Groton Youth Services
Groton Youth Services
September - October 2017 Junior High Programs
SIGN UP NOW—SPACE IS LIMITED! Programs are for Groton Junior High School youth in grades 6-8. All programs meet in the cafeteria and run from 2:45-5:30. Participants will be able to take the late bus home on Wednesdays but need to be picked up on Mondays. 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 the program(s) your child would like to attend. ____ Just Try it—Mondays Sept 25— October 30, 2:45– 5:30 (parent pick up day) Whether you are new to Groton Youth Services programs or just want to try something new– this program is for you! Enjoy the great fall weather and hike local trails, make your own tasty snacks, complete science and tech challenges, or help plan something that interests you! ____ Groton Pride- Wednesdays Sept 20—October 25, 2:45– 5:30 (late bus available) Come, plan and create some great things for our community! Activities will including: Host a fun and free community Halloween party, help run a new trunk or treat, clean up the new playground at Groton Memorial Park and more. A trip to the Wizarding Weekend in Ithaca will round out this hands on program _____ Halloween Party Helper– Fri October 27th, 3:00– 4:30 pm and Sat October 28, 11am– 1:00pm at the American Legion Come dressed up or not, but be prepared to see all sorts of witches, goblins and princesses at the community Halloween party! You will be decorating and hosting the party including snacks, kiddie games, hayrides and more. 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 Junior High 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 Junior High 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 school 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 Junior High Programs
SIGN UP NOW—SPACE IS LIMITED! Programs are for Groton Junior High School youth in grades 6-8. All programs meet in the cafeteria and run from 2:45-5:30. Participants will be able to take the late bus home on Wednesdays but need to be picked up on Mondays. 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 the program(s) your child would like to attend. ____ Just Try it—Mondays Sept 25— October 30, 2:45– 5:30 (parent pick up day) Whether you are new to Groton Youth Services programs or just want to try something new– this program is for you! Enjoy the great fall weather and hike local trails, make your own tasty snacks, complete science and tech challenges, or help plan something that interests you! ____ Groton Pride- Wednesdays Sept 20—October 25, 2:45– 5:30 (late bus available) Come, plan and create some great things for our community! Activities will including: Host a fun and free community Halloween party, help run a new trunk or treat, clean up the new playground at Groton Memorial Park and more. A trip to the Wizarding Weekend in Ithaca will round out this hands on program _____ Halloween Party Helper– Fri October 27th, 3:00– 4:30 pm and Sat October 28, 11am– 1:00pm at the American Legion Come dressed up or not, but be prepared to see all sorts of witches, goblins and princesses at the community Halloween party! You will be decorating and hosting the party including snacks, kiddie games, hayrides and more. 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 Junior High 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 Junior High 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 school 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
