TML Summer Application 2025 (Child/Youth Information Form) "*" indicates required fields Step 1 of 9 11% Child's Name* First Middle Last Child's Date of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child's Gender* Female Male Non-Binary / Gender Non-Conforming Transgender Other Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child's Caregiver (Full Name)* First Last Primary Caregiver Email Address* Primary Phone Number*Is this a cell/mobile phone?* Yes No Student Phone NumberShirt Size*Please note that The Children’s Trust may contact you via postal mail, email, or text to ask about your satisfaction with services and inform you of other Trust-funded programs, initiatives, and events that may interest you. Miami-Dade County Public Schools ID #*ALL STUDENTS ATTENDING PUBLIC OR CHARTER SCHOOLS MUST HAVE A SCHOOL ID # ENTERED.Child's Current School*Child's Current Grade*Pre-K - 12th GradeIs your child proficient in English?* Yes No Preferred language for contact?*Other languages spoken in your home* Spanish Haitian Creole Other None Which other languages are spoken in your home?*Child's Ethnicity* Hispanic Haitian Other Please specify the child's ethnicity*Child's Race* American Indian or Alaskan Asian Black or African American Pacific Islander White Multiracial Other Interested in adult literacy? Yes No Emergency Contact(s) other than parent/guardian (If I can can't be reached, please try to contact my designated alternate[s])*Tap or click the "+" sign on the right of the Phone Number field to add additional contactsNamePhone Number Add Remove We want to get to know your child better so that we can provide the best possible experience in our programs. Please tell us more about your child.What are the main ways in which your child communicates?*Mark all that apply Speaks and is easily understood Speaks but is difficult to understand Uses communication devices like pictures or a board Uses gestures or expressions like pointing, pulling, frowning or blinking Uses sign language Uses sounds that are not words like laughing, crying or grunting What, if any, help does your child receive at this time?*Mark all that apply Behavioral therapy or services Counseling for emotional concerns Daily medication (not including vitamins) Occupational therapy (OT) Physical therapy (PT) Special education services in school Speech/language therapy None of the above What conditions does your child have that are expected to last for a year or more?*Mark all that apply Autism spectrum disorder Developmental delay (only if under age 5) Intellectual/developmental disability (over age 5) Hearing impairment or deaf Learning disability (school age) Medical condition or illness Physical disability or impairment Problems with aggression or temper Problems with attention and hyperactivity (ADHD) Problems with depression or anxiety Speech or language condition Visual impairment or blind None of the above Do any of the conditions noted make it harder for your child to do things that other children of the same age can do?* Yes No To support your child’s successful participation in this program, in which areas might s/he need extra assistance?*Mark all that apply Holding a crayon/pencil, writing, using scissors or other fine motor tasks Sports or physical activities like running or other gross motor tasks Managing feelings and behavior Academic, learning or reading activities Adapting activities to take into account a visual or hearing impairment Using assistive device(s) like a wheelchair, crutches, brace or walker Personal services like help with feeding, toileting or changing clothes Other No specific help needed Please specify which other areas s/he may need extra assistance in?*Please tell us anything else you think is important for us to know about your child: Does your child have health insurance?*(ex., private insurance, KidCare, Medicaid) Yes No We may be able to help you find affordable coverage. Call 211 or visit www.thechildrenstrust.org/parents/health-connect/insurance.Dependency System? (Foster System)* Yes No Delinquency System? (Juvenile Detention)* Yes No Child receives free/reduced lunch?* Yes No Has your child ever been retained?* Yes No Which grades?*Number of children living at home:*Number of adults living at home:* CHILD’S MEDICAL INFORMATION EXCEPT AS NOTED, this child is in good health, has no allergies and no chronic conditions which would affect treatment.Food allergies?* Yes No Please list which food(s) your child is allergic to:*Drug allergies?* Yes No Please list which drug(s) your child is allergic to:*Other allergies?* Yes No Please list which other allergies your child has:*Chronic conditions?* Yes No Please list the chronic condition(s) your child has:*Are your child's Immunization records current?* Yes No Does your child know how to swim?* Yes No Does your child take medication?* Yes No Please list the medications that your child takes:*Tap or click the "+" sign on the right to add additional medicationsName of medicationHow often is this taken? Add RemoveHas your family ever experienced gun violence?