CHOP

CHOP Family Advocacy and Support (FAS) REFERRAL

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APPLICANT INFORMATION

Applicant Type(Required)

Entry Term/Program (When would you like to start?)(Required)

Which program are you interested in? Review programs at https://popartacademy.org/programs(Required)

Paint Greater Than Initiative (PGTI)

ASPIRE

After School

Summer Camp

POP Art Academy

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 help@popartacademy.org)

DEMOGRAPHIC INFORMATION

Child #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 INFORMATION

Name(Required)

First Last

Relationship to "Child(ren)"(Required)

Email(Required)

Cell Phone(Required)

Other Phone

Address(Required)

Street Address Address Line 2 City State ZIP Code

Is the participant currently receiving any supplemental assistance such as SNAP, TANF, Medicaid, CHIP, LIHEAP or similar benefits?(Required)

This 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)

This is for information purposes only, used for state reporting requirements of individuals we served.

HEALTH INFORMATION

All health and mental health information shared will remain confidential and is used only to ensure your child’s safety and well-being while in our care.

Are there any emotional, social, or behavioral needs our team should be aware of to best support your child?(Required)

Are there any situations, activities, or triggers that might cause your child stress or discomfort? If so, what helps them feel calm or safe?(Required)

Are there any sensory, emotional, or behavioral needs our team should know about to best support your child?(Required)

Please share any medical conditions, allergies, or health needs that would help us keep your child safe and supported during the program.(Required)

Does your child take any medications that staff should be aware of while they’re with us?(Required)

Physician’s contact info and preferred hospital(Required)

If your child has a mental health diagnosis, IEP, or 504 plan that may affect their experience in the program, you may share anything you feel would help staff provide appropriate support. (Sharing is optional and confidential.)

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)

Release of Information

PLEASE UPLOAD A COPY OF PARTICIPANT(S) RELEASE OF INFORMATION, IF AVAILABLE

Max. file size: 512 MB.

ANY ADDITIONAL DOCUMENTS

Max. file size: 512 MB.

File

Max. file size: 512 MB.

File

Max. file size: 512 MB.

COMMUNITY AGREEMENTS

At Power of Paint, we create a safe and supportive space where every child can learn, create, and connect. Occasionally, children may struggle with following program routines or interacting safely with others. When this happens, our staﬀ respond with care, guidance, and support to help children regulate their emotions, build positive skills, and engage successfully with peers and staﬀ. Our focus is always on safety, respect, and growth for all participants.

Guidelines (please check box to indicate you have reviewed the guidelines)(Required)

1. Check in to the assigned program upon arrival to site; check out upon departure. 2. Do not bring valuables to the facilities. We are not responsible for loss or stolen items. 3. Vandalism of any sort is prohibited. 4. Participants must be respectful toward staﬀ members and fellow students. We have a no-bullying culture at Power of Paint. Bystander behavior must also show respect for all. Respect the rights and privacy of others. If someone wants you to know something about them, they will tell you. Gossiping and talking behind people’s backs is unacceptable. Treat others kindly and expect the same from them. If you have a problem, let a staﬀ person know. 5. Respect the personal dignity, opinions, and possessions of others. Understand that everyone is diﬀerent. Your ideas might be diﬀerent, but that does not make you right. If someone chooses not to share possessions with you, that is their decision. Do not play jokes on others. Take care not to hurt, upset, or embarrass anyone. Name-calling is not tolerated. 6. Participant’s must be respectful of others’ property, including, but not limited to property of other students, campers, other participants, and all POP Art’s business supplies, equipment, facilities and property. 7. Treat the employees—of places we visit, eat, or stay—with respect and use good manners. Do everything you can to make their job easier. 8. Stealing is prohibited. 9. Fighting or hitting of any sort is not tolerated. 10. Abusive or oﬀensive language/behavior is not permitted. Participants must always use appropriate language. 11. Participants may not possess lighters/matches, knives, or other dangerous items. 12. Participants must help in cleaning up after themselves in all activities. 13. Never leave the P .O.P site or assigned group without permission from a P .O.P staﬀ member. 14. Sneakers or closed- toes shoes are recommended at all times; please note that clothing may get messy and may acquire stains based on activities. 15. Please do not bring outside food and/or beverages that may contain common allergens. We are a nut-free, egg, and shellfish free campus. 16. Be willing to share information related to the health, safety, and wellbeing of the group. Talking about something that you think we should know is not squealing/”snitching”; it’s making the learning environment safer and better for all. 17. Be aware of the daily schedule and be on time. 18. During transportation, stay seated with your seatbelt fastened, use your inside voice, and treat the bus driver respectfully. 19. Be aware of and abide by all program rules and if you are not sure of something, ask!

Behavior Support Plan (please check box to indicate you have reviewed the "Behavior Support Plan")(Required)

1. We, as an organization, follow the “Reset & Reflect” policy of the program. The Reset & Reflect space is a safe, supportive area where children can pause to settle their emotions, center themselves, and reflect on their actions. Its goal is to help children develop self- regulation, problem-solving, and positive decision-making skills, while fostering a sense of care, connection, and community, rather than enforcing control or punitive actions. • Staff may offer the child the option to use the Reset & Reflect space when emotions are strong or behavior challenges arise. • Time in this space is brief and structured, just long enough to regain calm and focus. • Staff provide co-regulation support and guided reflection, helping the child process feelings and think about next steps. • After Reset & Reflect, staff and child will discuss strategies for improvement, positive choices, or restorative actions as appropriate. 2. If a participant continues to struggle with program expectations, staﬀ will reach out to the parent/guardian to discuss the behavior and collaborate on ways to support the child’s success. The participant may be placed on a behavior support plan, which provides structured guidance and check-ins. 3. If challenges continue despite the support plan, staﬀ may need to temporarily pause the participant’s enrollment to ensure the safety and well-being of all participants while we develop additional strategies to support their growth. 4. In serious situations that pose a risk to the participant or others, such as fighting, vandalism, or threatening behavior, the participant will be immediately removed from the program to ensure safety. Staﬀ will contact the parent/guardian promptly for pick- up, and the focus will be on ensuring the participant’s well- being and connecting them with appropriate support.

