PCYC Summer Freedom School Enrollment

PCYC Summer Freedom School Child Enrollment Form

Child Information

Name(Required)

First Last

Birthdate(Required)

Child’s birthdate

MM slash DD slash YYYY

Gender Identity(Required)

Child’s gender identity

Male

Female

Non-binary

Decline to answer

Other

Preferred Pronouns(Required)

Child’s preferred pronoun

She

They

Other

Prefer not to say

Assigned Grade Level(Required)

Child’s grade level in fall 2026

Level 1 (grades 1 – 2)

Level 2 (grades 3 – 4)

Level 3 (5th grade)

Ethnicity: (Please check all that apply.)(Required)

American Indian or Alaska Native

Native Hawaiian or Pacific Islander

Asian

Black or African American

Hispanic Latino

White

Other

Prefer not to say

Child's Home Street Address:(Required)

Childs home street address

Street Address Address Line 2 City State ZIP Code

Grade Just Completed:(Required)

Grade your child will be completing in spring 2026

Type of School Attended:(Required)

Type of school your child attended in the 2025-2026 school year

Public

Charter

Private

Home

Other

School Name(Required)

School City, State(Required)

Free or Reduced Lunch:

Does your child receive free or a reduced price lunch at school during the academic school year?

Yes

Had/Have an IEP or 504 plan?(Required)

Has your child ever qualified for an Individual Educational Plan (IEP) or 504 plan?

IEP

504

Reading Proficiency Level:(Required)

If you don’t know, please ask your child’s teacher

Below Grade Level

At Grade Level

Above Grade Level

Other

Language(s) Spoken at Home:(Required)

List all languages your child speaks at home

English Language Learner:(Required)

Is your child an English Language Learner? (English is not their first language)

Yes

Health Insurance:(Required)

Child has health Insurance

Child does not have health Insurance

Health Insurance Carrier:(Required)

Medicaid

State

Private

Other

None

Attended a Children’s Defense Fund Freedom Schools Summer program?(Required)

Has your child ever attended a CDF Freedom Schools® summer or after school program?

Yes

If so, how many years?(Required)

How many years has your child participated in the program? Count both summer years and any after school years.

6 or more

Family Information & Emergency Contact Information

Family Information – Name:(Required)

Full name of the adult completing this form.

Family Information – Mobile Phone:(Required)

Mobile phone number for the adult completing this form.

Family Information – Home Phone:(Required)

Home phone number for the adult completing this form.

Family Information – Work Phone:

Work phone number for the adult completing this form.

Family Information – Email:(Required)

Email address for the adult completing this form. This person will receive information about the program and child.

Family Information – Relation to child:(Required)

How is the adult (who’s completing this form) related to the child?

Mother

Father

Grandmother

Grandfather

Other relative

Other (non-relative)

Family Information – Legal Guardian?(Required)

Is the adult completing this form the child’s legal guardian?

Yes

Family Information – Gender Identity:(Required)

What is the gender identity of the adult completing this form?

Male

Female

Non-binary

Prefer not to say

Other

Family Information – Preferred Pronouns:(Required)

What is the preferred pronoun for the adult completing this form?

She

They

Prefer not to say

Other

Family Information – Number in Household:(Required)

How many people are in the child’s household? Please enter a number from 2 to 10.

Please enter a number from 2 to 10.

Family Information – Number of Children age 0-5:(Required)

How many children (age 0-5) are in the child’s household? Please enter a number from 0 to 10.

Please enter a number from 0 to 10.

Family Information – Number of Children age 6-18(Required)

How many children and young people (age 6-18) are in the child’s household? Please enter a number from 0 to 10.

Please enter a number from 0 to 10.

Emergency Contact – Name:(Required)

If a child-emergency occurs and the adult completing this form is not available, please provide information about who should be contacted. Full name of the child’s emergency contact.

Emergency Contact – Mobile Phone:(Required)

Mobile phone number for the emergency contact.

Emergency Contact – Home Phone:(Required)

Home phone number for the emergency contact.

Emergency Contact – Work Phone:

Work phone number for the emergency contact.

