Bright Futures Youth Application

(We ask that all youth be able to arrive directly from their school to PCYC by 3:30pm.)

Welcome to PCYC’s Bright Futures! The following form will gather the information required to begin the registration process. Please note that completing this form does not guarantee enrollment.

This application process will take about 10-15 minutes to complete. Please complete an application for each youth that you would like to enroll.

Please read all instructions and proceed through all sections of the form. Be sure to fill out the entire form. ‘Electronic Signature’ is required. You must then press the submit button to complete the form. Application is valid for one (1) year.

If you have any questions, please contact Jaleeza Smith-Breedlove (612) 643-2096.

Page 1

Youth Information

Parent / Caregiver Information

Page 2

Parent / Caregiver Information Continued

Page 3

 Emergency Contact (to call if parent / caregiver cannot be reached)

In addition to those listed above, please list below all other authorized adults who are allowed to sign your scholar out of our program. Note: Bright Futures will not release scholars to individuals who are not listed on this form without parental consent.

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Health Information & History
The following information must be completed by the parent / caregiver. The intent of this information is to give staff the background information they need in order to provide appropriate care. Please provide complete information so we’ll be aware of all your youth’s needs.
List all medications by prescription name, purpose, dose and how often it's taken for each medication that your scholar takes every day or as needed. If medication needs to be administered during program hours, please contact the program director.
Authorization of Consent for Treatment of a Minor
Insert your full name here.
Insert scholar's name below.

I do hereby give my consent to Bright Futures for said scholar to receive medical or surgical aid as may be deemed necessary and practical by a suitably licensed or recognized physician or surgeon, in case of an emergency when caregivers cannot be reached. Consent is also given for Bright Futures to transport said scholar for emergency medical treatment if caregivers cannot be reached. This authorization shall remain effective until the end of my scholar’s participation in Bright Futures.

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Transportation
Parent Acknowledgement
Please initial the box below to show that you have read and acknowledge these statements:
  • By enrolling my scholar, I am giving Bright Futures and/or parties designated by Bright Futures permission to record audio and / or images (still or moving) of my scholar and to use such media at Bright Futures’s sole discretion.
  • By enrolling my scholar, I am giving permission for my scholar to attend field trips or excursions away from Bright Futures’s main facility, under proper supervision, and including transportation provided or arranged by Bright Futures.
  • By enrolling my scholar, I understand that Bright Futures and / or collaborating partners collect data to be used for the purposes of evaluating the program and for ongoing improvement. I further understand that my scholar’s data will be kept confidential.
  • By enrolling my scholar, I am giving Bright Futures permission to request and receive my scholar’s written and verbal education and behavioral data including but not limited to IEP and standardized testing results from teachers, social workers and school administrators.
Consent and Authorization For Specific Release of Information (ROI)
Due to your scholar’s enrollment with Bright Futures, each scholar is required to have a Release of Information (ROI) on file. This release of information gives BF consent to share and receive written and verbal information about your scholar from the agencies and for the information categories listed. The information provided will be used and/or disclosed for the following purposes: To create a collaborative case management system that is directly related to providing goods and services to your scholar by one or more of the Agencies. For Collaborative Case Management Collaborative: Northside Achievement Zone
Expiration Date: One Year from signing date

This consent is given to the Agencies and for the information categories in the following table:

Agency Name SetUp Info Demographics/Contact Ed – K12 Ed – Expanded Learning
Minneapolis Public Schools X X X X
Plymouth Christian Youth Center X X X X
Northside Achievement Zone X X X X

 

I authorize the Agencies listed above and NAZ, including staff, data management and evaluation contractors and consultants, case managers, and other employees, to share with each other written and verbal information about me as described below:

  1. The Agencies will share information about the Agencies I have visited and what items and services I have received;
  2. Information in the categories above will be shared with an Agency if the Agency’s category box is checked on the table above;
  3. If this Release of Information pertains to a minor who is currently enrolled as a student, then it also covers the student’s educational data. Educational data includes attendance, enrollment history, transcripts, and test scores;
  4. Verbal correspondence in person and over the phone will occur with the Agencies listed above to support NAZ engagement, achievement planning, and partner collaboration. I understand that the information shared, both verbally and in written form, will be treated as confidential information and will be exchanged solely for the purposes of supporting my family and children.

The information provided will be used and/or disclosed for the following purposes: To create a collaborative case management system that is directly related to providing goods and services to me by one or more of the Agencies.

The Agencies may also disclose “Anonymous Information” (which means information about me if my name, social security

number, address, and phone numbers have been removed) to research, governmental, or funding entities such as universities, grantmakers, and government offices that compile general statistics about social services, for the following limited purposes:

  1. To identify gaps in community services;
  2. To assist in ongoing study and development of more effective methods of assisting those in need; and
  3. To provide required reports to funders providing the service resources.

This Release of Information (ROI) expires one year from the signing date or sooner if requested.

I have read and understand the following statements about my rights:

  • I understand that information disclosed pursuant to this ROI might be redisclosed by the recipient and may no longer be protected by federal or state law.
  • As a database run by a vendor based in Rockford, IL, I understand that I may revoke this ROI at any time by writing to the Agencies’ vendor called SupplyCore, 303 N. Main Street, Suite 803, Rockford, Illinois, 61101. Any revocation will be effective at or before noon of the next business day after I submit the written revocation. If I revoke this ROI at an Agency and not at SupplyCore, the revocation will be effective by noon on the third business day after I submit the written revocation. I understand that I may not revoke this ROI to the extent that any of the Agencies have taken action in reliance upon it. I understand that I must sign any revocation.
  • I understand that I may refuse to sign this ROI and that my refusal to sign in no way affects my right to receive treatment or benefits of any kind.
  • I understand that refusal to sign this ROI may inhibit an effective assessment and coordination of services on my behalf.
  • I have the right, upon my request, to inspect and copy the information and communications disclosed hereunder.
Student Name
Name of Parent, Legal Guardian or other authorized representative