Attention: Nicole Pearsall

TTTR E D H O O K P (718) 923-8258TTllllF (718) 923-

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TB COMMUNITY jjjjjjiB 88 Visitation Place (between Van Brunt &
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Red Hook Community Justice Center
Photography Project
Applications must be received by the Red Hook Youth Court Office by May 1, 2008. If
you choose to fax or mail your application please keep a copy and call to ensure that it has been received.
Applications can also be delivered in person.

Date received: __________________ FOR OFFICE USE ONLY

Date of interview: _______________

Name:_________________________________________________________________________________

Date of Birth: ________________________________ Gender:_____ Social Security #: __________

Address:_____________________________________ Apt#_______ Home Phone: ( )___-_______

City:_________________________________ State:_______ Zip Code:________________

Please mark the neighborhood you live in:

__ Red Hook __Sunset Park __Carroll Gardens __Cobble Hill __Gowanus __Park Slope
__Windsor Terrace
Other:_____________________________________________________________________________

What subway/bus lines are accessible to you? ________________________________________________

Grade:___________________
School:_________________________________________

School Address:_________________________________________________________________________

City:___________________________________ State:_________ Zip Code:____________

Anticipated high school graduation date (Month/ Year) : ___________________________________

Please note that the Photography Project take place from 10 AM to 4 PM on weekdays. If you are
not available weekday mornings and afternoons, you may not be eligible for placement.

Are you able during the day in the summer? (morning and afternoon, Monday-Friday) ____________
Will you be attending summer school this summer? If yes, please note your class schedule (days, hours).
___________________________________________________________________________________
____________________________________________________________
____________________________________________________________

What other activities will you be involved in this summer? (dates, schedule, times)
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Are you legally eligible to work in the United States? _____________

We give priority for interviews to youth who have previously used services at the Red Hook
Community Justice Center.
Have you ever used services at Red Hook Community Justice Center before? Please check all that
apply.

Probation _____ JOIN _____

Criminal Court _____ Rites of Passage _____
Family Court _____ Dare to be King _____
TEACH _____ Youth Echo _____
Red Hook Youth Court (member) _____ Red Hook Youth Court (respondent) _____
TEACH _____ Mentoring & Internships _____
RHCJC GED _____
Other (Please specify.):
Has anyone in your family used services here? If yes, please specify.

Why do you want to participate in this program? Why an art program? What do you hope to learn from
participation in the program?

What do you plan to do next fall? If you will be enrolled in school, where will you be enrolled?
The following information is used only in ensuring the services provided to you by the Red Hook
Community Justice Center and internship placements accommodate participants adequately. It is not
considered in determining your eligibility for the internship program.

Do you have any special dietary needs? (allergies, religious restrictions, etc) If yes, please specifiy:
_____________________________________________________________
_____________________________________________________________
Please describe any health conditions that our staff should be aware of (asthma, hearing impairments, etc):

______________________________________________________________________________________

______________________________________________________________________________________

Do you take any prescribed medications? Yes ________ No _________

If yes, specify medication and reason: _______________________________________________________

______________________________________________________________________________________

Are you in Special Education? _________________

Please list any special needs you may have: ___________________________________________________

Emergency Contact:

Name: ________________________________________________________________

Relationship to child: ________________________________________________________________

Phone number: ________________________________________________________________

I hereby certify that the information provided in this application is true, correct and complete. If selected
to participate in the Photography Project, I understand that any misstatement of fact on this application
may result in dismissal.

______________________________________________________________________________________
Applicant’s Signature Date

I agree to give my child permission to participate in the Red Hook Community Justice Center Photography
Project..

______________________________________________________________________________________
Parent/ Guardian Signature Date
 RED HOOK

B bb COMMUNITY BB B

JUSTICE CENTER

Photography Project
Permission Slip
(Please Read Carefully and Sign)

I give my child, _____________________________________________________________, permission to

participate in the Red Hook Youth Court Photography Project.

I understand and agree that:

1. As part of the process, my child will participate in an unpaid orientation prior to being placed with the
Photography Project. Active participation in all sessions is a requirement for participation in the
program.

2. As part of the process, my child will participate from 10 AM to 4 PM three days per week for the
duration of the program from June 30 - August 2008. I will be informed, prior to my daughter/son’s
first day at work of the specific weekdays.

3. My child will participate in sessions at the Red Hook Community Justice Center and supervised
program field trips and excursions.

4. Transportation to and from sessions will be arranged between me and my child.

5. As part of the agency’s application process, additional information may be obtained from my child and
myself by the Red Hook Youth Court.

__________________________________________ ___________________
_
Parent/Guardian Signature Date

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