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Groton Youth Services
September - October 2017 Elementary Programs
SIGN UP NOW—SPACE IS LIMITED! Programs are for Groton elementary school youth in grades 2-5. All programs meet in room 41 and run from2:55-4:30. Participants will be able to take the late bus home or need to be picked up at 4:30. If School is on holiday or cancelled Groton Youth Programs will also be cancelled. There is no cost for the after school programs but space is limited Please call Monica at 237-2723 if you have any questions.
Programs with Monica Dykeman Please check which program(s) your child would like to attend. ____ Spells, Potions & Creepy Concoctions—Tuesdays Sept 26— October 24, 3:00- 4:30
Come and create a spooky variety of science experiments will bring out the mad scientist in everyone! Oozy slime, bubbling potions, and magical experiments will amaze you!
_____ Busy Bees– Thursdays October 5th– 26th, 3:00-4:30 Start the new school year off right with homework help to begin the program. For the second half of the program, explore all the fall has to offer– leaf collecting and pressing, apple treats, carve a pumpkin, and more! My child will ride the late bus home _________ My child will be picked up at 4:30 by ____________________________________________ Other Dates to remember: Saturday October 28- Community Halloween Party 11:00am-1:00pm at the Groton American Legion Tuesday October 31– Trunk or Treat Community event 5:00-7:00pm at the Old Schara’s lot on Main Street
Please return completed form to Groton Elementary School to be put in Monica Dyekman’s mailbox
The Groton Youth Commission
PLEASE SEE THE OTHER SIDE FOR THE PERMISSION FORM!
2017 Groton Youth Services Elementary Fall Program Registration Form Pre Registration Is Required! Space is limited, please fill out this form and return it ASAP You will be contacted only if the program or programs you have registered for are full. Fill out a separate form for each youth. Please keep the attached program calendar for reference. Be sure to check the box next to the programs that your child is signing up for. Please return form to the elementary schhol Youth Information (Please Print) Youth Name: Birth date: ___ M/F: ________ Grade: School: _______________________________________________________________________ Address: _____________________________________________________________ Ethnicity: ____Hispanic ____Non-Hispanic Race: ____Black or African American ____American Indian or Alaskan Native ____Native Hawaiian or Pacific Islander ____Asian ____White ____Prefer Not to State Residence: _____Farm _____Rural/Town less than 10,000 _____Town/City: 10,000-50,000 Medical Conditions/Restrictions, or special needs? _____________________________________________________ Allergies? _____________________________________________________ Parent/Guardian Name: _______ Phone:: (Home) (Work) __________________________(e-mail)_________________________________ Emergency Contact Information Name: Phone:: (Home) (Work) _____ Yes, I give permission for my child to fully participate in 4-H Rural Youth Services programs and to ride in Cooperative Extension program van if necessary to get to and from activities, field trips and to transport youth home if necessary. _____ Yes, I give permission for program staff and/or other emergency care personnel to administer first aid or medical treatment in the event of an emergency involving my child. ______ YES if your child requires prescription or over the counter medication during the trip, A PRN order must be obtained by your child’s physician, the child must be able to self-administer the medication, which should come in the original container with only the specific dosages necessary for the duration of the trip . Parents must sign the PRN. _____ Yes, I give permission for my child to use a knife for carving and cooking purposes after they have had instruction on safe use and handling. _____ Yes, I give permission for my child to participate in program evaluation activities for the purpose identifying the program’s value and ways to strengthen and improve it in the future. Activities may include: skills checklists, informal discussion, surveys, observation, or group activities. Any feedback or information gathered will remain anonymous. ______Yes, I give permission for my child’s photo to be taken during the activity and for any photo to be use for documentation and publicity purposes. ______If my child is unable to attend a scheduled event, I will alert the program manager at © 237-2723 ______ Yes, I understand that my child should dress appropriately for the programs that they are attending. ______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. Parent/Guardian Signature:
Date:_______
Please send completed form to:
Tom Archibald at Cornell Cooperative Extension Tompkins County 615 Willow Ave, Ithaca, NY 14850 (607) 272-2292 ext. 222 or ext.223 Or drop off labeled Youth’ in Middle
Cornell Cooperative Extension of Tompkins County is an employer and educator recognized for valuing AA/EEO, Protected Veterans, and Individuals with Disabilities and provides equal program and employment opportunities.
in mailbox ‘Dryden the Dryden School Office
September - October 2017 Elementary Programs
SIGN UP NOW—SPACE IS LIMITED! Programs are for Groton elementary school youth in grades 2-5. All programs meet in room 41 and run from2:55-4:30. Participants will be able to take the late bus home or need to be picked up at 4:30. If School is on holiday or cancelled Groton Youth Programs will also be cancelled. There is no cost for the after school programs but space is limited Please call Monica at 237-2723 if you have any questions.
