Jóvenes en Acción Application | Hyde Square Task Force

Program Selection

I would like to participate in the following session(s):*

Fall Session
Spring Session
Summer Session

Which art program would be your first choice?*

DANCE – Ritmo en Acción (REA)
MUSIC – Musicians in Community (MIC)
THEATRE – Acción Community Theatre (ACT)

Which art program would be your second choice?*

DANCE – Ritmo en Acción (REA)
MUSIC – Musicians in Community (MIC)
THEATRE – Acción Community Theatre (ACT)

Which art program would be your third choice?*

DANCE – Ritmo en Acción (REA)
MUSIC – Musicians in Community (MIC)
THEATRE – Acción Community Theatre (ACT)

Participant Information

Name:*

First Last

Date of Birth:*

MM

DD

YYYY

Age:*

Gender:*

Male
Female
Other

Address:*

Street Address City State / Province / Region ZIP / Postal Code

Which neighborhood do you live in?*

If other:*

Please elaborate

Home Phone Number:*

Cell Phone Number:*

Email Address:*

Race (Check all that apply):*

Black
White
Latino
Asian
Other

Ethnicity:*

Country of Birth:*

Primary language spoken at home:*

English
Spanish
Other

If other:*

Please elaborate

Other language(s) spoken at home:

English
Spanish
Other

If other:*

Please elaborate

Do you live with:*

Both Parents
Single Parent
Guardian(s)
Other

If other:*

Please elaborate

Please select your household size (make sure to include yourself):*

Income Bracket:*

$0 to $20,650
$20,651 to $34,350
$34,351 to $51,150

Income Bracket:*

$0 to $23,600
$23,601 to $39,250
$39,251 to $58,450

Income Bracket:*

$0 to $26,550
$26,551 to $44,150
$44,151 to $65,750

Income Bracket:*

$0 to $29,450
$29,451 to $49,050
$49,051 to $73,050

Income Bracket:*

$0 to $31,850
$31,851 to $53,000
$53,001 to $78,900

Income Bracket:*

$0 to $34,200
$34,201 to $56,900
$56,901 to $84,750

Income Bracket:*

$0 to $36,730
$36,731 to $60,850
$60,851 to $90,600

Income Bracket:*

$0 to $40,890
$40,891 to $64,750
$64,751 to $96,450

If your selected household generated an income outside of the Income Bracket, please provide your income here:

Housing:*

Rent
Own
Shelter
Foster Home
Other

If other:*

Please elaborate.

If you rent do any of these apply to you:*

Section 8 (Subsidized Housing)
Public Housing
No

Which Public Housing?*

Does your family receive any public assistance?*

Food Stamps
Child Support
Welfare
AFDC
SSI/SSDI
TANF
Other
No

If other:*

Please elaborate.

What school do you currently attend?*

What grade are you in?*

How did you hear about Hyde Square Task Force?*

Family
Friend
School
Social Media
Event
Flyer
Other

If family:*

Please write their full name below.

If friend:*

Please write their full name below.

If school:*

What school? Please write name below.

If social media:*

Which platform? Please write below.

If event:*

Which event? Please write below.

If flyer:*

Where did you see the flyer? Please write below.

If other:*

Please elaborate

Were you previously enrolled in a Hyde Square Task Force program?*

Yes
No

If yes, which program?*

Parent / Guardian 1 Information

Parent / Guardian Name:*

First Last

Relationship to youth:*

Address:*

Street Address City State / Province / Region ZIP / Postal Code

Home Phone Number:*

Cell Phone Number:*

Email Address:*

Parent / Guardian Country of Birth:*

Employment Status:*

Employed
Self-employed or business Owner
Unemployed

Employer:*

Occupation:*

Work Phone Number:

Please describe parent's highest educational level:*

High School Graduate
Some College
College Graduate
Continued Education
Other

If other:*

Please elaborate

Parent / Guardian 2 Information

Parent / Guardian Name:

First Last

Relationship to youth:

Address:

Street Address City State / Province / Region ZIP / Postal Code

Home Phone Number:

Cell Phone Number:

Email Address:

Parent / Guardian Country of Birth:

Employment Status:

Employed
Self employed or business Owner
Unemployed

Occupation:

Employer:

Work Phone Number:

Please describe parent's highest educational level:

High School Graduate
Some College
College Graduate
Continued Education
Other

If other:

Please elaborate

Emergency Contact Information

Emergency Contact 1:*

First Last

Relationship to youth:*

Phone Number:*

Emergency Contact 2:

First Last

Relationship to youth:

Phone Number:

Medical Information

Do you have medical coverage?*

Yes
No

Insurance Policy (Name):*

Policy #:*

Does your child/teen have any of the following:*

Allergies
Physical difficulties
Medications
an IEP
a 504 plan
Emotional/behavioral challenges
Learning challenges
Mental health diagnosis

Please check all that apply.

Allergies*

Food
Environment
Medical
Other

If other, please elaborate:*

If you have a food allergy, please name it:*

If you have an environmental allergy, please name it:*

If you have a medical allergy, please name it:*

If physical difficulties, please describe:*

If your child/teen is on medications, please elaborate:*

If your child/teen is on an IEP, please describe:*

If your child/teen is on a 504 plan, please describe:*

If your child/teen has emotional/behavioral challenges, please describe:*

If your child/teen has an learning challenges, please describe:*

If your child/teen has a mental health diagnosis, please describe:*

Medical Consent*

I hereby give Hyde Square Task Force permission to administer basic First/Aid and/or CPR and/or take my child to a hospital and secure medical treatment when I cannot be reached or when delay would be dangerous to my child's health.

You have my consent

Parent/Guardian Signature:*

Date*

Consent*

The information provided on this form is true and accurate to the best of my knowledge and I give permission for my son/daughter to participate in Hyde Square Task Force programs and activities.

You have my consent

Parent/Guardian Signature:*

Participant Signature:*

Date*

Personal Reflection

What excites you about joining Jóvenes en Acción? What aspects of this program interest you most?*

Please answer the following questions in the space below. Each answer should have a minimum of 4 sentences.

What artistic skill(s) are you hoping to develop?*

Please answer the following questions in the space below. Each answer should have a minimum of 4 sentences.

Describe a current issue in your community and explain how you could improve it.*

Please answer the following questions in the space below. Each answer should have a minimum of 4 sentences.

What are your academic strengths and weaknesses?*

Please answer the following questions in the space below. Each answer should have a minimum of 4 sentences.

Photo/Video Consent and Release Form*

I hereby give permission for Hyde Square Task Force to use any photographs, film, or video taken of my child during the course of his or her participation in Hyde Square Task Force programming for educational and/or publicity purposes only. I understand that my child and/or any other identifying information may be used in accounts of Hyde Square Task Force programs, including newspaper and magazine articles, website and other internet materials, television, and other presentations or publications concerning the programs. I understand and acknowledge that my consent to the use of the above information is purely voluntary and is not required by Hyde Square Task Force as a condition of my child's participation in Hyde Square Task Force programming. I knowingly and voluntarily release and hold harmless Hyde Square Task Force, its agents and employees from an liability of any kind resulting from use of the information as set forth above. This release and waiver of liability is binding upon my successors, heirs and assigns.

Yes (you have my promotional release)
No (you do NOT have my promotional release)

Participant Signature:*

Parent/Guardian Signature:*

Date*