Summer Program 2024 Application Form GUARDIAN 1 INFORMATION Guardian 1 Name * First Name Last Name Guardian 1 Email * Guardian 1 Phone # * (###) ### #### Guardian 1 Relationship to Child(ren) * Guardian 1 Pronouns Guardian 1 Race / Ethnicity * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country GUARDIAN 2 INFORMATION (skip this section if there are no more guardians) Guardian 2 Name First Name Last Name Guardian 2 Email Guardian 2 Phone # (###) ### #### Guardian 2 Relationship to Child(ren) Guardian 2 Pronouns Guardian 2 Race / Ethnicity CHILD 1 INFORMATION Child 1 Name * First Name Last Name Child 1 Birthday * Please note: your child needs to be 2 years old (or nearing 2) upon enrollment MM DD YYYY Child 1 Race / Ethnicity * Child 1 Pronouns Child 1 Medical / Allergy information * We will need an up-to-date medical form from your child's doctor (medical forms are good for 1 year after a physical) meeting DOHMH required vaccinations. Anything you'd like us to know now about your child's medical needs? Learning Services (EI / CPSE / Private) Is your child currently receiving any services through EI, CPSE, or private providers? CHILD 2 INFORMATION (skip this section if no other child) Child 2 Name First Name Last Name Child 2 Birthday Please note: your child needs to be 2 years old (or nearing 2) upon enrollment MM DD YYYY Child 2 Pronouns Child 2 Race / Ethnicity Child 2 Medical / Allergy Information We will need an up-to-date medical form from your child's doctor (medical forms are good for 1 year). Anything you'd like us to know now? Learning Services (EI / CPSE / Private) Is your child currently receiving any services through EI, CPSE, or private providers? DESIRED SCHOOL LOCATION Your PREFERRED school location is: * Fort Greene (150 Clermont Ave) Prospect Lefferts Gardens (511 Rogers Av) Gowanus (94 9th St) TODDLER PROGRAM 14mo-3YO If the preferred location is not available, your SECOND choice is: Fort Greene Prospect Lefferts Gowanus TODDLER PROGRAM 14mo-3YO DESIRED SCHOOL SCHEDULE Choose your weeks: Minimum 2 weeks Week 1: (Thurs 4th of July CLOSED) July 1, 2, 3 + 5 SOUTH AMERICA Week 2: July 8-12 ASIA Week 3: July 15-19 AFRICA Week 4: July 22-26 EUROPE Week 5: July 29-Aug 2 NORTH AMERICA Week 6: Aug 5-9 AUSTRALIA Week 7: Aug 12-16 ANTARCTICA Week 8: Aug 19-23 THE OCEANS Your PREFERRED schedule is: * 5 days / week 4 days / week 3 days / week 2 days / week Not Sure If the preferred schedule is not available, your SECOND choice is: 5 days / week 3 days / week 2 days / week Not sure DESIRED HOURS Your PREFERRED hours are: * Half day 8:30-11:30am Full day 8:30-3:30pm If the preferred hours are not available, your SECOND choice is: Half day 8:30-11:30am Full day 8:30-3:30pm Full day + Afternoon 8:30-5:30pm Afternoon ONLY at Clermont 3:00-5:30pm Afternoon ONLY at Rogers 3:30-5:30pm Family Information Family household income * You can base your response on the gross income on your most recent tax return. Under $50K $50K-125K $125K-200K $200K-275K Over $275K Is there anything you'd like to tell us about your family? Examples include: Languages spoken at home? Physical, mental, cognitive or developmental differences? How did you hear about us? Friend Community Listserv Facebook Instagram Online search We have attended an Adult-Child class in the past Other THANK YOU! Be sure to hit the submit button, Based on your household income, please send your application processing fee through Zelle (preferred) or Venmo: <$50K = $20 $50K-125K = $25 $125K-200K = $30 $200K-275K = $35 >$275K = $40 We will in touch over the next 3 days to setup a phone call. Please reach out with any questions: hello@thecollectivekind.com Thank you for completing the Summer School Application. One of our school directors will be in touch with you soon.
