LHPUSD MASTER Inspiring Summers Form 2023 ENG Header Image

La Honda Pescadero Unified School District: The Big Lift Inspiring Summers Application

The Big Lift Inspiring Summers program is a five week, full day summer camp for children who will enter kindergarten, first, second and third grade in Fall 2023. The curriculum makes learning fun and rewarding for students. This fun-filled summer program will inspire your child through books, project based learning, yoga, exciting field trips and other activities!

This program is offered for free through a Measure K grant from the County of San Mateo (income limits apply).

Please complete this online form to apply. We will review your application and notify your family about enrollment by email. 

Staff Use Only Priority Rank
Based on prior enrollments
Staff Use Only Student Enrolled
For removing from waitlist
For assigning student to specific session

The Big Lift Self-Declaration of Family Size

To qualify for this program, families must be income eligible. This is determined by your gross income and family size.

Family Size. Please count the members of your family. Family size includes parents / primary caregivers living in the home with the child, siblings under the age of 18 living at home with the child, and the child him/herself. Primary caregivers living with the child include: biological parents, adoptive parents, foster parents, other custodial parents, or a relative caregiver(s) who is / are primarily caring for the child in lieu of (in place of) a biological or custodial parent. Primary caregivers not living with the child do not count toward family size.










Total Family Size:

Count parents / primary caregivers, the child being enrolled in the summer program, and siblings living in the home with your child

Helpful Hint: If you are filling out this form on a computer, you can use the TAB key to easily move between fields. The ENTER/RETURN key will take you to the next page.

The Big Lift Self Declaration of Annual Gross Income

Please list income for any individuals counted in the family size. Report all amounts in annual gross income only, before taxes and deductions. (Exception: If someone is self-employed, applicants may provide NET income.) Primary caregivers not living with the child do not count toward family size and their income does not need to be reported.

The following list includes examples of income sources that should be counted toward the family annual gross income.

  • Financial assistance received for the care of a child living with an adult other than the biological or adoptive parent
  • Dividends, interest, savings bonds, income from estates or trusts, and other investment income
  • Net rental income or royalties
  • Wages for migrant, agricultural or seasonal work
  • Disability
  • Net income from self employment (income after expenses)
  • Housing or automobile allowances
  • Social Security
  • Foster grants, payments or clothing allowance for children placed through CPS
  • Workers compensation
  • Inheritance
  • Wages, salary, commissions, tips, overtime, bonuses
  • Public cash assistance (CalWorks/TANF)
  • Alimony, spousal support and child support received from a former spouse or absent parent
  • Unemployment benefits
  • Regular cash payments from outside the home
  • Income from other enterprises
  • Pension and annuities
  • Gambling and lottery winnings
  • Veteran's benefits, including pensions
  • Survivor (e.g. SSA) and retirement benefits
  • Supplemental Security Income (SSI)

Family ANNUAL GROSS INCOME (Before Taxes):

$


Child #1 Information

The Big Lift is committed to implementing a high quality, enriching Inspiring Summers program for all of our families. The information requested as part of the registration process helps us meet the needs of all families enrolled, ensure a positive and enriching summer experience, and evaluate the program’s effectiveness. Individual student and family records will only be seen by the school district, and staff of BellXcel and San Mateo County Libraries (BellXcel and San Mateo County Libraries are the summer program providers).

The Big Lift will not release information regarding immigration status or related matters contained in pupil records to federal agencies or other authorities enforcing immigration laws without the permission of the student’s parents or guardian or pursuant to a judicial warrant, subpoena, court order, or as otherwise required by law. All families are welcome to participate in our program regardless of immigration status.


First Name (enter child’s name as it appears on his/her birth certificate or passport)
Middle Name (optional)
Last Name
Child Birthdate*
Child Gender*
Is the child of Hispanic or Latino origin?*
Child Race*
Check all that apply
Child's Current Grade*
Grade Child Will Enter in Fall 2023*

Child #1: Additional Family and Child Information

Has a doctor or other professional ever diagnosed your child with a developmental delay, disability or special need?*
Does your child require special accommodations?*
Did your child ever attend a preschool program in the year before kindergarten?*
A preschool program is sometimes also called a child care center, pre-kindergarten, Head Start, nursery school, or a co-op.
All students who do not have a library card will receive a FREE library card. All library cards are free and there are no fines if your child returns an item late. Please let us know if you want your child to receive a library card or not:*

Child #1: Emergency Contact and Medical Information

The parents / primary caregivers listed in the previous section will be called immediately in case of illness, accident, or other emergency. Please list two additional adults living in the area who are authorized to pick up your child in your absence in the event of an emergency, or at the end of class.


My child has permission to eat the food provided in the Big Lift Inspiring Summers program.*
Does your child have any food allergies or food restrictions?*
Does your child have a medical condition that requires special attention or prescription medication?*
Does your child's prescription medication need to be administered during the school day?*
Do you have another child you would like to enroll in the Big Lift Inspiring Summers program? *

Child #2 Information

The Big Lift is committed to implementing a high quality, enriching Inspiring Summers program for all of our families. The information requested as part of the registration process helps us meet the needs of all families enrolled, ensure a positive and enriching summer experience, and evaluate the program’s effectiveness. Individual student and family records will only be seen by the school district, and staff of BellXcel and San Mateo County Libraries (BellXcel and San Mateo County Libraries are the summer program providers).

