Bethany Cares, Inc.

Freedom School

275 West Market – Newark, New Jersey

973-6231468

Dear Parents and Scholars,

Thank you for your interest in BethanyCaresInc. Freedom School for Summer 2016. We are very excited about serving our families for our tenth consecutive year.

For both new and returning families, due to cost increases and budget constraints we made some notable changes to our program in both size and financial obligations.

For 2016, we will only accept a maximum of up to 75-80 new and returning scholars (TOTAL)from k-5 and there will be a modest program fee for all weeks of the program. Before and aftercare will be set at a fixed rate for parents choosing this option. Program dates are June 27, 2016 – July 29, 2016.

Please take a moment to carefully review our updated application format including the Freedom School program description, fees, mandatory program dates and parental obligations. Of course, we will be more than happy to address any questions you have concerning the application.

All the best for a successful Bethany Cares Inc. Freedom School summer!

Best Regards,

BCI Administration

Bethany Cares Inc., FreedomSchool

Application Information

BethanyCaresInc.FreedomSchool Program Description: The BethanyCaresInc. Freedom School is a summer literacy program with a focus on culture, social action, family and parental involvement. Children begin each day in a 30-45 minute Harambee!--a call to order of chants and cheers--that is used to energize participants every morning, make announcements for the day and highlight one book and grade for the day with scholars and visitors taking turns reading out loud to participants. The day is then broken into an integrated reading curriculum based on grade. Scholars participate in interactive reading and are strongly encouraged to keep abreast on current events throughout their community and the world. These endeavors often require our scholars to participate in a variety of events such as community voter registration barbeques, community greening, and refurbishment of the Freedom School mural, health care advocacy and facilitation of parent meetings demonstrating health and wellness activities.

The daily schedule is as follows:

8:00-9:00 a.m. Before Care/ Breakfast
9:00-9:30 a.m. Harambee!
9:30-11:00 a.m. Reading curriculum
11:00-11:15 a.m.Drop everything and read
11:15-11:30 a.m. Break
11:30-12:30 p.m.Math curriculum
12:30-1:40 p.m.Lunch
1:40-3:30 p.m.Afternoon activities
3:30-5:30 p.m.Dismissal/Aftercare

Parental and Scholar Obligations:Mandatory biweekly parent meetings and a full commitment is required from both parents and scholars in order to participate.We do allow up to 3 absences for personal issues or illnesses with a note. After 3 absences we are unable to hold your scholars’ space and the slot will be given to another scholar on our waiting list. Parent meetings are also another mandatory component to Freedom School. While we realize your time is valuable, we are committed to providing vital information that will help both you and your scholar in a mental, social and educational way that will assist in uplifting yourself and your community. Our parent meetings occur Wednesday evenings from 5:30pm-6:30pm. Parent meetings are now held every other week. As such, parents or a representative must attend all three meetings. Meetings will consist of many different topics such as health care, local community issues, advocacy tools, health and nutrition (with your scholar as the hosts and presenters)possible job information, but mainly updates about program activities. We like to think of Freedom School as a family and welcome any suggestions for meetings.

Program fee and before and after care: Should your scholar be accepted to our program, to attend for the entireprogram will cost $135 per child. Siblings who are accepted will be charged $135 for the first child and $75 for each additional child. Proof of sibling relationship required.An additional fee of $135 per child for both before and aftercare will be required at the time of your scholars acceptance fee payment. Siblings will be offered the rate of $135 for the first scholar and $50 for each additional scholar. Field trips will also be offered and may require an additional cost.All fees are non-refundable and non-transferable. Aftercare is subject to availability.

Application Due Dates and Fee: Applications will be available fromMarch1st, 2016 via BCI’s new website through our main office.Applications may be emailed [or dropped off at the Bethany Cares office between the hours of 9am-5pm. The application fee of $15 (per application), must be handed in with the application. Payments must be made by money order(to Bethany Cares Inc.) or cashONLY. No checks will be accepted. Application fee’s are non-refundable and non-exchangeable and does NOT guarantee acceptance into the program. Please indicate if you will require an additional receipt for your application other than your money order stub. Please make sure you include a recent copy of the scholars’ report card, as data is anonymously used for program scheduling, reporting and analysis. Any incomplete applications will be rejected. Any scholars not accepted into the program will be placed on a waiting list.

