The Fresh Air Fund 2018 CHILD APPLICATION

1 The Fresh Air fund 2018 CHILD APPLICATION General Information Thank you for applying to The Fresh Air fund s 2018 Summer Programs. Our sleepaway programs are free of charge to families that meet our eligibility criteria. Please complete and submit the APPLICATION as soon as possible. Spots are filled as soon as applications are deemed complete by the Community Outreach Team. Please call 1-800-367-0003 if you have questions or need help completing the APPLICATION . ELIGIBILITY CRITERIA 1. Age For Camp Girls: 8 - 12 years old by 08/06/18 Boys: 8 - 15 years old by 08/06/18 Career Awareness Program (CAP/Camp Mariah): currently in 6th grade and 11 - 12 years old by 06/27/18 For Friendly Towns New applicants: 7 - 12 years old by 08/06/18 Returning applicants: 13 -18 years old are welcome to reapply; 14+ must be re-invited by a previous Host Family or a Host Family from the same Friendly Towns area 3.

2 Address Children must live in and go to school in any one of NYC s five boroughs: Bronx/ Brooklyn/ Manhattan/ Queens/ Staten Island 2. Income Families are income eligible if: The CHILD is currently in foster care The family receives Public Assistance: TANF/ SNAP/ Medicaid/ Section 8 voucher The family s total household income is no more than $20,000 above the USDA income guidelines. (See page 4 of this information packet for more information) Spots are filled on a first come, first served basis - after the APPLICATION is complete, even if you are a returning applicant We accommodate most applicants, but submitting an APPLICATION does not guarantee acceptance, even after it is complete; you will receive verbal and written confirmation of your CHILD s acceptance In some instances, additional or updated information may be needed in order to make an APPLICATION decision Children must be able to participate in the full trip and use transportation arranged by The Fresh Air fund If in foster care, please ensure that the APPLICATION is signed by the person legally authorized to make decisions for the CHILD Medical Form Our 2-page medical form must be completed (signed, dated, and stamped) by the doctor Camp Applicants: the most recent physical exam must have happened on or after 06/01/17 Friendly Towns Applicants.

3 The most recent physical exam must have happened on or after 01/01/17 - DOE/DOH medical form is only accepted for returning applicants Parent Orientation Once accepted, NEW parents/caregivers must attend an orientation before their CHILD s trip Returning parents are welcome to attend OTHER INFORMATION Priority Review Regular Review Returning Applicants 11/01/17 - 12/31/17 01/02/18 - 04/30/18 We will continue to accept applications until all spots are filled. New Applicants N/A * applications will not be reviewed until 01/02/18 Evaluation Form (if applicable) Dated after 01/02/18 and received by 04/30/18 Please note: If required, the APPLICATION is not complete without the evaluation form. We may not be able to make an APPLICATION decision if the evaluation form is received after this date.

4 Submit your completed APPLICATION and documents: Online: (after November 6, 2017) by email: by fax: 212-681-0158 in person/ The Fresh Air fund by mail: 633 Third Avenue, 14th Fl New York, NY 10017 Attn: Community Outreach by agency partners: (to find an agency near you) SUBMISSION INFORMATION Please call 1-800-367-0003 if you have questions or need help completing the APPLICATION . Keep a copy of your CHILD s APPLICATION for your records Call us to track your APPLICATION - DO NOT wait to hear from us Placement is not automatic or guaranteed - your CHILD s summer experience is not confirmed until you hear from us Confirmation will be communicated by phone, text, email and/or mailed letter We strongly recommend that you submit the APPLICATION before the dates indicated below: Please review the APPLICATION Checklist.

5 If you do not know which program you want, follow the checklist for the Camp Program. The APPLICATION should be submitted by 04/30/18. Please contact the Community Outreach Team at 1-800-367-0003 if you have questions. CAMP PROGRAM FRIENDLY TOWNS PROGRAM Page 1: CHILD & Family Information Page 1: CHILD & Family Information Page 2: Session Preference Page 2: Session Preference Page 3: Health Information Copy of Health Insurance Card(s) (Front & Back) Page 3: Health Information Copy of Health Insurance Card(s) (Front & Back) Page 4: Additional CHILD & Family Information Page 4: Additional CHILD & Family Information Page 5: Food Service Form Page 5: Food Service Form Page 6 & 7: Parental Consent & Release Form Page 6 & 7: Parental Consent & Release Form The Fresh Air fund Medical Form Dated on or after 06/01/17 All Applicants - Fresh Air fund Form Required (DOE/DOH form is not accepted) The Fresh Air fund Medical Form Dated on or after 01/01/17 New Applicants Fresh Air fund Form Required Returning Applicants Fresh Air fund Form or DOE/DOH Medical Form is accepted Meningococcal Meningitis Vaccination Form Vision Van Form Passport, for Canada trips only Supplemental Documents for ALL APPLICANTS Required if applicable: We encourage you to call the Community Outreach Team periodically to track the progress of your CHILD s APPLICATION .

6 Do not submit this page with your CHILD s APPLICATION Legal Guardianship Papers (Court-approved) Foster Care Information Page Evaluation Form Dated after 01/02/18 & Received by 04/30/18 Treatment Plan(s) Allergies/ Asthma/ Diabetes/ Seizure Disorder Special Dietary Plan Summer Food Service Program: Information for Parents Summer 2018 This insert relates to Page 5 of the CHILD APPLICATION . Read it carefully and keep it for your records. The Fresh Air fund participates in the Summer Food Service Program. Meals will be provided to all eligible children free of charge. (For The Fresh Air fund to be eligible to receive reimbursement for meals at a camp, children must meet the income guidelines for reduced price meals in the National School Lunch Program). Children in households that receive food stamps or benefits under the Food Distribution Program on Indian Reservations (FDPIR), or Temporary Assistance to Needy Families (TANF) are automatically eligible for the program.

7 The following 2017- 2018 income eligibility standards will be used for determining eligibility for reimbursement: Household Size Income Eligibility Guidelines Yearly Monthly Weekly 1 $22,311 $1,860 $ 430 2 $30,044 $2,504 $ 578 3 $37,777 $3,149 $ 727 4 $45,510 $3,793 $ 876 5 $53,243 $4,437 $1,024 6 $60,976 $5,082 $1,173 7 $68,709 $5,726 $1,322 8 $76,442 $6,371 $1,471 For each additional family member, add: $ 7,733 $ 645 $ 149 In accordance with Federal civil rights law and Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

8 Persons with disabilities who require alternative means of communication for program information ( Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. Meals will be provided at site(s) and times as follows: Camps Anita Bliss Coler (ABC), Hayden Marks Memorial, Hidden Valley, and Tommy will serve Breakfast at 8:00am, Lunch at 12:30pm, and Dinner at 6:00pm on the following dates: Wednesday, June 27, 2018 - Friday, July 6, 2018 Monday, July 9, 2018 - Friday, July 20, 2018 Monday, July 23, 2018 - Friday, August 3, 2018 Monday, August 6, 2018 - Friday, August 17, 2018 Camp Mariah will serve Breakfast at 8:00am, Lunch at 12:30pm; and Dinner at 6:00pm on the following dates: Wednesday, June 27, 2018 - Thursday, July 19, 2018 Thursday, July 26, 2018 - Friday, August 17, 2018 Please fill out the enclosed Summer Food Service Program Form (Page 5) and include it in your APPLICATION .

9 This institution is an equal opportunity provider. Persons interested in receiving more information should contact: The Fresh Air fund , 633 Third Avenue, 14th floor, New York, NY 10017 Telephone: 212-897-8900 To file a complaint of discrimination, complete the USDA Program Discrimination Complaint Form (AD-3027) found online at: , and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: 1) mail: USDA, Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, , Washington, 20250-9410. 2) fax: (202) 690-7442 3) email: 11/01/17 Signature of Authorized Representative Date 2018 Income Guidelines for Families Participating in Fresh Air fund Programs The Fresh Air fund 's income guidelines are based on the United States Department of Agriculture's guidelines for reduced price meals.

10 We will accept applications from families earning up to $20,000 per year over the published USDA income guidelines. These guidelines are released annually, and are printed on the other side of this page. The size of a family's household should be calculated including children. We work hard to serve as many New York City children as possible every year, but since spaces in host families and at camp are limited, we can only accept applications for those who meet these guidelines. Families that earn more than $20,000 per year above the USDA income guidelines are not eligible for any Fresh Air fund programs. Alternative summer programs can be found by contacting organizations such as the American Camp Association, available at or 1-800-777-CAMP. Instructions for completing Page 5 of the CHILD APPLICATION . Income Eligibility Form for the Summer Food Service Program Please complete the Summer Food Service Form (Page 5) using the instructions below.