Back Together Again Summer Enrichment Twilight Program Registration Form
United Community Corporation, the City of Newark and the Newark Board of Education are teaming up to host a Back Together Again Summer Enrichment Twilight Program. The program runs from Monday, Aug. 1 - Sept. 2, Monday through Friday from 2 p.m. - 8 p.m. (immediately following each school's summer day program). The program is for students aged 7 - 14 and will be located at 5 Newark Public Schools.

Lunch will be provided.

Activities include: Tutoring, Chess, Arts & Craft, STEAM, Robotics/ Coding, Dance (Variety), Drumming, Entrepreneurship, Physical Fitness, soccer, football, basketball, and tennis, and Photography.

For more information, call 973-642-0181 or email info@uccnewark.org with "Back Together Again" in the Subject Line.
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Email *
Student's First and Last Name: *
Student's Date of Birth *
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Student's Address (Street, City, State, Zip Code) *
Student's Cell Phone number *
Gender *
Student's Grade Level *
Location Preference
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Primary Language Spoken at Home *
Race/Ethnicity *
Does your child quality for Free or Reduced Price Lunch at School *
Does your child have special needs? *
If yes to the above question, please explain.
Parent/Guardian's Relationship to Child *
Can your family benefit from counseling or additional services provided by United Community Corporation and do we have your permission to call you about this? *
Parent/Guardian's Home Phone number *
Parent/Guardian's Cell Phone number *
Parent/Guardian's Work Phone Number *
Parent/Guardian's Email *
Preferred method of contact *
Best Time to Call *
Secondary Parent/Guardian *
Secondary Parent/Guardian's Relationship to Child *
If English is not your first language, is there an English-speaking adult (family member or friend) whom we can contact regarding your child’s progress? If so, list their name and phone number: *
EMERGENCY CONTACT: NAME *
EMERGENCY CONTACT: Relationship to Child *
EMERGENCY CONTACT: Primary Phone Number *
EMERGENCY CONTACT: Secondary Phone Number *
First Aid and Medial Care: Child's Doctor/Clinic *
First Aid and Medial Care: Child's Doctor/Clinic Phone Number *
Does your child have allergies, special diets, or medications? *
If Yes to the Above Question, please describe.
Does your child have special limitations or concerns? *
If yes, please describe (Include your child's full name)
Does your child have any serious medical conditions? *
If yes, please describe
Transportation: Please select a daily departure transportation option. My child will depart from school by: *
Child Release Contact: Please indicate any additional adults, other than the parents/guardians and emergency contact already listed, who are authorized to pick up your child from school.  Please list their full name and phone number. *
Consent for Emergency Medical Care: In case of an emergency, in the event that I or the Emergency Contact I’ve listed cannot be reached, I give permission to the medical personnel selected by United community Corporations' staff to provide medical treatment required by my child. To provide that medical treatment, I grant permission to release my child’s medical records. *
Photographs/Video/Internet I hereby give permission for my child’s photograph to be taken and for him/her to be captured on video in connection with the activities of United Community Corporation and to be used in newspaper and magazine articles, on television and other presentations concerning the program, or on the internet. I understand that my child would only be identified by first name, if at all. I understand that my child, identified only by first name or as a member of a group, may also be included on video streams of events over the Internet that are organized and supervised by United Community Corporations’ staff. I give permission for the following information to be made available publicly, at the discretion of United Community Corporation: ● My child’s first name and/or picture ● Video of students in a group ● My child’s intellectual property (such as artwork, poetry, essays, performances, etc.) *
Parent/Guardian Signature Required: By typing your name below, you certify that the information provided on this form is accurate: Please type your name, the student's name, student's grade entering and today's date *
CONSENT TO RELEASE DATA FOR PROGRAM EVALUATION:  Purpose: United Community Corporation requests your permission to collect and use information about your child’s participation and performance in After-School programs as well as in school. United Community Corporation would like to use this information about your child to examine the influence of United Community Corporations programming on student achievement and engagement both during and after your child’s participation (e.g., middle school, high school and college). This information will help United Community Corporation make improvements to its program to have an even greater impact on the students served. Data Collected Directly by United Community Corporation: Information about your child will be collected by United Community Corporation directly or by evaluators or researchers contracted by United Community Corporation. By proving your consent, the following information will be used for program evaluation: ▪ Information about your child’s background obtained from this enrollment form. ▪ Information collected by United Community Corporation about your child’s program attendance, his or her performance on academic skills assessments conducted during the After-School program, and his or her survey responses. Data Obtained from External Sources By providing your consent, electronic data, records, and/or documentation about your child will be shared with United Community Corporation by your child’s school, school district, state Department of Education, or the National Student Clearinghouse (a national database of students’ college enrollment and completion). This information describes your child’s demographics, school enrollment and attendance, program participation, in and out of school suspension records, and academic performance (including course grades and state test scores) starting in grade two (prior to your child’s enrollment in the United Community Corporation) and enrollment in elementary school, middle school, high school, and college. United Community Corporation will collect your child’s state-assigned or locally assigned student identification number from your child’s school to be used to access these academic records. How Information is Used The only persons authorized to access your child’s information will be trained United Community Corporation staff, contractors, and/or trusted partner organizations who have agreed in writing to maintain the confidentiality of student information as required by the Family Educational Rights and Privacy Act (FERPA). United Community Corporation may use or disclose information in aggregate form to further the purpose discussed above. However, no child will be identifiable through information provided in any report or public document. Consent to Release Data for Program Evaluation: Please indicate by checking a box below whether you agree to allow United Community Corporation to collect and use information about your child in connection with the purpose described above. Your child may participate in After-School programming whether or not you provide this consent. You may revoke your consent to share data for this evaluation at any time. If you have any questions or if you would like to revoke consent for this program evaluation please contact Jamila Colin, at (973) 642-0181, ext. 3181 or at Jamila.colin@uccnewark.org. *
Parent/Guardian Signature Required: By typing your name below, you certify that the information provided on this form is accurate: Please type your name, the student's name, student's grade entering and today's date *
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