The Big Lift will not release information regarding immigration status or related matters contained in pupil records to federal agencies or other authorities enforcing immigration laws without the permission of the student’s parents or guardian or pursuant to a judicial warrant, subpoena, court order, or as otherwise required by law. All families are welcome to participate in our program regardless of immigration status.


First Name (enter child’s name as it appears on his/her birth certificate or passport)
Middle Name (optional)
Last Name
Child Birthdate*
Child Gender*
Is the child of Hispanic or Latino origin?*
Child Race*
Check all that apply
Child's Current Grade*
Grade Child Will Enter in Fall 2023*

Child #2 - Additional Family and Child Information

Has a doctor or other professional ever diagnosed your child with a developmental delay, disability or special need?*
Does your child require special accommodations?*
Did your child ever attend a preschool program in the year before kindergarten?*
A preschool program is sometimes also called a child care center, pre-kindergarten, Head Start, nursery school, or a co-op.
All students who do not have a library card will receive a FREE library card. All library cards are free and there are no fines if your child returns an item late. Please let us know if you want your child to receive a library card or not:*

Child #2 - Emergency Contact and Medical Information

The parents / primary caregivers listed in the previous section will be called immediately in case of illness, accident, or other emergency. Please list two additional adults living in the area who are authorized to pick up your child in your absence in the event of an emergency, or at the end of class.


My child has permission to eat the food provided in the Big Lift Inspiring Summers program.*
Does your child have any food allergies or food restrictions?*
Does your child have a medical condition that requires special attention or prescription medication?*
Does your child's prescription medication need to be administered during the school day?*
Do you have another child you would like to enroll in the Big Lift Inspiring Summers program? *

Child #3 Information

The Big Lift is committed to implementing a high quality, enriching Inspiring Summers program for all of our families. The information requested as part of the registration process helps us meet the needs of all families enrolled, ensure a positive and enriching summer experience, and evaluate the program’s effectiveness. Individual student and family records will only be seen by the school district, and staff of BellXcel and San Mateo County Libraries (BellXcel and San Mateo County Libraries are the summer program providers).

The Big Lift will not release information regarding immigration status or related matters contained in pupil records to federal agencies or other authorities enforcing immigration laws without the permission of the student’s parents or guardian or pursuant to a judicial warrant, subpoena, court order, or as otherwise required by law. All families are welcome to participate in our program regardless of immigration status.


First Name (enter child’s name as it appears on his/her birth certificate or passport)
Middle Name (optional)
Last Name
Child Birthdate*
Child Gender*
Is the child of Hispanic or Latino origin?*
Child Race*
Check all that apply
Child's Current Grade*
Grade Child Will Enter in Fall 2023*

Child #3: Additional Family and Child Information

Has a doctor or other professional ever diagnosed your child with a developmental delay, disability or special need?*
Does your child require special accommodations?*
Did your child ever attend a preschool program in the year before kindergarten?*
A preschool program is sometimes also called a child care center, pre-kindergarten, Head Start, nursery school, or a co-op.
All students who do not have a library card will receive a FREE library card. All library cards are free and there are no fines if your child returns an item late. Please let us know if you want your child to receive a library card or not:*

Child #3: Emergency Contact and Medical Information

The parents / primary caregivers listed in the previous section will be called immediately in case of illness, accident, or other emergency. Please list two additional adults living in the area who are authorized to pick up your child in your absence in the event of an emergency, or at the end of class.


My child has permission to eat the food provided in the Big Lift Inspiring Summers program.*
Does your child have any food allergies or food restrictions?*
Does your child have a medical condition that requires special attention or prescription medication?*
Does your child's prescription medication need to be administered during the school day?*
Do you have another child you would like to enroll in the Big Lift Inspiring Summers program? *

Child #4 Information

The Big Lift is committed to implementing a high quality, enriching Inspiring Summers program for all of our families. The information requested as part of the registration process helps us meet the needs of all families enrolled, ensure a positive and enriching summer experience, and evaluate the program’s effectiveness. Individual student and family records will only be seen by the school district, and staff of BellXcel and San Mateo County Libraries (BellXcel and San Mateo County Libraries are the summer program providers).

The Big Lift will not release information regarding immigration status or related matters contained in pupil records to federal agencies or other authorities enforcing immigration laws without the permission of the student’s parents or guardian or pursuant to a judicial warrant, subpoena, court order, or as otherwise required by law. All families are welcome to participate in our program regardless of immigration status.


