IT Help Desk Apprenticeship

Teen TechnoAcademy

Lil Bitties TechnoCamp

Community Development

Accomplishments
Urban Ed, Inc.
2041 Martin Luther King Jr. Ave., SE
Suite M-2
Washington, DC 20020
202-610-2344
202-610-2355 fax

info@UrbanEd.org

www.UrbanEd.org

rban Ed welcomes your Application for Enrollment into our TechnoAcademy and TechnoCamp!

Your application will be accepted at anytime. Enrollment is now open for the Teen program only. The Lil Bitties program will be open in May 2011. Click here to view the Teen Program Flyer. Click here to view the past summer's Lil Bitties Summer Camp Flyer. If you have questions, feel free to call 202-610-2344.

Which program are you applying to?
Teen TechnoAcademy
Children TechnoCamp [ages 5-8]
Child's Name:

Address:
 
City/State/ZIP:
Social Security Number
Date of Birth
DCPS School ID#
Child's Current Age
Child's Gender
Female Male
What race does the child belong to or identify with?
African-American/Black
American Indian/Alaska Native
Chinese/Chinese-American
East Indian/Pakistani
Filipino/Filipino-American
Japanese/Japanese-American
Korean/Korean-American
Mexican/Mexican-American/Chicano
Hispanic/Hispanic-American
Pacific Islander
Vietnamese/Vietnamese-American
White/Caucasian
Other, please specify
Is your child in school? Yes No
If yes, what school. If not in school, last grade attended:
Does your child have any medical conditions? Yes No
If yes, please explain?
Does your child have any dietary restrictions or food allergies?
Yes No
If yes, please explain?
Parent or Legal Guardian's Name
Area Code & Home Phone Number
Area Code & Cell Number
E-mail Address (if any):
Does the parent(s)/guardian work? Yes No
If working, weekly pay
Area Code & Work Number
What is the annual household income level?
Less than $10,000
$10,000 - $25,000
Over $25,000
How many people are in the primary household?
1
2
3
4 and over
Are the parent(s)/guardian currently or have been on welfare, TANF or public assistance?
Yes No
Have the parent(s)/guardian ever been convicted of a misdemeanor or felony within the past five years? Yes No
If yes, please explain?
Have the parent(s)/guardian ever been convicted of a drug related charge? Yes No
If yes, please explain?
Has your child had an IEP or in need of one? Yes No
If yes, please explain?
Has your child had or have any other problems or issues that Urban Ed and staff should be aware of? Please list:
Child MUST have at least four emergency contact people:
Emergency Contact Name 1:

Emergency Phone 1:

Emergency 1 Relationship to Child:
Emergency Contact Name 2:

Emergency Phone 2:

Emergency 2 Relationship to Child:
Emergency Contact Name 3:

Emergency Phone 3:

Emergency 3 Relationship to Child:
Emergency Contact Name 4:

Emergency Phone 4:

Emergency 4 Relationship to Child:
Please list the adult individuals that are granted pick up rights other than parent(s)/guardian:
Name:

Phone:

Relationship to Child:
Name:

Phone:

Relationship to Child:
Name:

Phone:

Relationship to Child:
Name:

Phone:

Relationship to Child:
Name:

Phone:

Relationship to Child:
Why are you, the parent or guardian interested in our technology learning program for your child?
Once your child completes this program what do you, the parent or guardian hope will happen? What would be your goals?
Consents (Required, to complete the application)
I give permission for my child to participate in Urban Ed's program, which includes attending field trips (we will always inform parents of any trips in advance).

I give permission for my child to receive medical attention only in the event of an emergency.

I give permission for my child to be included in non-commercial radio, television, internet, photographs or print media reports while my child participates in the program. Generally, this will include being in Urban Ed's printed and electronic materials such as brochures, their company website or in their annual report.

I give permission to complete confidential or anonymous surveys and/or participate in interviews for evaluation purposes that may include with funders who underwrite Urban Ed's summer program.

I understand that if my child is not picked up from Urban Ed by 4:00 p.m. he/she may be taken to the Office of Child Protective/Emergency Family Services located at 400 Sixth Street, SW 202-671-SAFE.
How did you hear about us? Select all that apply.
Friend
Parent
Word on the street
School program
Court system
Mailing/Flyer
Support service agency
Counselor/Case Manager
Another nonprofit
Passing by/Walk-in
Other

I have reviewed my information for completeness. Please accept my application for enrollment.