CHOP CHOP Family Advocacy and Support (FAS) REFERRAL Step 1 of 6 16% APPLICANT INFORMATIONApplicant Type(Required)First-Time ParticipantReturning ParticipantTransferring from another POP programEntry Term/Program (When would you like to start?)(Required)Fall/WinterSpringSummerWhich program are you interested in? Review programs at https://popartacademy.org/programs(Required) Paint Greater Than Initiative (PGTI) ASPIRE After School Camp POP Are you enrolling multiple children from the same household?(Required) Yes (If yes, please complete info for all children below under “Demographic”. If you are enrolling more than 4 children please call 215.948.9417 or email [email protected]) No DEMOGRAPHIC INFORMATIONChild #1 Name(Required) First Last Gender(Required) Race/Ethnicity(Required) Current Age(Required) Date of Birth(Required) MM slash DD slash YYYY Current Grade Level(Required) Name of School(Required) Child #2 Name First Last Gender Race/Ethnicity Current Age Date of Birth MM slash DD slash YYYY School Grade Entering in the Fall Name of School Child # 3 Name First Last Gender Race/Ethnicity Current Age Date of Birth MM slash DD slash YYYY School Grade Entering in the Fall Name of School Child #4 Name First Last Gender Race/Ethnicity Current Age Date of Birth MM slash DD slash YYYY School Grade Entering in the Fall Name of School PARENT/GUARDIAN DEMOGRAPHIC INFORMATIONName(Required) First Last Relationship to "Child(ren)"(Required) Email(Required) Cell Phone(Required)Other PhoneAddress(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is the participant currently receiving any supplemental assistance such as SNAP, TANF, Medicaid, CHIP, LIHEAP or similar benefits?(Required)SNAPTANFCHIPMedicaidOtherNone/Not ApplicableThis is for information purposes only, used for state reporting requirements of individuals we served.HOUSEHOLD INCOME (Please check the appropriate range for your gross family income)(Required)$0 – 10,000$10,001 – 20,000$20,001 – 30,000$30,001 – 40,000$40,001 – 50,000$50,001 – 60,000$60,001 – 70,000$70,001 – 80,000$80,000 – 90,000$90,000+UnknownThis is for information purposes only, used for state reporting requirements of individuals we served. HEALTH INFORMATIONAre there any medical, behavioral, mental health, dietary restrictions, and/or special needs that's important to know about the participant(s) [(asthma, seizures, allergies, diabetes, nosebleeds, ADHD, grief/trauma, oppositional defiance/conduct disorder, autism spectrum, etc.)](Required)Does the participant(s) have an IEP (Individualized Educational Plan)?(Required)Does the participant(s) have any DHS involvement (currently or in the past?)(Required)Is there a custody agreement in place between primary caregivers?(Required)Does the participant(s) have anyone in the community who works with them and their families to provide extra support, for example: Caseworkers/Social Worker, Mentor, Therapist, Psychiatrist, Probation Officer, or other providers? If yes, please explain.(Required)PLEASE UPLOAD A COPY OF PARTICIPANT(S) RELEASE OF INFORMATION, IF AVAILABLEMax. file size: 512 MB.ANY ADDITIONAL DOCUMENTSMax. file size: 512 MB.FileMax. file size: 512 MB.FileMax. file size: 512 MB. Consent(Required) By checking this box, you are consenting that you, as the parent/legal guardian of the above-named child, have understand and have reviewed the code of conduct with your child(ren). This check box represents your signature and indicates your/your child(ren)’s willingness to comply with these expectations and guidelines. Power of Paint reserves the right to dismiss, without refund, any participant whose influence is not conducive for the organization or for other participants. As partners in parenting, we thank you for your willingness to contribute to our positive community. We look forward to a successful, fun, and safe year. Registration Agreement(Required) I agree to the policies and procedures set forth in the Power of Paint Art Academy & Management (POP Art Academy) policies and acknowledge that my child is self-sufficient with regard to toileting, eating and dressing. My child and I have discussed and understand that while participating in POP Art Academy’s programs, the staff is in charge. My child is aware that guidelines and/or instructions made by a staff member are to be followed. I acknowledge that my child has been informed that they have the right to grieve any guidelines they believe may have violated their rights. I accept the Power of Paint Art Academy & Management (POP Art Academy)’s behavior policy.I certify that all information submitted in the enrollment process — including this application and any other supporting materials — is my own (or have legal right to share), factually true, and honestly presented, and that these documents will become the property of the organization to which I am applying and will not be returned to me (copies can be requested in writing for any records.) In place of your signature, please type your full legal name:(Required) Have you previously engaged in any other program at Power of Paint (POP Art)?(Required)YesNoUnknown ADDITIONAL INFORMATIONWhat is the name of your CHOP Social Worker?(Required) How did you hear about our program?(Required)CONTACT DETAILSWhat are the best ways to communicate with you? (select all that apply.)(Required) Email Text Phone Call Standard Mail Consent(Required) I acknowledge that I am at least 14 years old, have read the photo release policy, & am giving my consent without reservation to the foregoing.Please provide a mobile phone number to receive important updates via text regarding the status of your application and portfolio, important deadlines, and events from Power of Paint (POP Art Academy.)UntitledPhoneThis field is for validation purposes and should be left unchanged.