* Yes No Please briefly explain how your family has experienced gun violence:*Has your child ever experienced any psychological or physical trauma?*(death, divorce/separation, parent jail/prison, witness to accident/crime) Yes No Please briefly detail the psychological or psychiatric counseling or treatment that your child has received:*Has your child ever received psychological or psychiatric counseling or treatment?* Yes No Please briefly explain how your child has experienced psychological or physical trauma:*Does your child have any past/present illnesses of which we should be aware?* Yes No Please describe which illnesses we should be aware of:* DISMISSAL INFORMATION Dismissal is at 5:45 PM during the School Year and 5:00 PM during the Summer Months. Jam Nights: (8th-12th grade only) 6:00-8:00 PM Overtown Site: Wednesdays Homestead Site: Thursdays Select one category for your child's dismissal:* I will be picking my child(ren) up each day. I will give permission for someone else to pick up my child. My child is in 3rd grade or higher and I give permission to have them walk home (younger siblings are allowed to walk with 3rd graders). I will give permission for my child to go home with someone else. I will give permission for my child to be dropped off somewhere. List the person(s) authorized to pick up your child:*Tap or click the "+" sign on the right to add additional namesFirst NameLast Name Add RemoveList the person(s) NOT authorized to pick up your child:Tap or click the "+" sign on the right to add additional namesFirst NameLast Name Add RemoveList the person(s) that your child is authorized to go home with:*Tap or click the "+" sign on the right to add additional namesFirst NameLast Name Add RemoveList the place(s) where your child is authorized to get dropped off:*Tap or click the "+" sign on the right to add additional placesName of placeAddress of place Add RemoveTouching Miami with Love is NOT responsible for student(s) who do not get on our bus at the designated pickup areas after school. PARENT, GUARDIAN, OR PRIMARY CAREGIVER INFORMATION FORM Please note that The Children’s Trust may contact you vial postal mail, email and/or text to ask about your satisfaction with services, and to make you aware of other Trust-funded programs, initiatives and events that may interest you.Are you a parent, guardian or primary caregiver?* Yes No How many children are in your care?*How many of the children in your care have a disability or condition expected to last for a year or more that makes it harder for them to do things that other children of the same age can do?*What is the highest level of education you’ve completed?* Didn't graduate high school HS Diploma / GED Some College Associate Degree Bachelor's Degree Graduate Degree What is the highest grade you completed in school?*Are you proficient in English?* Yes No Other language(s) spoken in your home:*Select all that apply Spanish Haitian Creole Other None Please specify which other language is spoken in your home:*Please select your ethnicity:* Hispanic Haitian Other Please specify which ethnicity you are:*Please select your race:* American Indian or Alaskan Asian Black or African American Pacific Islander White Multiracial Other Migrant family?* Yes No Military family? Yes No Parent in jail/prison?* Yes No Is there a computer in the home?* Yes No Is there internet access in the home?* Yes No Head of household type* Single Parent Married Two Parents Grandparent / Relative Monthly family range:* Under $10,000 $11,000 - $20,000 $21,000 - $35,000 Over $35,000 Do you receive any assistance?* Single Parent Married Two Parents Grandparent / Relative Is there anything that you would like to share? NON-DISCRIMINATION POLICY: Touching Miami with Love does not discriminate in any program or activity on the basis of sex, race, immigration status of children or parents, health, religion, color, national origin, age, sexual orientation, gender expression, gender identity, disability, or ability to pay for services. Children with physical, emotional or behavior disabilities/conditions may find programs specially designed to meet their needs through other Children’s Trust Programs; efforts will be made to assist with a referral to the most suitable placement for each child. PARENTAL CONSENT RELEASE AND WAIVER OF LIABLITY FOR TOUCHING MIAMI WITH LOVE By signing the application below, I agree I have read the following and certify the following: I acknowledge that the application information and medical information I have provided above is true and complete to the best of my knowledge and ability. I understand that every effort will be made to reach me for instructions if my child should become ill or injured while on the site or on a field trip. If, in the judgment of the staff or a medical professional, delay in reaching me might jeopardize the child’s well-being, I hereby