WAIVERS & LIABILITY

Please review and check all waivers below indicating that you have read, reviewed, and agreed to the following:

Authorization for Emergency Medical Care(Required)

I hereby give my permission to Power of Paint Art Academy & Management (POP Art Academy) staﬀ to call a doctor or emergency medical service and for the doctor, hospital, or medical service to provide emergency medical or surgical care for my child(ren) should an emergency arise. It is understood that the POP Art Academy’s staﬀ will make a conscientious eﬀort to locate the parent/guardian, or the emergency contact listed on the registration document before any action will be taken. If it is not possible to locate the emergency contact listed, I will accept the expense of emergency medical or surgical treatment

Authorization to Administer Over-the-Counter Medication(Required)

Power of Paint Art Academy & Management (POP Art Academy) staﬀ cannot supply your child(ren) with any over the counter medication unless we have a permission on file. If your child(ren) has needs beyond over-the-counter medication, please contact the Executive Director, Teisha Brown, tbrown@popartacademy.org, to make those arrangements. Please check if you would like your child(ren) to be able to receive over the counter medication, at the discretion of staﬀ, for mild conditions such as headaches, stomach-aches, low-grade fever, allergic reactions, etc. I hereby give my permission to POP Art Academy to administer the following to my child(ren) in the manner described on the packaging, if necessary: Bug spray Antibiotic cream, Children’s Tylenol/Motrin, Sunburn cream/ointment, Sunscreen, Heat/cold pack, First Aid Antiseptic Ointment. If you would like to add a special note for any of the above, please use the additional space in the “Additional Information” section on this form.

General Liability Waiver(Required)

I, as parent or legal guardians of the above named child(ren), approve and give my permission for him/her/them to participate in any class or program oﬀered by Power of Paint Art Academy & Management (POP Art Academy). By registering for programs through POP Art Academy, registrant acknowledges that the activities carried out in the program can carry certain risks for the participant. Registrant has independently reviewed and evaluated the risks and determined to engage in the program with full knowledge and acceptance of the risk. The registrants agrees to and hereby releases and forever discharge the Power of Paint Art Academy & Management, their oﬃcers, employees, agents, facilities, and volunteers from any and all liability for damages, loss or personal injury arising out of or related to registrant’s participation in youth recreational programs.

Lost or Stolen Items(Required)

I understand that Power of Paint Art Academy & Management (POP Art Academy) is not responsible for personal property that is lost or stolen while program participants are using the facilities or on the premises. We encourage participants to secure their property and encourage that valuable items are left at home, if possible.

Bike/Walk To &/or from Program Permission Form (if applicable)(Required)

My child has my permission to bike or walk to and from the facilities and be released on his/her/their own. He/she/they will be responsible for signing himself/herself/themself into and/or out of the program each day. I agree that POP Art Academy and employees will not be responsible for the welfare of my child before camp and once released to go home.

Walking/Biking Field Trip Permission Form(Required)

We will be leaving the premises on occasions (program & weather-specific) to bike, play tennis, football, soccer, fishing, gardening, etc. Check to give your child(ren) permission to do those activities. My child(ren) has my permission leave camp under counselor supervision for walking/short biking field trips (weather and ability permitting.)

Emergency Evacuation(Required)

I, the parent/legal guardian of the above name minor(s), hereby give permission for my child(ren) to be transported in the event of inclement weather, such as tornado, floods, hurricane, etc., or for the purpose of an emergency evacuation.

Promotional/Media Release(Required)

I hereby grant Power of Paint Art Academy & Management (POP Art Academy), and their agents, consent; and, authorize them to use photographic portraits, pictures, digital images or videotapes of my child(ren), or in which my child(ren) may be included in whole or part, or reproductions thereof in color or otherwise for any lawful purpose whatsoever related to any and all business related to Power of Paint Art Academy & Management, including but not limited to use in any Power of Paint publication or on the POP Art Academy’s websites, without payment or any other consideration. I hereby waive any right that I may have to inspect and/or approve the finished product or the copy that may be used in connection therewith, wherein my child(ren)’s likeness appears, or the use to which it may be applied. I hereby release, discharge, and agree to indemnify and hold harmless POP Art Academy and their agents from all claims, demands, and causes of action that I or my child(ren) have or may have by reason of this authorization or use of my child(ren)’s photographic portraits, pictures, digital images or videotapes, including any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said images or videotapes, or in processing tending towards the completion of the finished product, including publication on the internet, in brochures, or any other advertisements or promotional materials. I understand that in instances where confidentiality is required, this agreement does not apply. I represent that I am at least eighteen (18) years of age and am fully competent to sign this release.

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 understand that while participating in POP Art Academy’s programs, staff will guide and support all activities to ensure a safe and positive environment; and make decisions necessary to support the safety and well-being of all participants. My child understands that staff guidelines and instructions are meant to help keep everyone safe and supported, and agrees to follow them during program activities. I acknowledge that my child has been informed that they have the right to grieve any guidelines they believe may have violated their rights.

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.

ADDITIONAL INFORMATION

Have you previously engaged in any other program at Power of Paint (POP Art)?(Required)

What is the name of your CHOP Social Worker?(Required)

How did you hear about our program?(Required)

CONTACT DETAILS

What are the best ways to communicate with you? (select all that apply.)(Required)

Text

Phone Call

Standard Mail

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)