First Name (enter child’s name as it appears on his/her birth certificate or passport)
Middle Name (optional)
Last Name
Child Birthdate*
Child Gender*
Is the child of Hispanic or Latino origin?*
Child Race*
Check all that apply
Child's Current Grade*
Grade Child Will Enter in Fall 2023*

Child #4: Additional Family and Child Information

Has a doctor or other professional ever diagnosed your child with a developmental delay, disability or special need?*
Does your child require special accommodations?*
Did your child ever attend a preschool program in the year before kindergarten?*
A preschool program is sometimes also called a child care center, pre-kindergarten, Head Start, nursery school, or a co-op.
All students who do not have a library card will receive a FREE library card. All library cards are free and there are no fines if your child returns an item late. Please let us know if you want your child to receive a library card or not:*

Child #4: Emergency Contact and Medical Information

The parents / primary caregivers listed in the previous section will be called immediately in case of illness, accident, or other emergency. Please list two additional adults living in the area who are authorized to pick up your child in your absence in the event of an emergency, or at the end of class.


My child has permission to eat the food provided in the Big Lift Inspiring Summers program.*
Does your child have any food allergies or food restrictions?*
Does your child have a medical condition that requires special attention or prescription medication?*
Does your child's prescription medication need to be administered during the school day?*

Parent / Primary Caregiver A Information

(Primary caregiver with whom child/ren live)

Caregiver A Name*
Caregiver A Birthdate*
Caregiver A Home Address*
Relationship to Child/ren*
This email address will receive your application submission confirmation and enrollment updates. Please list an email address you check regularly.
Is this person the sole parent or caregiver of the child/ren being enrolled in the summer program?

Parent / Primary Caregiver B Information

Caregiver B Name*
Caregiver B Birthdate*
Does this caregiver have the same home address as Parent / Primary Caregiver A?*
Caregiver B Home Address*
Does the child live with this adult?*
Relationship to Child/ren*

The following questions are for your child(ren) that you are applying for.

Liability


Through this form, I realize that no medical insurance is provided for The Big Lift Inspiring Summers activities and I agree to assume the risk for any injury related to my participation or the participation of my dependent/s. The undersigned agrees to indemnify and hold harmless, Building Educated Leaders for Life, San Mateo County Libraries, the school district, its council, Officers, Boards, Commissions, Agents, and/or any of its officers, employees or volunteers for any loss or liability which results or is alleged to have resulted from participation in this program. I am physically able (or my dependent/s is physically able) to participate in this activity. I consent to any medical treatment my dependent/s needs while involved in this activity and agree to pay for it. I realize that The Big Lift Inspiring Summers program is not responsible for any lost or stolen articles.


I have read, understand, and agree to the statement above.*

Data Sharing Information for The Big Lift

As a part of The Big Lift Inspiring Summers program, The Big Lift collects the information in this application along with child assessment data collected by your child/ren's teacher for The Big Lift. This information will help The Big Lift learn about the children and families served. This information will be used by San Mateo County Libraries and the San Mateo County Office of Education to implement and evaluate the program.

  • Families can skip any question they do not want to answer, except for the information that is required to enroll their child/ren in the program.
  • At some point during the program, families may be asked to complete a survey that asks additional questions about their experience with the program.

The information collected by The Big Lift is only used for program and evaluation purposes and will help manage and improve The Big Lift Inspiring Summers program for children and families in San Mateo County.

  • San Mateo County Libraries and San Mateo County Office of Education places the highest priority on the security and confidentiality of child/ren and family information and ensures it will be protected as required by law and in accordance with data security mandates.
  • In compliance with the Family Educational Rights and Privacy Act (FERPA), San Mateo County Libraries and the San Mateo County Office of Education (SMCOE) will only share information about me and my child/family for program evaluation purposes. The evaluation partner that data can be shared with includes: Building Educated Leaders for Life (BELL). Data will only be shared with authorized individuals from these agencies. This agency can only use the information for evaluating The Big Lift and cannot share any child or family information with anyone.
  • Reports will never include information that can identify me. Reports will never include my name, my child(ren)’s name(s) or any of my family’s other private or personal information.

If you have questions or concerns about how The Big Lift uses data, please contact: Early Learning Support Services, San Mateo County Office of Education, 101 Twin Dolphin Drive, Redwood City, CA 94065 at elss@smcoe.org.


I have read and understand the information above.*

Media Release

Your child/ren is/are enrolled in a program that is supported with funding from The Big Lift. The Big Lift is a partnership between San Mateo County Libraries, the San Mateo County Office of Education and the County of San Mateo. The Big Lift's goal is to help children get ready for kindergarten and improve third grade reading proficiency in San Mateo County.

Occasionally, The Big Lift's partners -- including the San Mateo County Office of Education, the County of San Mateo, Building Educated Leaders for Life, and San Mateo County Libraries -- photograph or film children, parents, or community members or receive photographs or videos from programs for The Big Lift publications, website, and social media postings or distribution to the media. In addition, updates about The Big Lift events may sometimes include quotes from participants, images of children, parents or community members, and may be featured in newspaper articles, television news shows, or documentary films. Your written permission will allow us to use images or films of your child/ren and family to share news about The Big Lift.

Children and parents / caregivers whose photographs are selected for Big Lift website or social media sites will not be identified by name. No demographic information will appear; however, identification of the school district and/or program name may be part of the web page design.

Children and parents / caregivers whose artwork, other schoolwork, and/or quotes are selected to appear in any Big Lift publications, websites, or social media sites will be identified by first name only.


Permission to release / publish photos or videos:*
Parent / Guardian Name*
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