O u td oor Adve ntures O u td oor Adve ntures
Please direct any questions to: Eric Carter Enfield Youth Program Educator (607) 272-2292 ext. 226 [email protected]
Follow our adventures online! Facebook: www.facebook.com/ enfieldrys Instagram: EnfieldRYS
Want to learn how to build fires, shelters and play some awesome nature games!? Do all these things and more in this wilderness skills program! Meets @ Enfield Elementary School. Pick up @ Enfield Elementary. * Priority is given to 5th graders *
Want to learn how to build fires, shelters and play some awesome nature games!? Do all these things and more in this wilderness skills program! Meets @ Enfield Elementary School. Pick up @ Enfield Elementary. * Priority is given to 5th graders *
Follow our adventures online! Facebook: www.facebook.com/ enfieldrys Instagram: EnfieldRYS
Mondays, 2:15 - 4:15 PM (Jan 09 - Feb 13) There is no program on 01/16
Mondays, 2:15 - 4:15 PM (Jan 09 - Feb 13) There is no program on 01/16
Please direct any questions to: Eric Carter Enfield Youth Program Educator (607) 272-2292 ext. 226 [email protected]
Outdoor Adventures
Outdoor Adventures
Date of Birth: __________________ Grade: ________ Parent/Guardian Name:__________________________________________________ Home/Cell Phone: _______________________________________________________ Work Phone: _________________________________________ E-mail Address: ________________________________________________________ Emergency Contact (other than parent/guardian): Name: ___________________________________Phone: ________________________ Relation: ______________________________________
Date of Birth: __________________ Grade: ________
Parent/Guardian Name:__________________________________________________
Home/Cell Phone: _______________________________________________________
Work Phone: _________________________________________
E-mail Address: ________________________________________________________
Emergency Contact (other than parent/guardian):
Name: ___________________________________Phone: ________________________
Relation: ______________________________________
Parental Permission _____Yes, I give permission for my child to participate in Enfield Community Council’s Youth Programs. _____ I understand that I should call Eric by 1p.m. if my child will not be attending program. Additionally, I understand that if my child is unexpectedly absent from a program Eric will attempt to notify Parents and or Guardians. ______I fully understand and acknowledge that there are inherent risks and dangers in my child’s participation in the above activities and my child’s participation in such activities and use of any equipment related to such activities may result in injury, illness, or death, and damage to personal property. I understand other participants, accidents, forces of nature, or other incidents may cause these risks and dangers and I hereby accept these risks and dangers. _____ I give permission for my child to use a knife (for carving and cooking purposes), pruning tools, bow saws and other trail maintenance tools, after they have had instruction on safe use and handling. _____ I understand that my child should bring a water bottle to program. _____ Yes, I give permission for the Program Educator to transport my child if necessary. _____ Yes, I give permission for my child to participate in program evaluations in order to assess the program’s value. Any information gathered will remain anonymous. _____ Yes, I give permission for program staff and/or emergency personnel to administer first aid or medical treatment in the event of an emergency involving my child. _____ Yes, I give permission for my child’s photo to be taken during activities and for these photos to be used for documentation and publicity purposes (including on social media like Facebook & Instagram). _____ Yes, I understand that I must pick up my child at the end of each program and that supervision of my child is not provided beyond program time, unless otherwise arranged (this is not optional). _____ Yes, I give permission for Primitive Pursuits to contact me regarding additional programming. _____ Yes, I give permission for the release and exchange of my youth’s records and information (progress reports, etc.) to be shared between the Ithaca City School District Guidance Office at Enfield Elementary School and the Enfield Youth Program.
Parent Signature: ___________________________________________ Date: __________
Parental Permission _____Yes, I give permission for my child to participate in Enfield Community Council’s Youth
Programs. _____ I understand that I should call Eric by 1p.m. if my child will not be attending program. Additionally, I understand that if my child is unexpectedly absent from a program Eric will attempt to notify Parents and or Guardians. ______I fully understand and acknowledge that there are inherent risks and dangers in my child’s participation in the above activities and my child’s participation in such activities and use of any equipment related to such activities may result in injury, illness, or death, and damage to personal property. I understand other participants, accidents, forces of nature, or other incidents may cause these risks and dangers and I hereby accept these risks and dangers. _____ I give permission for my child to use a knife (for carving and cooking purposes), pruning tools, bow saws and other trail maintenance tools, after they have had instruction on safe use and handling. _____ I understand that my child should bring a water bottle to program. _____ Yes, I give permission for the Program Educator to transport my child if necessary. _____ Yes, I give permission for my child to participate in program evaluations in order to assess the program’s value. Any information gathered will remain anonymous. _____ Yes, I give permission for program staff and/or emergency personnel to administer first aid or medical treatment in the event of an emergency involving my child. _____ Yes, I give permission for my child’s photo to be taken during activities and for these photos to be used for documentation and publicity purposes (including on social media like Facebook & Instagram). _____ Yes, I understand that I must pick up my child at the end of each program and that supervision of my child is not provided beyond program time, unless otherwise arranged (this is not optional). _____ Yes, I give permission for Primitive Pursuits to contact me regarding additional programming. _____ Yes, I give permission for the release and exchange of my youth’s records and information (progress reports, etc.) to be shared between the Ithaca City School District Guidance Office at Enfield Elementary School and the Enfield Youth Program.
Parent Signature: ___________________________________________ Date: __________
Any allergies, special needs, or medical conditions of which we should be aware?
Address:_______________________________________________________________
Address:_______________________________________________________________
Any allergies, special needs, or medical conditions of which we should be aware?