Selection Process: Due to program changes BCI is no longer partnered with Children’s Defense Fund. We do however maintain our dedication to literacy and social action. BCI’s curriculum has been reformatted to include math, history, language arts, and some science. Our main objective is to expose scholars to material they may have briefly touched upon in school or have not been introduced to at all. Through our dynamic curriculum changes we strive to push our young scholars to increase their awareness and knowledge base.

Program Acceptance: Parents will be notified of their child’s acceptance on a rolling basis.

Bethany Cares Inc., FreedomSchool

Child Enrollment Form 2016

(Please complete one form for each child)

INCOMPLETE APPLICATIONS WILL BE REJECTED

NO APPLICATIONS WILL BE ACCEPTED WITHOUT $15 APPLICATION FEE

APPLICATION FEE’S ARE NON-REFUNDABLE AND NON- TRANSFERABLE

AND DO NOT GUARANTEE ADMITTANCE IN THE PROGRAM.

Please include the following information with your application:

____ Application Fee

____ Report Card

Name of Site: BethanyFreedomSchoolToday’s Date: ______

Child’s Name ______Preferred Name or Nickname ______

Date of Birth ______/______/______Gender MaleFemale

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Race/Ethnicity

African American/Black, non Latino

American Indian or Alaskan Native

Asian, Native Hawaiian or Pacific Islander

Hispanic/Latino

White, Non-Latino

Other

Name of School ______

Do any of your children receive free/reduced price lunch at school during the school year?

Yes

No

How many people live in your household? ______

How many children live in your household? ______

Household Annual Income: $______

Is your scholar enrolled in additional academic programs throughout the school year?

Yes Program Name:______

No

Type of school your child attends

Public

CharterSchool

Faith-based

Private

2014-2015Grade Level ______

Has this child ever repeated a grade?

Yes

No

Has this child attended a Freedom

Schools® program before?

Yes

No

If yes, how many summers has child

participated in Freedom School

(not including the current summer)? ______

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How did you hear about this program?

______

What other enrichment or extra-curricular activities does your child participate during the year (for example, organized sports, music or dance lessons, academic tutoring, clubs or organizations)? ______

  1. Parent/Guardian’s Name ______

Relationship to Child: ______

Number and Street ______

City______State ______Zip Code ______

Occupation ______Highest Grade Completed or Degree Earned ______

Home Phone (____) ____ - ______Work Phone (____) ____ - ______

Cell Phone (____) ____ - ______Email: ______

Does the child live with this parent or guardian?YesNo

  1. Parent/Guardian’s Name ______

Relationship to Child: ______

Number and Street ______

City______State ______Zip Code ______

Occupation ______Highest Grade Completed or Degree Earned ______

Home Phone (____) ____ - ______Work Phone (____) ____ - ______

Cell Phone (____) ____ - ______Email: ______

Does the child live with this parent or guardian?YesNo

  1. Please list other adults authorize to pick up your child ***

NameRelationship to Child ______Phone Number______

1.______

2.______

3.______

4.______

5.______

*** Please be specific. Anyone NOT listed will not be able to pick up your child.***

Emergency Contact (If parent or guardian cannot be reached):

Name ______Relationship to Child: ______

Home Phone (____) ____ - ______Work Phone (____) ______- ______

Cell Phone (____) ____ - ______

Name ______Relationship to Child: ______

Home Phone (____) ____ - ______Work Phone (____) ______- ______

Cell Phone (____) ____ - ______

Bethany Cares Inc., Freedom School 2016

Medical Information Form

Has a doctor or health professional ever told you that this child has any of the following conditions?

