PAGE 1 The Fresh Air Fund: Child & Family …

1 PAGE 1 The Fresh Air Fund: Child & Family Information 2018 Child APPLICATION. Program: Friendly Towns Camp Career Awareness *PAGEA1*. Please do not cover New applicant Returning applicant barcode . Child Information Please PRINT clearly and use INK pen. Is this Child in foster care? Yes No First Name: Last Name: Date of birth: Age: Gender: Male Female Other: M M D D Y Y Y Y. Home address: Apt #: City: Borough: Zip: School: _____ School borough: _____ Current grade: Type: Public Charter Parochial/Religious Independent/Private Other: 1. Has your Child ever spent the night away from home? Yes No If yes, how many nights? 2. Child 's T-shirt Size: (Pick one) Youth: S M L Adult: S M L XL. 3. How did you hear about us? Friend/ Family Website School Ad Flyer Community Agency Other: Household Information Please PRINT FIRST then LAST NAME.

2 Those listed below must be authorized to pick up the Child . Parent / Guardian 1: Currently living with Child . Daytime : Cell : Evening : Email: * Relationship to Child : Mother Father Other: _____. Parent / Guardian 2: Currently living with Child Daytime : Cell : Evening : Email: * Relationship to Child : Mother Father Other: _____. * Please note: If you are the Legal Guardian, provide a copy of court approved guardianship papers.. Emergency Contacts . If we are unable to reach you about this application or during your Child 's trip, we will call the contacts in the order listed below. Emergency contacts must be 18 years or older and must be authorized to pick up your Child . Contact name Relationship 18 or older? Phone numbers ( cell, home, work). (not a parent or guardian listed above). 1. Yes No 2. Yes No 3. Yes No OFFICIAL USE ONLY.

3 Partnering Agency DATE RECEIVED BY FAF: Source: Walk-in Mail Email Fax Agency Partner School Event Street Outreach PAGE 2 The Fresh Air Fund: Session Preferences 2018 Child APPLICATION. Please do Must be Completed by Parent/Legal Guardian not cover barcode *PAGEA11*. Child 's first name: _____ Child 's last name: _____. Child 's date of birth: _____/_____/_____. MM DD YYYY. Please complete information for all programs of interest We will try to accommodate your choices Note: Placement is not guaranteed Camp Career Awareness Program Please indicate session preferences by filling in the If applying to the Career Awareness Program boxes with numbers 1- 4. (Camp Mariah) for the first time, indicate session 1 = MOST preferable preference: 4 = LEAST preferable 1 = MOST preferable 2 = LEAST preferable Session 1 June 27 - July 6 (9 days).

4 Session 2 July 9 - July 20 (12 days). Session 1 June 27 - July 19 (23 days). Session 3 July 23 - August 3 (12 days). Session 2 July 26 - August 17 (22 days). Session 4 August 6 - August 17 (12 days). All applicants: Once the Camp Program is full, please consider my Child for the Friendly Towns Program Returning campers will attend the same session as Summer 2017. Yes No Friendly Towns (Host Family Program). Child is NOT able to travel during the following period(s): 1. One of our Friendly Towns is in Canada. For those interested: Does Child have a valid passport? Yes No From _____ To _____ If yes, when does it expire? _____/_____/_____. MM DD YYYY. **Include a copy of your Child 's passport From _____ To _____. 2. Returning participants only: Does Child want to return to their Summer 2017 host Family From _____ To _____ if they are available?

5 Yes No Please Note: Children must par cipate in the full session and use The Fresh Air Fund arranged transporta on. Late arrivals to or early departures from sessions/trips are not allowed. PAGE 3 The Fresh Air Fund: Health Information 2018 Child APPLICATION. Must be Completed by Parent/Legal Guardian Please do not cover barcode *PAGEA15*. Child 's first name: Child 's last name: Child 's date of birth: _____/_____/_____. MM DD YYYY. Health Insurance Please submit a clear copy (front and back) of your Child 's health insurance card(s). 1. Check one of the following: Child has private health insurance ( through my employer or the open market). Does this policy include dental coverage? Yes No Child has health insurance through NYS Medicaid If applicable, check provider and submit copy of insurance card with Medicaid card: HealthFirst MetroPlus Fidelis Other: _____.