authorize the staff or medical professional to secure whatever medical treatment is deemed necessary, including the administration of anesthetics and surgery. I acknowledge and I am aware of the risks and hazards connected with the that participation by my child in the Program sponsored by Touching Miami with Love and its partners and funded by the Children’s Trust involves physical education, organized sports, meals, and off-site field trips. As these activities may carry some degree of risk to my child’s physical and emotional health, and may include risks and hazards unknown to me or my child. I understand that part of the risk involved in undertaking any activity is relative to my child’s own state of fitness. I acknowledge that my child has no physical condition that would prevent him/her from safely participating in these activities. I, for myself, for my child hereby release, hold harmless, relinquish, and waive Touching Miami with Love, the Children’s Trust, and all employees, officers, directors, agents, and volunteers associated with the out-of-school program from all claims, demands, damages, actions, and cause of actions arising out of injuries, damages, or death sustained by me or my child resulting from participation in this out-of-school program. I further expressly agree that this release and waiver of liability is intended to be as broad and as inclusive as the Laws of the State of Florida will allow, and that, in any portion thereof is held to be invalid, it is agreed that the balance shall, notwithstanding the invalid portion, continue in full force and effect. I agree to make every effort to ensure that my child participates in the program daily, unless he/she is too ill to attend. I also agree that I or my representative will sign-out my child every day he/she attends the program. I agree to all the program standards. I am aware that if I (parent) is LATE picking up my child at the end of the day after 5:00 PM, there is a $25 Late Fee. If not paid within one week, I understand that my child will be suspended and possibly removed from Touching Miami with Love programs. I understand that some of the program sites are being held on the premises of religious institutions for the primary purpose of providing academic enrichment and a safe environment during out-of-school time. In some cases, religious instruction may be offered as an option to the children on the premises, but only with written parental permission. Unless express written permission has been given for my child to participate in religious instruction, an optional non-religious activity will be conducted. No Children’s Trust funds will be used for teacher stipends, books, curriculum or other expenses related to religious instruction. I understand that TML follows strict client confidentiality policies. TML will not release any confidential information to unauthorized persons. All records are kept in locked filing cabinets and access is granted only to direct care staff members. In addition, HIPPA confidentiality laws are followed if applicable. I understand that TML is not responsible for your child once he/she is dropped off home/destination. It is my responsibility to have either myself or someone home/destination to meet my child. I consent to allow the taking of photos or videos of my child and/or me during program activities. Photos/videos may reveal my child’s and/or my identity without any compensation paid to my child, to me or to others. All photos and videos shall be the sole property of TML and may be used for educational and/or promotional purposes. And all recordings taken of you, your children or wards, shall be the property of TML. With regard to the use of any Recordings taken of you, your children or wards, you hereby waive any and all present and future claims you may have against TML their staff, service providers, employees, agents, affiliates and Board members. I authorize my data to be shared with a 3rd party for research and evaluation purposes. Any data will be kept confidential and reported anonymously. I give my permission for this information to be submitted to The Children's Trust for program quality and evaluation purposes. The Children’s Trust provides funding for the program. For questions go to www.thechildrenstrust.org or call The Children’s Trust at 305-571-5700. I acknowledge that I have received and understand the “Parent Guidebook”. Completing an application does NOT mean that it is approved. You will receive a phone call once it's approved.Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Select today's dateSignature*I give my permission for this information to be submitted to The Children's Trust for program quality and evaluation purposes. The Children’s Trust provides funding for the program and follows strict data privacy protections for the information collected (for example, following the Family Educational Rights and Privacy Act/FERPA guidelines). Product Name Price: Total Credit Card*
