Funky Furniture
Enfield Community Council Youth Programs Spring 2017 Registration Form Name of Participant: ____________________________________________________ Address:_______________________________________________________________ Date of Birth: __________________
Grade: ________
Parent/Guardian Name:__________________________________________________ Cell Phone: ____________ Home Phone:___________ Work Phone: _____________ E-mail Address: ________________________________________________________ Emergency Contact (other than parent/guardian): Name: _____________________Relation: _______________Phone: __________________
* All Programs are FREE of Charge!!! *
Please check the box for programs your child will be attending.
Funky Furniture
Funky Furniture, Tuesdays, 04/04 - 05/09 (4:30 - 6:30 pm) Wild Wednesdays, 04/05 - 05/10 (3:30 - 6:30 pm) Finally Fridays, 04/07– 05/12 (4:30 - 6:30 pm) Any allergies, special needs, or medical conditions of which we should be aware? Parental Permission _____Yes, I give permission for my child to participate in Enfield Community Council’s Youth
Programs in Spring 2017. ______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), wrenches, ratchets and other handheld tools, after they have had instruction on safe use and handling. _____ 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 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 Boynton Middle School and the Enfield Youth Program.
Parent Signature: ___________________________________________ Date: __________
Tuesdays, 4:30 - 6:30 PM (April 04 - May 09)
Try out your carpentry skills in this fun and creative program. We will be repurposing furniture, making bird houses and other creations. No experience necessary! Meets @ Enfield Community Center Pick up @ Enfield Community Center
Follow our adventures online! Facebook: www.facebook.com/ enfieldrys Instagram: EnfieldRYS
Please direct any questions to: Eric Carter Enfield Youth Program Educator (607) 279-2981 [email protected]
Wild Wednesdays Wednesdays, 3:30 - 6:30 PM (April 05 - May 10)
Fridays, 4:30 - 6:30 PM (April 07 - May 12)
We will be taking road trips and adventures throughout the greater Finger Lakes region. During these excursions, there will be lots of hiking, exploring and enjoying the spring air!
Come join us where we will be forging metal, building a trebuchet and working on small engines! Help us decide what the projects will be!!!
Meets @ Boynton Middle School Pickup @ Enfield Community Center
Meets @ Enfield Community Center Pick up @ Enfield Community Center
Grade: ________
Parent/Guardian Name:__________________________________________________ Cell Phone: ____________ Home Phone:___________ Work Phone: _____________ E-mail Address: ________________________________________________________ Emergency Contact (other than parent/guardian): Name: _____________________Relation: _______________Phone: __________________
* All Programs are FREE of Charge!!! *
Please check the box for programs your child will be attending.
Funky Furniture
Funky Furniture, Tuesdays, 04/04 - 05/09 (4:30 - 6:30 pm) Wild Wednesdays, 04/05 - 05/10 (3:30 - 6:30 pm) Finally Fridays, 04/07– 05/12 (4:30 - 6:30 pm) Any allergies, special needs, or medical conditions of which we should be aware? Parental Permission _____Yes, I give permission for my child to participate in Enfield Community Council’s Youth
Programs in Spring 2017. ______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), wrenches, ratchets and other handheld tools, after they have had instruction on safe use and handling. _____ 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 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 Boynton Middle School and the Enfield Youth Program.
Parent Signature: ___________________________________________ Date: __________
Tuesdays, 4:30 - 6:30 PM (April 04 - May 09)
Try out your carpentry skills in this fun and creative program. We will be repurposing furniture, making bird houses and other creations. No experience necessary! Meets @ Enfield Community Center Pick up @ Enfield Community Center
Follow our adventures online! Facebook: www.facebook.com/ enfieldrys Instagram: EnfieldRYS
Please direct any questions to: Eric Carter Enfield Youth Program Educator (607) 279-2981 [email protected]
Wild Wednesdays Wednesdays, 3:30 - 6:30 PM (April 05 - May 10)
Fridays, 4:30 - 6:30 PM (April 07 - May 12)
We will be taking road trips and adventures throughout the greater Finger Lakes region. During these excursions, there will be lots of hiking, exploring and enjoying the spring air!
Come join us where we will be forging metal, building a trebuchet and working on small engines! Help us decide what the projects will be!!!
Meets @ Boynton Middle School Pickup @ Enfield Community Center
Meets @ Enfield Community Center Pick up @ Enfield Community Center