6 Child does not have health insurance Child is in foster care Questions about your Child 2. Mark all service(s) your Child receives: 3. Mark all service provider(s) your Child sees: IEP (Individualized Education Plan) Psychiatrist Counseling/ Therapy (in or out of school) Psychologist 504 Accommodations. Please explain: _____ Social Worker Other: _____ Other: _____. None None Is your Child in English Language Learner (ELL) classes in school? Yes No If yes, what native language(s)? _____. If you marked a service/provider above, call 1-800-367-0003 to obtain The Fresh Air Fund's Evaluation Form 4. Has/does your Child : YES NO YES NO. A. Had a recent injury, illness or infectious disease? L. Been treated for head lice in last six months? . B. Had a chronic or recurring illness/condition? M. Ever had problems with diarrhea/constipation?

7 C. Ever been hospitalized? N. Ever had an eating disorder? . D. Ever had surgery? O. Wear glasses, contacts or protective eye wear? . E. Had frequent headaches? P. If female, begun to menstruate? . F. Ever had a head injury? If not, does she know about the menstrual cycle? . G. Ever been knocked unconscious? Q. Know how to swim?(If yes, no explanation needed) . H. Ever had frequent ear infections? R. Have a fear of being in the water? . I. Ever been diagnosed with a heart murmur? S. Have a fear of being around animals? . J. Ever had seizures? T. Wet his/her bed? . K. Had skin problems ( itching, acne, eczema)? If yes, how often? _____. If yes, is it a medical issue? . Please explain any yes' answers. Include the question number and the most recent occurrence. _____. _____. *PAGEA4*. Please do Must be Completed by Parent/Legal Guardian not cover barcode.

8 Child 's first name: _____ Child 's last name: _____. Child 's date of birth: _____/_____/_____. MM DD YYYY. 1. Does your Child have any dietary restrictions ( vegetarian, no pork, lactose intolerant, gluten-free)? Yes No If yes, please explain:_____. These dietary restrictions are due to: Allergies/Medical Condition(s) Religious Beliefs Personal Preferences Other _____. 2. Does your Child have any of the following? (check all that apply). Asthma Allergies Diabetes Seizure Disorder None If checked, please explain: _____. 3. Is your Child currently taking any medication? Yes No If yes, please list: _____. 1. Preferred language to communicate with The Fresh Air Fund: English Spanish Mandarin Cantonese Korean Other: 2. Language(s) spoken at home: (check all that apply). English Spanish Mandarin Cantonese Korean French French Creole Arabic Bengali Other:_____.

9 3. Race/Ethnicity: (check all that apply). African American/Black African American Indian/Alaskan Native Asian South Asian Hispanic/Latino White Other: Prefer not to say 4. Country/Countries of origin: 5. Household type: Single parent/guardian Two parents/ guardians Other: _____ Prefer not to say 4. Total number of people in the household: 5. Do you receive public assistance? Yes No If yes, check all that apply TANF SNAP Section 8 Medicaid Other: 8. Is your Family currently homeless? If yes, where are you living? Yes No If yes, check all that apply In a shelter With Family /friends Other: Prefer not to say Please do Part 1. Name of Child enrolled in The Fresh Air Fund summer program. not cover barcode *PAGEN6*. Names (First, Middle Initial, Last) SNAP, TANF or FDPIR Case # (if any) Foster Child *. Child 's name: .. 1) Enter Child 's first and last name.

10 2) If receiving SNAP/ TANF/ FDPIR: provide Case # in Part 1. Skip Part 2. Go to Part 3.. 3) If Child is in foster care, provide Child 's name and check box in Part 1. Skip Part 2. Go to Part 3.. *Foster children are eligible for free and reduced-price meals regardless of household income. Please ensure that you have checked the Foster Child box for any foster children listed above. Complete Part 2 if you are applying for other children in your household and you did not enter a SNAP, TANF or FDPIR case number in Part 1 above. If not, skip to Part 3. Part 2. Total Household Gross Income. You must tell us how much you earn and how often it is received. Name(s) Gross income and how often it is received List everyone in the household, including children List all earnings from: work ( before deductions); welfare; Child support; alimony.