JYC Summer Youth Programs
Youth Information (Please Print) Youth Name: ____ Birth date: ___ M/F/Other: ________ 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
JYC Summer Youth Programs
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 participate in the 4-H Rural Youth Services programs. _____Yes, I give permission for my child 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 my child requires prescription or over the counter medication during the trip, A PRN order must be obtained by my child’s physician, my 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 of 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 607227-9532 (text is ok) or 272-2292 ext. 229. ______ 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:_____________
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.
Summer 2018 Please direct any and all questions to: Beth Bannister JYC Youth Program Educator Phone: (607) 272 2292 ext. 229 Email: [email protected]
Facebook: www.facebook.com/JYCYouthPrograms Instagram: JYCyouthprogams
Summer 2018 Programs Lake Life (6/25-6/27/18 Mon-Wed only) 9:00 am-4:00 pm @ Myer’s Point Park in Lansing Come explore the unique and important waterways of Cayuga Lake. Be prepared to get your feet wet! We will meet at Myers Park in Lansing for swimming, water life science, fishing and bird watching. Wednesday we will be on the Floating Classroom’s new boat for some science and time on the lake!
Choose Your Own Adventure (7/9-7/12/18) 9:00 am-4:00 pm @ Cornell Cooperative Extension Are you interested in anything? This is the program for you! Youth will decide what projects we participate in. Crafts, creative cooking, geocaching, volunteering—there are many options. Youth will learn to use TCAT to explore new places as well—Scavenger Hunt anyone?
ART and SOUL (7/23-7/26/18) 9:00 am-3:00 pm @ Dewitt Middle School In Art and Soul we will explore a variety of art forms. Youth will be learning photo transfer techniques, painting, jewelry making, embroidery, book-making and more, depending on the interest of participants. Digital Photography (7/31-8/3/18 Note-Tues-Friday program)
9:00 am-1:30 pm @ Cornell Cooperative Extension Come explore the fun and rewarding world of digital photography. Students can bring their own camera or share one of the 4H cameras. Participants can look forward to learning about composition and editing to make their work something truly unique.
DIY Summer Edition (8/6-8/9/18) 9:00 am-4:00 pm @ Dewitt Middle School Do It Yourself- Summer Edition will provide individual and group projects, so come learn some new skills and make something awesome for yourself!
Sky’s the Limit (8/27-8/30/18) 9:00 am-4:00 pm @ Cornell Cooperative Extension Are you interested in flight, aerospace, engineering and design of planes, or how about building a rocket to launch? Or birds and other flying animals? Sky’s the Limit will be full of flight, whether it’s building a model plane, glider or rocket. There will be trips to a Local Airport , the Lab of Ornithology and the National Soaring Museum in Big Flats, NY to see real gliders in action!
All Outdoor programs require weather-appropriate clothing and footwear that may get dirty. These materials are neither sponsored nor endorsed by the Board of Education of the Ithaca City School District, the superintendent, or this school.
2018 JYC Summer 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. 1. Fill out a separate form for each youth & return it with your check. Please remember to keep the other side of this form and or make a copy of your form for your own records. 2. Please make checks payable to Cornell Cooperative Extension. Payment is voluntary (suggested donation of $20-40 per program) and helps to support Joint Youth Commission (JYC) programs at CCETC. No one will be turned away due to inability to pay. 3. Please send this half of registration form and check to: Beth Bannister Cornell Cooperative Extension 615 Willow Ave. Ithaca NY 14850.
Please check programs that your child will be attending: Lake Life (6/25-6/27/18 Mon-Wed only) 9:00 am-4:00 pm @ Myer’s Point Park, Lansing Choose Your Own Adventure (7/9-7/12/18) 9:00 am-4:00 pm @ Cornell Cooperative Extension ART and SOUL (7/23-7/26/18) 9:00 am-3:00 pm @ Dewitt Middle School Digital Photography (7/31-8/3/18 Note-Tues-Friday program) 9:00 am-1:30 pm @ Cornell Cooperative Extension DIY Summer Edition (8/6-8/9/18) 9:00 am-4:00 pm @ Dewitt Middle School Sky’s the Limit (8/27-8/30/18) 9:00 am-4:00 pm @ Cornell Cooperative Extension
Youth must be picked up by a parent or guardian at the program site at the conclusion of each program, unless pickup/drop-off is arranged otherwise. Please Contact Beth for information about carpooling and possible shuttles from the Caroline/Brooktondale area.
