Packard Court Community Center &
Doris W. Jones Family Resource Building

After School Program

2026 – 2027

Students ages 5 -12 years old

Monday through Friday 3:30 p.m. to 6:30 p.m.

To Learn More and Stay up to Date Follow Us

Packard Court Community Center
4300 Pine Avenue
Niagara Falls, NY 14301
(716) 278-0228

PCCC Facebook Link

Doris W. Jones Family Resource Building
3001 Ninth St
Niagara Falls, NY 14301
(716) 285-5374

DWJFRB Facebook Link

Packard Court Community Center &
Doris W. Jones Family Resource Building

After School Program

Important Info

Sign Up Below

1After School Form (Start)

2Permission to Walk Home

3Permission Slip Form

4Transportation Consent Form

5Income Verification

After School Form (Start)

Child's Name(Required)

Age(Required)

Gender

Female

Male

Grade(Required)

T-Shirt Size(Required)

Birth Date(Required)

MM slash DD slash YYYY

School(Required)

Parent / Guardian(Required)

Phone/Cell(Required)

Address(Required)

Street Address (State / Region) (ZIP Code)

Emergency Contact Person(Required)

Person's Name

Phone/Cell

(Click the + to add more)

Please list ALL responsible persons able to pick your child up from the After school Program. Be informed, if their name is not listed your son/daughter WILL NOT be released to that person:(Required)

(Click the + to add more)

In the case of an emergency, accident or acute illness, the staff has permission to contact me at home or work and to seek medical assistance for my child. If I am unable to be reached, emergency contacts will be contacted.(Required)

(Initial)

I agree that the Niagara Falls Housing Authority will NOT be responsible for any unforeseen accidents, incident or lost or stolen items.(Required)

(Initial)

The Niagara Falls Housing Authority has permission to use any photos or video footage taken of my children or family during Summer Enrichment Program to be used for publication and advertisement of their programs.(Required)

(Initial)

Does your child have ANY illness/allergies food or otherwise that we should be aware of? {IF YES, Please List}

(Click the + to add more)

Does your child have ANY Behavioral, Social, Emotional, Special Needs etc. issues/concerns or otherwise that we should be aware of? {IF YES, Please List}

(Click the + to add more)

List all Medication Taken By Your Child:

(Click the + to add more)

Permission To Walk Home

ONLY for Children 9 YEARS OLD AND OLDER - NO EXCEPTION (5-8 can NOT walk home alone)
Must be Signed Out by A Parent/Guardian, Authorized Pick Up/Adult

If child walks home every day or if on occasion; please complete the following:

(Parents/Guardian Name)

Give permission for my child

(Child's Name)

to walk home after the Summer Enrichment Program.

Parent Signature(Required)

Date(Required)

MM slash DD slash YYYY

Permission Slip Form

Please, completely fill out this form if you wish your child to attend the Niagara Falls Housing Authority's Summer Camp Fields trips/outings

I,(Required)

(Parent / Guardian Name)

Give my child(Required)

(Child's Name)

permission to attend all the After School Program field trips, operated by the Niagara Falls Housing Authority.

I grant the Niagara Falls Housing Authority permission to transport my child by bus, van and/ or public transportation to these various trips.

I believe that he/she will be under competent leadership at all times and that all reasonable measures will be observed.

In the case of an emergency, accident or acute illness, the staff has permission to contact me at home or work and to seek medical assistance for my child. If I am unable to be reached, emergency contacts will be contacted.

I give the Niagara Falls Housing Authority permission to use any photos or video footage taken of my children during after school camp to be used for publication and advertisement of their programs ONLY.

I agree that the Niagara Falls Housing Authority will NOT be responsible for any unforeseen accidents, incidents, problems, etc., or lost, stolen or misplaced items.

To be signed by Parent/Guardian

I have read this application and approve of participation in this program. I assume full responsibility for my child’s conduct.

Parent Signature(Required)

Date(Required)

MM slash DD slash YYYY

I understand that as a member of the Packard Court Community Center Program(s), I will attend sessions, participate in the program and be on my best behavior.