Asthma

Hearing problems

Vision problems

Attention Deficit Disorder or Attention Deficit Hyperactive Disorder, that is ADD or ADHD

Depression or anxiety problems

Behavior or conduct problems

Bone, joint, or muscle problems

Diabetes

Autism

Any developmental delay or physical impairment

None

During the past 12 months, have you been told by a doctor or other health professional that this child had any of the following conditions?

Hay fever or any kind of respiratory allergy

Any kind of food or digestive allergy

Eczema or any kind of skin allergy

Frequent or severe headaches, including migraines

Stuttering, stammering, or other speech problems

Three or more ear infections

None

Please list any and all allergies:

______

______

______

Does this child currently need or use medicine prescribed by a doctor?

Yes No

Please list the medication(s) and attach a copy of the doctor’s prescription:

______

______

______

Is this child limited or prevented in any way in his/her ability to do the things most children of the same age can do?  Yes  No

If yes, please explain:

______

______

______

Has a doctor, health professional, teacher, or school official ever told you that this child has a learning disability?  Yes  No

If yes, please explain:

______

______

______

Has this child been to the doctor for any reason in the last 12 months? Yes No

Has this child been to the dentist in the last 12 months? Yes No

Please provide the following information:

Does this child have health insurance? Yes No

If yes, all information is required to be entered below:

Health Insurance Carrier: ______Name of Policy Holder: ______

Identification Number: ______Group Number: ______

Please explain any special procedures that should be followed in the event of a medical emergency:

______

______

______

Bethany Cares Inc., Freedom School 2016

PARENT/GUARDIAN CONSENT FORM

I, ______(Parent/Guardian’s Name), give permission to Bethany Cares Inc. and its designees to collect and record data on my child(ren),

______(Child’s Name). This data gathering may include, but is not restricted to the following:

  • Surveys and/or interviews about his/her/their knowledge, attitudes, skills, and behaviors in regard to his/her/their academic development such as motivation to read; nonacademic development such as leadership and conflict resolution skills; and, overall satisfaction with the Bethany Cares Inc. Freedom School program.

I understand that the purposes of these surveys and interviews are to document the impact of the Bethany Cares Inc. Freedom Schoolon its participants, and to identify areas for improvement. I also understand that this information will remain private, and that only my child(ren)’s site director(s) and research assistants approved by Bethany Cares Inc. will be able to look at his/her responses.I also understand that my child(ren)’s responses may be grouped together with the responses of other data sets for any public presentations of findings, and that my child(ren) will not be individually linked to his/her/their responses.

Print Name ______

Signature ______Date ______

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BETHANY CARES INC.,(B.C.I.)MEDIA RELEASE FORM

I hereby authorize and irrevocably grant to Bethany Cares., Inc (B.C.I.) and its affiliates, licensees, agents and assigns, the unrestricted right to use and publish any part of the information that I have given to B.C.I. and the right to record my name, voice, appearance, likeness, and comments on film, videotape, audiotape, still photographs, print, and any other media now known or hereafter invented. I acknowledge that B.C.I. shall own all right, title and interest in and to this media. I further agree that B.C.I. may cause all or parts of this media to be used for any and all publications, exhibitions, public displays, editorials, advertising or other purposes.I waive any inspection or approval of the media or any advertising or publicity in which my name, voice, appearance, likeness narrative, or comments might appear. I expressly release and agree to hold harmless B.C.I. and its agents, employees, licensees and assigns from and against any and all claims including, but not limited to, invasion of privacy, that I might ever have in any way relating to my interview or its use.

Print Name ______

Signature ______Date ______

PARENT CLOSING STATEMENT

I hereby certify that the statements in this application are correct and true. I understand that my child(ren)’s enrollment as a Bethany Cares Inc. Scholar is based, in part, on the information provided within this application and my agreeing to the terms as outlined in writing by Bethany Cares Inc. I also understand that this application and any fee (s) involved are not a guarantee of enrollment and are non-refundable. I authorize the local program sponsor to furnish a copy of this form to B.C.I. for use in any demographic/longitudinal evaluations that may be developed to strengthen the program

Print Name ______

Signature ______Date ______

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