JYC Summer Youth Programs
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 participate in the 4-H Rural Youth Services programs. _____Yes, I give permission for my child 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 my child requires prescription or over the counter medication during the trip, A PRN order must be obtained by my child’s physician, my 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 of 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 607227-9532 (text is ok) or 272-2292 ext. 229. ______ 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:_____________
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.
Summer 2018 Please direct any and all questions to: Beth Bannister JYC Youth Program Educator Phone: (607) 272 2292 ext. 229 Email: [email protected]
Facebook: www.facebook.com/JYCYouthPrograms Instagram: JYCyouthprogams
Summer 2018 Programs Lake Life (6/25-6/27/18 Mon-Wed only) 9:00 am-4:00 pm @ Myer’s Point Park in Lansing Come explore the unique and important waterways of Cayuga Lake. Be prepared to get your feet wet! We will meet at Myers Park in Lansing for swimming, water life science, fishing and bird watching. Wednesday we will be on the Floating Classroom’s new boat for some science and time on the lake!
Choose Your Own Adventure (7/9-7/12/18) 9:00 am-4:00 pm @ Cornell Cooperative Extension Are you interested in anything? This is the program for you! Youth will decide what projects we participate in. Crafts, creative cooking, geocaching, volunteering—there are many options. Youth will learn to use TCAT to explore new places as well—Scavenger Hunt anyone?
ART and SOUL (7/23-7/26/18) 9:00 am-3:00 pm @ Dewitt Middle School In Art and Soul we will explore a variety of art forms. Youth will be learning photo transfer techniques, painting, jewelry making, embroidery, book-making and more, depending on the interest of participants. Digital Photography (7/31-8/3/18 Note-Tues-Friday program)
9:00 am-1:30 pm @ Cornell Cooperative Extension Come explore the fun and rewarding world of digital photography. Students can bring their own camera or share one of the 4H cameras. Participants can look forward to learning about composition and editing to make their work something truly unique.
DIY Summer Edition (8/6-8/9/18) 9:00 am-4:00 pm @ Dewitt Middle School Do It Yourself- Summer Edition will provide individual and group projects, so come learn some new skills and make something awesome for yourself!
Sky’s the Limit (8/27-8/30/18) 9:00 am-4:00 pm @ Cornell Cooperative Extension Are you interested in flight, aerospace, engineering and design of planes, or how about building a rocket to launch? Or birds and other flying animals? Sky’s the Limit will be full of flight, whether it’s building a model plane, glider or rocket. There will be trips to a Local Airport , the Lab of Ornithology and the National Soaring Museum in Big Flats, NY to see real gliders in action!
All Outdoor programs require weather-appropriate clothing and footwear that may get dirty. These materials are neither sponsored nor endorsed by the Board of Education of the Ithaca City School District, the superintendent, or this school.
2018 JYC Summer 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. 1. Fill out a separate form for each youth & return it with your check. Please remember to keep the other side of this form and or make a copy of your form for your own records. 2. Please make checks payable to Cornell Cooperative Extension. Payment is voluntary (suggested donation of $20-40 per program) and helps to support Joint Youth Commission (JYC) programs at CCETC. No one will be turned away due to inability to pay. 3. Please send this half of registration form and check to: Beth Bannister Cornell Cooperative Extension 615 Willow Ave. Ithaca NY 14850.
Please check programs that your child will be attending: Lake Life (6/25-6/27/18 Mon-Wed only) 9:00 am-4:00 pm @ Myer’s Point Park, Lansing Choose Your Own Adventure (7/9-7/12/18) 9:00 am-4:00 pm @ Cornell Cooperative Extension ART and SOUL (7/23-7/26/18) 9:00 am-3:00 pm @ Dewitt Middle School Digital Photography (7/31-8/3/18 Note-Tues-Friday program) 9:00 am-1:30 pm @ Cornell Cooperative Extension DIY Summer Edition (8/6-8/9/18) 9:00 am-4:00 pm @ Dewitt Middle School Sky’s the Limit (8/27-8/30/18) 9:00 am-4:00 pm @ Cornell Cooperative Extension
Youth must be picked up by a parent or guardian at the program site at the conclusion of each program, unless pickup/drop-off is arranged otherwise. Please Contact Beth for information about carpooling and possible shuttles from the Caroline/Brooktondale area.
