Groton Youth Services
Groton Youth Program Winter 2017 Middle School Registration Form Name of Participant: ________________________________
Groton Youth Services Winter 2017 Middle School Programs
Address:__________________________________________ Date of Birth: ________________Grade: ________ Parent/Guardian Name______________________________ Home Phone: ____________ Work Phone: ______________ Emergency Contact Name: ______________________ Phone: ______________ Allergies or medical conditions :_____________________ Please Check All That Apply _____ Yes, I give permission for my child to participate in Groton Youth Programs in Jan and Feb 2017 _____ Yes, I give permission for my child to participate in program evaluations for the purpose of assessing the program’s value. Any information gathered will remain anonymous. _____ 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, 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. _____ Yes, I understand that my child must ride the late bus or I must pick my child up at the end of each program and that supervision of my child is not provided beyond program time, unless otherwise arranged.
Parent Signature: ________________________________ Date: ______________________
Open to Students in 6th through 8th Grades Program Manager: Monica Dykeman Phone: 237-3723
Check out these Fun Programs! Dream It, Build It: Build your own robot, machine, or creation. If you can dream it– you can plan it and build it! Explore design, electrical circuits, and more. Mondays, Jan 23– Feb 27 2:50-4:20pm
Get Fit: Start your new year off right with healthy snacks, physical challenges and ways to manage stress. Meets at the elementary school and is open to 4th through 7th graders
Groton Youth Services Programs Registration Form Winter 2017 Please check the your child would like to attend. *Please note no afterschool programs 2/20-2/25 ______ Dream It, Build It: Mondays 1/23– 2/27 2:50– 4:20
Wednesdays, Jan 11– Feb 15 2:50-4:20pm Elementary
Program Helpers: Do you enjoy helping younger kids? If so this may be the perfect thing for you! If selected, you will come to the elementary school to help with afterschool programs. Please speak to Monica before signing up for this program as you need to be approved Tuesdays Jan 10– Feb 28 or Thursdays Jan 12– Feb 16 2:50-4:420 pm
SPACE IS LIMITED. REGISTER TODAY!!
_____ Spring Crafts: Wednesdays: 1/11– 2/15-4:20pm (4th through 7th graders only)
______Elementary Program Assistant: 2:50-4:20pm Check One: _____ Tuesdays, 1/10– 2/28 _____ Thursdays, 1/12-2/16 _______Check if participant will need to ride the late bus.
Detach and return completed form to the school main office.
Groton Youth Services Winter 2017 Middle School Programs
Address:__________________________________________ Date of Birth: ________________Grade: ________ Parent/Guardian Name______________________________ Home Phone: ____________ Work Phone: ______________ Emergency Contact Name: ______________________ Phone: ______________ Allergies or medical conditions :_____________________ Please Check All That Apply _____ Yes, I give permission for my child to participate in Groton Youth Programs in Jan and Feb 2017 _____ Yes, I give permission for my child to participate in program evaluations for the purpose of assessing the program’s value. Any information gathered will remain anonymous. _____ 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, 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. _____ Yes, I understand that my child must ride the late bus or I must pick my child up at the end of each program and that supervision of my child is not provided beyond program time, unless otherwise arranged.
Parent Signature: ________________________________ Date: ______________________
Open to Students in 6th through 8th Grades Program Manager: Monica Dykeman Phone: 237-3723
Check out these Fun Programs! Dream It, Build It: Build your own robot, machine, or creation. If you can dream it– you can plan it and build it! Explore design, electrical circuits, and more. Mondays, Jan 23– Feb 27 2:50-4:20pm
Get Fit: Start your new year off right with healthy snacks, physical challenges and ways to manage stress. Meets at the elementary school and is open to 4th through 7th graders
Groton Youth Services Programs Registration Form Winter 2017 Please check the your child would like to attend. *Please note no afterschool programs 2/20-2/25 ______ Dream It, Build It: Mondays 1/23– 2/27 2:50– 4:20
Wednesdays, Jan 11– Feb 15 2:50-4:20pm Elementary
Program Helpers: Do you enjoy helping younger kids? If so this may be the perfect thing for you! If selected, you will come to the elementary school to help with afterschool programs. Please speak to Monica before signing up for this program as you need to be approved Tuesdays Jan 10– Feb 28 or Thursdays Jan 12– Feb 16 2:50-4:420 pm
SPACE IS LIMITED. REGISTER TODAY!!
_____ Spring Crafts: Wednesdays: 1/11– 2/15-4:20pm (4th through 7th graders only)
______Elementary Program Assistant: 2:50-4:20pm Check One: _____ Tuesdays, 1/10– 2/28 _____ Thursdays, 1/12-2/16 _______Check if participant will need to ride the late bus.
Detach and return completed form to the school main office.
