Groton Youth Services
Groton Youth Services
January– February 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 home ec. room and run from 2:455:30. 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 the program(s) your child would like to attend.
____ Dream It, Build It—Mondays Jan 22— Feb 26 2:45-5:30 Build your own robot, machine, or creation. If you can dream it– you can it and build it! Explore design, electrical circuits, recycled projects and more.
plan
____ Y Not- Wednesdays Jan17—Feb 28 2:45– 5:30 Start your new year off right with healthy snacks, physical challenges and ways to manage stress. Participate in fun (and silly) Olympic style games and maybe even win a medal! Be sure to bring sneakers and outdoor gear (hats, gloves, boots).
Other Dates to remember: Dec 12 and Feb 16– Tween Night at the Groton Public Library 7-9:30pm ***Be sure a parent comes in to sign a permission form*** January 13– Roller skating at the Middle School Gym Watch for special events over February Break!
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!
2018 Groton Youth Services Junior High 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 in mailbox labeled ‘Dryden Youth’ in the Dryden Middle School Office
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.
January– February 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 home ec. room and run from 2:455:30. 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 the program(s) your child would like to attend.
____ Dream It, Build It—Mondays Jan 22— Feb 26 2:45-5:30 Build your own robot, machine, or creation. If you can dream it– you can it and build it! Explore design, electrical circuits, recycled projects and more.
plan
____ Y Not- Wednesdays Jan17—Feb 28 2:45– 5:30 Start your new year off right with healthy snacks, physical challenges and ways to manage stress. Participate in fun (and silly) Olympic style games and maybe even win a medal! Be sure to bring sneakers and outdoor gear (hats, gloves, boots).
Other Dates to remember: Dec 12 and Feb 16– Tween Night at the Groton Public Library 7-9:30pm ***Be sure a parent comes in to sign a permission form*** January 13– Roller skating at the Middle School Gym Watch for special events over February Break!
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!
2018 Groton Youth Services Junior High 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 in mailbox labeled ‘Dryden Youth’ in the Dryden Middle School Office
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.
