Sunrise of Philadelphia
JumpStartMiddle School Program
Application Form
This application is the first step to enrolling your child in the JumpStartprogram.By signing this form, you are telling Sunrise that you allow your child to attend ourJumpStart summer programfor students who will be in 9th grade in September, 2017.This program is FREE and students will earn minimum wage for participating. Breakfast and lunch will be provided. Weekly Field Trips. Your child will be better prepared for high school, explore their likes and interests, learn about various career paths, and build important skills.
JumpStart program dates: Wednesday, July 5 – Friday, August 11
JumpStart program times: Monday* – Thursday8:30 AM – 2 PM
Friday8:30 AM – 12PM
JumpStartprogram location: South Philadelphia High School
2101 South Broad Street
Philadelphia PA 19148
*The first week, there is no program on Mondayor Tuesday. Program will start on Wednesday, July 5th.
I, ______understand that I’m signing up my child to participate in the Sunrise of Philadelphia summer JumpStart program at South Philadelphia High School. I understand that this form is only the first step to enrolling my child. Additional paperwork and documents will be required to complete the enrollment process and to secure my child’s spot in the summer program.
______
Caregiver’s Signature Today’s Date
Sunrise of Philadelphia, Inc. follows an equal opportunity policy regarding clients enrolled in our programs. We do not discriminate with regard to race, creed, color, ethnicity, national origin, religion, sex, sexual orientation, gender expression, age, height, weight, or disability status.
JumpStartIntake Form
Please Print Clearly
Child’s Name: ______Date of Birth: ____/_____ /_____
Home Address: ______Philadelphia, PAZip Code: ______
Child’s School: ______Grade as of Sep 2017: ______
School ID Number: ______Gender: ______
Primary Language Spoken: ______
Child’s Race:
African American / Asian/Pacific Islander / Latino White / Biracial / Other (Specify): ______
Child’s Special Needs:
Deaf/Hard of Hearing / Homeless Developmentally Delayed / Behavioral/Mental Health
Individualized Education Program (IEP) (Please provide a copy for your child’s file) / Other (Specify): ______
Total Number of People Living in the Home: ______
If you are receiving any benefits, please provide your Case #: ______
and circle the following if they apply:
Cash Assistance S. S. I. Food Stamps Medicaid No Benefits
Caregiver’s Name: ______Relationship to Child: ______
Caregiver’s Contact Info: Home/Cell #: ______Work #: ______
E-mail Address: ______
* Application and enrollment information will be kept strictly confidential!