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In-PersonHybrid (some in-person, some remote)Remote

Urban Scholars Spring 2020 After School ProgramUrban Scholars Summer Day Camp

AsianBlack/African AmericanHispanicWhiteAmerican Indian/Alaska NativeNative Hawaiian/Other Pacific Islander



Parent/Legal Guardian #1

Parent/Legal Guardian #2

Please list emergency contact if parent(s)/guardian(s) cannot be reached.


YesYes, but with limited dataNo

Very wellWellNot wellNot at all

Very wellWellNot wellNot at all

NoYes, it is:SpanishFrenchASLOther

Employed Full-timeEmployed Part-timeUnemployedRetiredReceiving Disability

SingleMarriedCivil UnionLiving TogetherSeparatedDivorcedWidowed

We own homeRentPublic HousingSection 8Live with Family/FriendsHomelessShelter

Live with Parent/GuardianIn Foster CareGroup HomeLive with FriendsLive with Relatives

SNAP (Supplemental Nutrition Assistance Program)WIC (Women, Infants, and Children Nutrition Program)Health Insurance Benefits (HUSKY, Medicaid, etc.)TANF (Temporary Assistance to Needy Families)EITC (Earned Income Tax Credit)


For example, does your child have an IEP (individualized education plan) or work with an aide?

Certification and Consent:

I hereby certify that the information on this form is complete and correct to the best of my knowledge. I consent to have this information entered and saved into the LifeBridge Community Services confidential client database. I understand that client records are confidential and are not released or shared with anyone outside of LifeBridge Community Services without the parent/guardian’s written consent except as required by law.

I have read the Urban Scholars Program responsibilities and both my Scholar and I agree to meet those expectations.

I give my permission for my child to be photographed, recorded, and/or videotaped by LifeBridge Community Services during agency-sponsored activities. I also understand that these photos, audio, and/or videos may be used in future publications, as marketing material or as training material.

I understand that LifeBridge Community Services is operating the Urban Scholars Program with great care, but that COVID-19 is a transmittable disease and my child is only in LifeBridge’s care during the daytime program. I cannot hold LifeBridge Community Services liable if my child contracts COVID-19 or any other transmissible illness.

I give my permission for (Scholar’s name) to attend the Urban Scholars Summer Program at LifeBridge Community Services and to participate in all activities, subject to the authority of the Urban Scholars Program Director.


Medicaid/HuskyMedicareNo InsuranceOther



Connecticut law states that except in the case of an emergency which threatens life or limb, parent or guardian must sign consent to treat for a patient under the age of 18. Please complete this section to allow your child to receive treatment for an accident, injury or illness at a medical facility.

  • Scholar will be transported to medical center
  • Program staff will always notify parent/guardian of need for medical care.
  • Scholar Health History and Registration Forms will be shared with the Medical Facility staff.

I request and authorize the nearest medical center, and its personnel to deliver medical care to my child listed here: . I also authorize LifeBridge Community Services to share Scholar Health History with the Medical Provider. This authorization will expire one year from the date of signature unless otherwise stated.

This health history is correct so far as I know and the person herein described has permission to engage in all prescribed program activities except as noted.

EMERGENCY AUTHORIZATION: : I hereby give permission to the medical personnel selected by the Urban Scholar Program Director to order x-rays, routine tests and treatment for me(staff) or my child, and in the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Urban Scholar Program Director to hospitalize, secure treatment for and to order injection and/ or anesthesia and/or surgery for me(staff)/or my child as named above. This form may be photo-copied for use off property. I also give permission for the Urban Scholar Program to provide routine medical care for my child.


The following questions are required for ALL Scholars. It is used to identify Scholars who require a plan of care to maintain health and maximize participation in the Urban Scholars Program. A more detailed Individual Plan of Care for a Child with Special Health Care Needs or Disabilities form is required for starred * items. The camp director will work with you to develop the Plan of Care.


Strict AvoidanceMedication as required. Please attach medical provider’s order/ care plan.Other

Medical Provider’s Order / Care Plan:

Strict AvoidanceMedication as required. Please attach medical provider’s order/ care plan.Other

Medical Provider’s Order / Care Plan: