Family Application | Mylez High Foundation

1 | Child & Family Information

Child’s full name *Preferred name / pronouns (optional)Date of birth / ageParent or legal guardian name *Phone numberEmail *City / ZIP codePreferred language / interpretation needs

Preferred program location

Franklin Park, NJBronx, NYEither

Preferred contact

PhoneTextEmail

2 | Interests, Strengths & Goals

Activities of interest

What does your child enjoy doing? What are their strengths?What would you most like your child to gain from participating? (e.g., friends, exercise, confidence, coordination)

Previous organized sports experience

NoneSomeRegular participation

3 | Communication & Learning Preferences

How does your child usually communicate? (select all that apply)

Helpful instruction approaches

What helps your child understand instructions and feel successful?

4 | Sensory, Emotional & Behavioral Supports

Sensitivities or challenges (optional)

Supports that may help

What situations are difficult, and what usually helps your child feel calm and safe?Are there any safety concerns we should plan for (e.g., leaving the activity area, unsafe climbing, difficulty recognizing danger)?

5 | Physical Access & Health/Safety Planning

Share only information relevant to safe participation. Additional health information may be requested securely before enrollment.

Does your child need any physical or accessibility accommodations?

YesNoUnsure

If yes, describe equipment, mobility, fatigue, or activity modifications needed.

Any allergies or emergency response needs staff should know about?

YesNoPrefer to discuss privately

If yes, describe relevant triggers and required response, or request a private follow-up.

Any seizure, asthma, cardiac, or other activity-related precautions?

YesNoPrefer to discuss privately

If yes, describe the precautions or indicate that you would like a private discussion.

6 | Support Level & Participation

Which support arrangement may work best?

Group coach supportSmall-group support1:1 assistanceUnsure / assess together

Can your child participate in a group activity for approximately 45–60 minutes with appropriate breaks?

UsuallySometimesNot yetUnsure

What has worked well or poorly in past programs or school/community activities?

7 | Family Access & Logistics

Preferred schedule

Potential participation barriers

Would scholarship or reduced-fee assistance be helpful?

YesNoMaybe

What could we do to make this program easier for your family to access?

8 | Emergency Contact & Authorized Pickup

Emergency contact nameRelationshipEmergency phoneAdditional authorized pickup person (optional)

9 | Parent / Guardian Acknowledgment

I confirm that the information provided is accurate to the best of my knowledge. I understand that this form is used to plan accommodations and determine program readiness; it is not a clinical evaluation, enrollment guarantee, medical clearance, or liability waiver. Program staff may contact me to clarify safety or support needs.

Permission to contact me about this assessment

YesNo

Parent / guardian signatureDate

10 | Optional Consent to Share Information

Please do not send medical records, IEPs, or clinical reports unless specifically requested through a secure process. Any future request to communicate with a school, clinician, or service provider should use a separate, specific written authorization.

Would you like staff to discuss whether coordination with your child’s existing support team could help?

YesNoMaybe later