Summer Skies Permission Form
Summer programs for youth entering grades 5-9, sponsored by Lansing Youth Services, provide weeks of fun, learning, and developing skills to build confidence and competence in school, at home, and out in the world. Registration for these programs must include a check made payable to Lansing Youth Services and the Registration Form found at the bottom of this page. Scholarships are available – please call or email for information. Space is limited and each week’s program fills fast, so register early. Please bring a lunch and a water bottle daily, as we hope to swim at Myers Park some days and at area state parks for those participating in programs that travel! Date: June 25-27 Lake Life Time: 9:00am-4:00pm Location: Lansing Middle School Fee: $40 Summer sun and Cayuga Lake! Come enjoy life on the lake as we take advantage of Myers Park and all the lake has to offer! Date: July 2-3 Dungeons and Dragons Time: 9:00am–1:30pm Location: Lansing Middle School Fee: $40 Be transported to another place and time with Dungeons & Dragons. Defeat monsters, cast magic spells, talk to animals and have epic adventures. Date: July 9-12 Get Lost! Time: 9:00am–4:00pm Location: Lansing Middle School Fee: $40 Practice backcountry navigation, survival and naturalist skills at Hammond Hill State Forest. Date: July 16-19 Iron Chef Time: 9:00am–1:30pm Location: Lansing Middle School Fee: $40 Challenge yourself in the kitchen as you prepare meals using surprise ingredients! A culinary adventure for chefs of all skill levels! Date: July 30- August 2 Funky Furniture Time: 9:00am–1:30pm Location: Lansing Middle School Fee: $40 Turn ugly into awesome! Do woodworking, painting, decorating, and create personalized furniture! Date: August 6-9 D.I.Y. Summer Edition Time: 9:00am–4:00pm Location: DeWitt Middle School Fee: $40 D.I.Y. will provide individual and group projects, come learn some new skills and make something awesome for yourself! Meets at DeWitt Middle School. Date: August 13-16 Primitives– 101 Time: 9:00am–4:00pm Location: Hammond Hill State Forest Fee: $40 Learn primitive living skills in this primitives technologies based program. Fire and tool making, plant and animal identification, and campfire cooking! Date: August 20-22 Backpacking Time: 9:00am Monday – 12:00pm Wednesday– Location: Finger Lakes National Forest Fee: $40 Backpacking takes place in the Finger Lakes National Forest for two nights in the field. Gear up and get ready for some fun in the woods! Date: August 27-30 Sky’s The Limit Time: 9:00am–4:00pm Location: Lansing Middle School Fee: $40 Trips to the Soaring Museum in Big Flats, Ithaca Airport, and the Cornell Lab of Ornithology are all on the list! We will also be designing and flying our own gliders and rockets- calling all engineers!
Summer Skies Permission Form Student Name: __________________________________________________ Grade in the Fall: _____ Date of Birth: _____/_____/_____ Address: _______________________________________________________ City: _______________________
Zip: ________________
Parent/Guardian Name: ___________________________________________ Phone: __________________________________________ Emergency Contact/Relation: _______________________________________ Phone: __________________________________________ Does your youth have any medical conditions, dietary restrictions, or special needs we should be aware of? ____ NO ____YES (If Yes, please explain on back) _____ 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 607-252-6758 or 533-4271 ext. 2118 or at [email protected]. ______ 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. ____ I understand that these programs meet at the middle school unless otherwise stated, and that I must pick my student up at the end of each program.
Parent Signature: ________________________________________________
Date: ______/______/18
Please return completed forms to Travis Judd, Lansing Youth Services, 6 Ludlowville Road, Lansing, NY, 14882 For more information please call (607) 5334271 ext. 2118 or email [email protected]
Summer Skies Permission Form Student Name: __________________________________________________ Grade in the Fall: _____ Date of Birth: _____/_____/_____ Address: _______________________________________________________ City: _______________________
Zip: ________________
Parent/Guardian Name: ___________________________________________ Phone: __________________________________________ Emergency Contact/Relation: _______________________________________ Phone: __________________________________________ Does your youth have any medical conditions, dietary restrictions, or special needs we should be aware of? ____ NO ____YES (If Yes, please explain on back) _____ 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 607-252-6758 or 533-4271 ext. 2118 or at [email protected]. ______ 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. ____ I understand that these programs meet at the middle school unless otherwise stated, and that I must pick my student up at the end of each program.
Parent Signature: ________________________________________________
Date: ______/______/18
Please return completed forms to Travis Judd, Lansing Youth Services, 6 Ludlowville Road, Lansing, NY, 14882 For more information please call (607) 5334271 ext. 2118 or email [email protected]