Enfield Community Council Youth Programs Winter 2017 Registration Form Name of Participant: ____________________________________________________
Enfield Community Council Youth Programs Winter 2017 Registration Form Name of Participant: ____________________________________________________
Follow our adventures online! Facebook: www.facebook.com/ enfieldrys Instagram: EnfieldRYS
Want to learn how to build fires, shelters and play some awesome nature games!? Do all these things and more in this wilderness skills program! Meets @ Enfield Elementary School. Pick up @ Enfield Elementary. * Priority is given to 5th graders *
Want to learn how to build fires, shelters and play some awesome nature games!? Do all these things and more in this wilderness skills program! Meets @ Enfield Elementary School. Pick up @ Enfield Elementary. * Priority is given to 5th graders *
Follow our adventures online! Facebook: www.facebook.com/ enfieldrys Instagram: EnfieldRYS
Mondays, 2:15 - 4:15 PM (Jan 09 - Feb 13) There is no program on 01/16
Mondays, 2:15 - 4:15 PM (Jan 09 - Feb 13) There is no program on 01/16
Please direct any questions to: Eric Carter Enfield Youth Program Educator (607) 272-2292 ext. 226 [email protected]
Outdoor Adventures
Outdoor Adventures
Date of Birth: __________________ Grade: ________ Parent/Guardian Name:__________________________________________________ Home/Cell Phone: _______________________________________________________ Work Phone: _________________________________________ E-mail Address: ________________________________________________________ Emergency Contact (other than parent/guardian): Name: ___________________________________Phone: ________________________ Relation: ______________________________________
Date of Birth: __________________ Grade: ________
Parent/Guardian Name:__________________________________________________
Home/Cell Phone: _______________________________________________________
Work Phone: _________________________________________
E-mail Address: ________________________________________________________
Emergency Contact (other than parent/guardian):
Name: ___________________________________Phone: ________________________
Relation: ______________________________________
Parental Permission _____Yes, I give permission for my child to participate in Enfield Community Council’s Youth Programs. _____ I understand that I should call Eric by 1p.m. if my child will not be attending program. Additionally, I understand that if my child is unexpectedly absent from a program Eric will attempt to notify Parents and or Guardians. ______I fully understand and acknowledge that there are inherent risks and dangers in my child’s participation in the above activities and my child’s participation in such activities and use of any equipment related to such activities may result in injury, illness, or death, and damage to personal property. I understand other participants, accidents, forces of nature, or other incidents may cause these risks and dangers and I hereby accept these risks and dangers. _____ I give permission for my child to use a knife (for carving and cooking purposes), pruning tools, bow saws and other trail maintenance tools, after they have had instruction on safe use and handling. _____ I understand that my child should bring a water bottle to program. _____ Yes, I give permission for the Program Educator to transport my child if necessary. _____ Yes, I give permission for my child to participate in program evaluations in order to assess the program’s value. Any information gathered will remain anonymous. _____ Yes, I give permission for program staff and/or emergency personnel to administer first aid or medical treatment in the event of an emergency involving my child. _____ Yes, I give permission for my child’s photo to be taken during activities and for these photos to be used for documentation and publicity purposes (including on social media like Facebook & Instagram). _____ Yes, I understand that I must pick up my child at the end of each program and that supervision of my child is not provided beyond program time, unless otherwise arranged (this is not optional). _____ Yes, I give permission for Primitive Pursuits to contact me regarding additional programming. _____ Yes, I give permission for the release and exchange of my youth’s records and information (progress reports, etc.) to be shared between the Ithaca City School District Guidance Office at Enfield Elementary School and the Enfield Youth Program.
Parent Signature: ___________________________________________ Date: __________
Parental Permission _____Yes, I give permission for my child to participate in Enfield Community Council’s Youth
Programs. _____ I understand that I should call Eric by 1p.m. if my child will not be attending program. Additionally, I understand that if my child is unexpectedly absent from a program Eric will attempt to notify Parents and or Guardians. ______I fully understand and acknowledge that there are inherent risks and dangers in my child’s participation in the above activities and my child’s participation in such activities and use of any equipment related to such activities may result in injury, illness, or death, and damage to personal property. I understand other participants, accidents, forces of nature, or other incidents may cause these risks and dangers and I hereby accept these risks and dangers. _____ I give permission for my child to use a knife (for carving and cooking purposes), pruning tools, bow saws and other trail maintenance tools, after they have had instruction on safe use and handling. _____ I understand that my child should bring a water bottle to program. _____ Yes, I give permission for the Program Educator to transport my child if necessary. _____ Yes, I give permission for my child to participate in program evaluations in order to assess the program’s value. Any information gathered will remain anonymous. _____ Yes, I give permission for program staff and/or emergency personnel to administer first aid or medical treatment in the event of an emergency involving my child. _____ Yes, I give permission for my child’s photo to be taken during activities and for these photos to be used for documentation and publicity purposes (including on social media like Facebook & Instagram). _____ Yes, I understand that I must pick up my child at the end of each program and that supervision of my child is not provided beyond program time, unless otherwise arranged (this is not optional). _____ Yes, I give permission for Primitive Pursuits to contact me regarding additional programming. _____ Yes, I give permission for the release and exchange of my youth’s records and information (progress reports, etc.) to be shared between the Ithaca City School District Guidance Office at Enfield Elementary School and the Enfield Youth Program.
Parent Signature: ___________________________________________ Date: __________
Any allergies, special needs, or medical conditions of which we should be aware?
Address:_______________________________________________________________
Address:_______________________________________________________________
Any allergies, special needs, or medical conditions of which we should be aware?
Enfield Community Council Youth Programs Winter 2017 Registration Form Name of Participant: ____________________________________________________
Enfield Community Council Youth Programs Winter 2017 Registration Form Name of Participant: ____________________________________________________
