive relationships with adults, peers, institutions, and family.
  3. Youth act responsibly and have voice in programs and broader communities.
  4. Youth use the necessary competencies and attitudes to achieve academic success in school.
  5. Youth use positive social skills and self awareness to make healthy life choices.

SUMMER URBAN PROGRAM CAMPS

Boston Refugee Youth Enrichment (BRYE) offers ESL instruction to recent immigrants living in Dorchester.

Cambridge Youth Enrichment Program (CYEP) operates across three sites in Cambridge, serving low-income students living in Cambridge, particularly those from the Roosevelt Towers, Jefferson Park or Newtowne Court housing developments.

Chinatown Adventure (CHAD) serves young people living in Chinatown, particularly in the subsidized housing complexes there, including Mass Pike Towers, Castle Square, Oak Terrace, Metropolitan, and Tai Tung Village.

Franklin I-O serves youth living in Dorchester’s Franklin Hill and Franklin Field housing developments.

Keylatch Summer Program serves youth living in the Villa Victoria, Castle Square or Cathedral housing developments in Boston’s South End.

Mission Hill Summer Program serves students living in the Mission Main and Alice Taylor housing developments in Mission Hill.

Native American Youth Enrichment Program (NAYEP) serves young people of Native American descent from the greater Boston area.

Refugee Youth Summer Enrichment (RYSE) offers ESL instruction to recently immigrated teenagers living in the greater Boston area.

Roxbury Youth Initiative (RYI) serves youth living in Roxbury, particularly those from Academy Homes, New Academy Homes, or Orchard Gardens.

South Boston Outreach Summer (SBOS) serves young people living in the West Broadway, Old Colony, or Mary Ellen McCormick housing developments in South Boston.

LEADERS! provides teens from Boston and Cambridge with full-time teaching and mentoring during the summer and college access, mentoring, and leadership development during the term.

Thank you for applying! Press submit below/Gracias por solicitar! Presione 'submit' abajo


You will receive a confirmation email that your information has been recorded successfully. Please check your email for further details about the application process.


(It may take a few seconds to submit).


Recibirá un correo electrónico confirmando que su información ha sido registrado exitosamente. Por favor compruebe su correo electrónico para mas información sobre el proceso de solicitar.


(Puede tomar unos minutos para enviar)