JYC Youth Programs Fall 2017 For Dewitt Youth Entering Grades 5-9
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 Youth Programs Fall 2017 For Dewitt Youth Entering Grades 5-9 For residents of the Towns of Caroline and Ithaca and the Villages of Cayuga Heights and Lansing
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. _____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 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.
Please direct any and all questions to: Beth Bannister JYC Youth Program Educator Phone: (607) 272 2292 ext. 229 Email: [email protected] Facebook: https://www.facebook.com/ JointYouthCommission/
Fall 2017 Programs Programs at Dewitt Middle School:
Lunch Bunch
Tuesdays 9/26-12/19
Your Lunch Period
Meet in the cafeteria during your lunch!
Dungeons and Dragons, Magic the Gathering , Board Games 9/26-12/19
3:20—5:30PM
Join us at Dewitt for a D & D, Magic and other games program. You do not need any experience, and we have what you need to play! Not only can you learn the basics, but if you want you will get instruction on deck-building, draft tournament play (including practice with a cube). We will have other games also, including Apples to Apples, Forbidden Island and more. Meet at 3:20PM in the Dewitt Art Room Pick up at 6:00PM at Dewitt Middle School (students can take the 4:30PM bus)
Art and Soul Thursdays
9/28-12/21
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. Be sure to check the box next to the programs that your child is signing up for. 2. Please make checks payable to Cornell Cooperative Extension. Payment is voluntary (suggested donation of $20 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 registration form and check to: Cornell Cooperative Extension (please refer to the address on the front of this brochure) Or drop off at Penny Boynton’s Office at Dewitt Middle School. Please put in envelope if dropping off at school.
3:20—5:30PM
Join us for creating, building and crafting. Projects will be student led, with options such as jewelry making, photo projects and upcycling. September/October focus will be on preparing for Wizarding Weekend– create Wizarding crafts, make your own wand and more! Meet at 3:20 PM in the DeWitt Art Room Pick up at 5:30 PM in front of Dewitt Middle School (students can take the 4:30PM bus)
Program at Brooktondale Community Building: Caroline Youth Afternoons Fridays (specific dates)
Pre Registration Is Required!
Space is limited, please fill out this form and return it ASAP
Join other students for an alternative to the everyday lunchroom experience. We will eat lunch together (with a fun food addition occasionally) as well as have occasional teambuilding games, activities, crafts and special guests.
Tuesdays
2017 JYC Fall Program Registration Form
4—6:30PM
By youth request, we are hosting some youth nights at the Brooktondale Community Center. Focus this fall will be board games and Magic (the card game), but occasional crafts could be added by request. This is a youth led program, so come and let us know what you would like for Caroline youth on Friday afternoons! Meets the following dates only. You MUST sign up ahead of time to get a bus pass.
Fridays September 29, October 13, November 3, December 15 ONLY Meet at 4PM at the Brookdondale Community Center (school bus passes are available) Pick up at 6:30 PM at the Brooktondale Community Center
Lunch Bunch Tuesdays at LUNCH (9/26-—12/19/17) Your Lunch Period at Dewitt Cafeteria D&D/MTG/Board Games Tuesdays Afterschool (9/26-12/19/17) 3:20PM-5:30PM in the Dewitt Art Room
Art and Soul (9/28-12/21/17) 3:20PM-5:30PM in the Dewitt Art Room Caroline Youth Afternoons (9/29. 10/13, 11/3 and 12/15 ONLY) 4PM-6:30PM at the Brooktondale Community Building
Late buses are available at 4:30PM from Dewitt Programs only. Otherwise, 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 rides and carpooling.
JYC Youth Programs Fall 2017 For Dewitt Youth Entering Grades 5-9 For residents of the Towns of Caroline and Ithaca and the Villages of Cayuga Heights and Lansing
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. _____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 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.
Please direct any and all questions to: Beth Bannister JYC Youth Program Educator Phone: (607) 272 2292 ext. 229 Email: [email protected] Facebook: https://www.facebook.com/ JointYouthCommission/
Fall 2017 Programs Programs at Dewitt Middle School:
Lunch Bunch
Tuesdays 9/26-12/19
Your Lunch Period
Meet in the cafeteria during your lunch!
Dungeons and Dragons, Magic the Gathering , Board Games 9/26-12/19
3:20—5:30PM
Join us at Dewitt for a D & D, Magic and other games program. You do not need any experience, and we have what you need to play! Not only can you learn the basics, but if you want you will get instruction on deck-building, draft tournament play (including practice with a cube). We will have other games also, including Apples to Apples, Forbidden Island and more. Meet at 3:20PM in the Dewitt Art Room Pick up at 6:00PM at Dewitt Middle School (students can take the 4:30PM bus)
Art and Soul Thursdays
9/28-12/21
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. Be sure to check the box next to the programs that your child is signing up for. 2. Please make checks payable to Cornell Cooperative Extension. Payment is voluntary (suggested donation of $20 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 registration form and check to: Cornell Cooperative Extension (please refer to the address on the front of this brochure) Or drop off at Penny Boynton’s Office at Dewitt Middle School. Please put in envelope if dropping off at school.
3:20—5:30PM
Join us for creating, building and crafting. Projects will be student led, with options such as jewelry making, photo projects and upcycling. September/October focus will be on preparing for Wizarding Weekend– create Wizarding crafts, make your own wand and more! Meet at 3:20 PM in the DeWitt Art Room Pick up at 5:30 PM in front of Dewitt Middle School (students can take the 4:30PM bus)
Program at Brooktondale Community Building: Caroline Youth Afternoons Fridays (specific dates)
Pre Registration Is Required!
Space is limited, please fill out this form and return it ASAP
Join other students for an alternative to the everyday lunchroom experience. We will eat lunch together (with a fun food addition occasionally) as well as have occasional teambuilding games, activities, crafts and special guests.
Tuesdays
2017 JYC Fall Program Registration Form
4—6:30PM
By youth request, we are hosting some youth nights at the Brooktondale Community Center. Focus this fall will be board games and Magic (the card game), but occasional crafts could be added by request. This is a youth led program, so come and let us know what you would like for Caroline youth on Friday afternoons! Meets the following dates only. You MUST sign up ahead of time to get a bus pass.
Fridays September 29, October 13, November 3, December 15 ONLY Meet at 4PM at the Brookdondale Community Center (school bus passes are available) Pick up at 6:30 PM at the Brooktondale Community Center
Lunch Bunch Tuesdays at LUNCH (9/26-—12/19/17) Your Lunch Period at Dewitt Cafeteria D&D/MTG/Board Games Tuesdays Afterschool (9/26-12/19/17) 3:20PM-5:30PM in the Dewitt Art Room
Art and Soul (9/28-12/21/17) 3:20PM-5:30PM in the Dewitt Art Room Caroline Youth Afternoons (9/29. 10/13, 11/3 and 12/15 ONLY) 4PM-6:30PM at the Brooktondale Community Building
Late buses are available at 4:30PM from Dewitt Programs only. Otherwise, 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 rides and carpooling.