Emergency Contact – Email:(Required)

Email address for the emergency contact.

Emergency Contact – Authorized to Pick Up?(Required)

Is the emergency contact authorized to pick up the child in your absence?

Yes, confirmed

Emergency Contact – Authorized to Pick Up(Required)

Confirmed

Authorized Pick-up

Authorized Pick Up – Name

Full name of someone who is authorized to pick up your child other than you.

2nd Authorized Pick Up – Name

Full name of someone who is authorized to pick up your child other than you.

Authorized pick up's relationship to the child.(Required)

Anyone picking up child will have to show Identification.

Mother

Father

Grandparent

Other relative

Other (non-relative)

2nd Authorized pick up's relationship to the child.(Required)

Anyone picking up child will have to show Identification.

Mother

Father

Grandparent

Other relative

Other (non-relative)

Authorized Pick Up – Cell Phone Number:(Required)

Mobile phone number for the authorized pick up.

2nd Authorized Pick Up – Cell Phone Number:(Required)

Mobile phone number for the authorized pick up.

Additional Information

Allergies or Health Conditions(Required)

Does your child have any allergies or health conditions that we should be aware of? If yes, please list.

Strategies To Support Child's Summer Learning(Required)

What are some strategies our team can use to best support your child’s learning throughout the program? (examples: needs additional reading help, prefers small groups)

Parent Notes About Child:(Required)

Is there anything else that you would like to share about your child?

T-Shirt Size(Required)

Child’s T-shirt size

XXL

Please note: In order to complete your registration and receive consent forms, attendance at our in-person parent orientation is required.

Once the session begins your attendance at weekly Parent Engagement Nights will also be required. These sessions will be held after 5pm during the week. Dates and times are to be determined and will be announced soon.

Parent Orientation(Required)

Thursday April 23, 5pm – 7pm

Thursday, April 30, 5pm – 7pm

I can’t attend either of these dates and will contact Program Director Andrew Hopkins to schedule an alternate time to meet. Email: ahopkins@pcyc-mpls.org • Call: 612-743-2508

Please remember that if you don’t attend the orientation or make an alternate appointment your child is not fully enrolled in the program and will not be able to participate.

Busing

We’re able to offer busing to some families who live in the general North Minneapolis area. However, it is the bus company that determines if your address is eligible for a child’s pick up and drop off. (We do not control the pick up or drop off locations, or times that are arranged by the bus company.) The bus company will let you know if your child is eligible for transportation.

Transportation(Required)

Yes – I live in North Minneapolis and I would like transportation for my child.

No – I will drop off and pick up my child.

If you live in North Minneapolis and would like bus transportation, please provide your pick up and drop off address below.(Required)

Photo/Video Permission

Photo/Video Permission(Required)

By checking the box below, I give permission for my child to be photographed and/or videotaped within the context of the PCYC Summer Freedom School program. I also give permission for PCYC to use any photograph/video segment for the purposes of advancing the mission of the organization.

Permission Granted

Parental Consent

Parent Consent(Required)

PCYC’s Summer Freedom School program is managed in partnership with the Children’s Defense Fund. We will be sharing program information and data outcomes about or on your child/ren, such as program enrollment, program attendance, and demographic information such as race/ethnicity, grade, and age.

The purpose of sharing this information is for program evaluation. Data will be kept confidential, and all reporting will occur at the group level and not the individual. This information will help us to better understand who is taking part in the PCYC programs through partnerships, evaluate its impact, and assess how we can best tailor programs to support our scholars. Data will be kept confidential by PCYC and our third-party evaluators, and all reporting will occur at the group level and not the individual.

I/we give consent for program information and data about or on my child/ren (e.g., enrollment/registration information, program attendance data, etc.) to be shared between PCYC and the Northside Achievement Zone and third party evaluators (such as Wilder Research). I/we understand the purpose for sharing this information and data is for program evaluation purposes and data tracking purposes. Data will be kept confidential and reporting will occur at the group and not the individual level.

I confirm my understanding by signing my name below.

Signature

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