Programs with Monica Dykeman Please check which program(s) your child would like to attend. ____ Spells, Potions & Creepy Concoctions—Tuesdays Sept 26— October 24, 3:00- 4:30
Come and create a spooky variety of science experiments will bring out the mad scientist in everyone! Oozy slime, bubbling potions, and magical experiments will amaze you!
_____ Busy Bees– Thursdays October 5th– 26th, 3:00-4:30 Start the new school year off right with homework help to begin the program. For the second half of the program, explore all the fall has to offer– leaf collecting and pressing, apple treats, carve a pumpkin, and more! My child will ride the late bus home _________ My child will be picked up at 4:30 by ____________________________________________ Other Dates to remember: Saturday October 28- Community Halloween Party 11:00am-1:00pm at the Groton American Legion Tuesday October 31– Trunk or Treat Community event 5:00-7:00pm at the Old Schara’s lot on Main Street
Please return completed form to Groton Elementary School to be put in Monica Dyekman’s mailbox
The Groton Youth Commission
PLEASE SEE THE OTHER SIDE FOR THE PERMISSION FORM!
2017 Groton Youth Services Elementary Fall Program Registration Form Pre Registration Is Required! Space is limited, please fill out this form and return it ASAP You will be contacted only if the program or programs you have registered for are full. Fill out a separate form for each youth. Please keep the attached program calendar for reference. Be sure to check the box next to the programs that your child is signing up for. Please return form to the elementary schhol Youth Information (Please Print) Youth Name: Birth date: ___ M/F: ________ Grade: School: _______________________________________________________________________ Address: _____________________________________________________________ Ethnicity: ____Hispanic ____Non-Hispanic Race: ____Black or African American ____American Indian or Alaskan Native ____Native Hawaiian or Pacific Islander ____Asian ____White ____Prefer Not to State Residence: _____Farm _____Rural/Town less than 10,000 _____Town/City: 10,000-50,000 Medical Conditions/Restrictions, or special needs? _____________________________________________________ Allergies? _____________________________________________________ Parent/Guardian Name: _______ Phone:: (Home) (Work) __________________________(e-mail)_________________________________ Emergency Contact Information Name: Phone:: (Home) (Work) _____ Yes, I give permission for my child to fully participate in 4-H Rural Youth Services programs and to ride in Cooperative Extension program van if necessary to get to and from activities, field trips and to transport youth home if necessary. _____ Yes, I give permission for program staff and/or other emergency care personnel to administer first aid or medical treatment in the event of an emergency involving my child. ______ YES if your child requires prescription or over the counter medication during the trip, A PRN order must be obtained by your child’s physician, the child must be able to self-administer the medication, which should come in the original container with only the specific dosages necessary for the duration of the trip . Parents must sign the PRN. _____ Yes, I give permission for my child to use a knife for carving and cooking purposes after they have had instruction on safe use and handling. _____ Yes, I give permission for my child to participate in program evaluation activities for the purpose identifying the program’s value and ways to strengthen and improve it in the future. Activities may include: skills checklists, informal discussion, surveys, observation, or group activities. Any feedback or information gathered will remain anonymous. ______Yes, I give permission for my child’s photo to be taken during the activity and for any photo to be use for documentation and publicity purposes. ______If my child is unable to attend a scheduled event, I will alert the program manager at © 237-2723 ______ Yes, I understand that my child should dress appropriately for the programs that they are attending. ______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. Parent/Guardian Signature:
Date:_______
Please send completed form to:
Tom Archibald at Cornell Cooperative Extension Tompkins County 615 Willow Ave, Ithaca, NY 14850 (607) 272-2292 ext. 222 or ext.223 Or drop off labeled Youth’ in Middle
Cornell Cooperative Extension of Tompkins County is an employer and educator recognized for valuing AA/EEO, Protected Veterans, and Individuals with Disabilities and provides equal program and employment opportunities.
in mailbox ‘Dryden the Dryden School Office