Student Signature(Required)

Date(Required)

MM slash DD slash YYYY

Transportation Consent Form

Provider Name: Niagara Falls Housing Authority

Facility ID Number: 001452343SACC/145238SACC

Program Name: NFHA After school programs, summer enrichment programs at PCCC/FRB

This form may be used to meet the regulatory requirement to obtain written consent from the parent of a child for any transportation provided or arranged for by a caregiver, and to inform the parent when the person who is providing transportation changes. This form is not the Transportation Plan.

Parents whose children receive transportation services must receive, at the time of enrollment of their children, a copy of the program's transportation plan. If the plan is amended, parents must receive a copy of the amended plan prior to its start date.

It is recommended that a separate Transportation Consent Form be completed for each child.(Required)

I have been informed of, and agree to, the transportation plan of the above child care program.

Transportation Plan is attached to this Transportation Consent Form

Yes

Date of Transportation Plan: 7/2016 rev. 8/2019 JW 8/2025 JW

Child's Name(Required)

I give permission for my child (noted above) to be transported by (caregiver names and/or transportation contractor arranged for by the program) - Niagara Falls Housing Authority

Yes

At the following times (check all that apply):

Only as recorded on the posted transportation schedule for my child

Other

Other (Explain)(Required)

By signing this form, I am giving consent for the above described transportation services.(Required)

(Parent / Guardian Name)

Parent Signature(Required)

Date(Required)

MM slash DD slash YYYY

Income Verification

This is for grant purposes only. The answer to income or race/ethnicity question is not considered in the review of the application and determining eligibility.

to be transported by (caregiver names and/or transportation contractor arranged for by the program).
Niagara Falls Housing Authority

Household Income

Number of Persons in Home

Race/Ethnicity Check All that Apply

Black/African American

Black/African American & White

American Indian & Black

American Indian & White

White

Other Multi-Racial

Check One

Hispanic/Latino

Non-Hispanic/Latino

NIAGARA FALLS HOUSING AUTHORITY AFTER SCHOOL PROGRAM

If at any time a parent, guardian or anyone dropping off or picking up a student, shows inappropriate behavior, {inappropriate behavior, swearing, yelling, touching, hitting etc. or behavior deemed inappropriate by the director} the police could be called, depending on the severity, or that person will be asked to never appear on behalf of the student at the After school Program, and/or the student could be terminated from the program.

- Space in the program is limited.

- We are only accepting up to 45 at the Packard Court Community Center.

- We are only accepting up to 111 at the Doris W. Jones Family Resource Building.

As always, this is a “First Come First Serve” policy.

Preferred Location(Required)

FRB Only

PCCC Only

FRB and PCCC as second Choice

PCCC and FRB as second Choice

Niagara Falls Housing Authority Packard Court Community Center Doris W. Jones Family Resource Building

I acknowledge that I have received the following information included in the after-school program application packet.

✓ Program of activities

✓ Transportation Plan

✓ Transportation Consent Form (Both NFHA & NFCSD)

✓ Emergency / Evacuation Plan

✓ Plan for Behavior Management

✓ Child Abuse and Maltreatment Safety Plan

✓ Help Prevent Child Abuse information sheet/publication

✓ Together We Can Raise Healthy Children brochure (CACFP)

✓ PCCC School Age Childcare Program Handbook

✓ ACES Understanding Adverse childhood experiences

✓ Anaphylaxis Policy

Parent Signature(Required)

Date(Required)

MM slash DD slash YYYY

Packard Court Community Center & Doris W. Jones Family Resource Building

After School Program

Students ages 5 -12 years old

To Learn More and Stay up to Date Follow Us

Packard Court Community Center & Doris W. Jones Family Resource Building

After School Program

Sign Up Below

After School Form (Start)

Permission To Walk Home

Permission Slip Form

To be signed by Parent/Guardian

Transportation Consent Form

Income Verification

NIAGARA FALLS HOUSING AUTHORITY AFTER SCHOOL PROGRAM

Niagara Falls Housing Authority Packard Court Community Center Doris W. Jones Family Resource Building

Packard Court Community Center &
Doris W. Jones Family Resource Building

Packard Court Community Center &
Doris W. Jones Family Resource Building