ISD #181 Community Education KinderClub / Fun ‘N’ Friends / Senior Leaders

$20.00 Yearly Membership Fee ________

Membership Form 2016-17

Transportation Form Returned________

Youth’s Name:_________________________________________________________ Last

First

Middle

Youth’s Home Address ___________________________________________________________________ City

Zip Code

Grade in Fall 2016_________ School _______________________________ Youth’s Date of Birth___________ Sex: Male or Female

Please Circle Program:

Please Circle Program: KinderClub (4-5 year old) WESB: Summer—School year Nisswa: Summer—School year

WESB: Fun ‘N’ Friends/Senior Leader (K-8th) Morning Program (K-8th) Nisswa: Fun ‘N’ Friends/Senior Leader (K-8th) Morning Program (K-4th)

Youth resides with: Both Parents- Mother - Father—Other___________________ Mother:_________________Home #________________Cell #:__________________Work #______________________ Home Address:________________________________________________________

Employer________________________

Father:________________Home #:________________Cell #:___________________Work #_____________________ Home Address:________________________________________________________ Employer_________________________

Additional persons authorized to pick up youth: ______________________ ______________________ ____________________ ________________________ ______________________________ ______________________________ _________________________

(Other than parent) Emergency Contact Name:_______________ Relationship :_____________Home/Cell#______________ Work#____________ Emergency Contact Name:_______________ Relationship:_____________Home/Cell#______________ Work#____________

Court Ordered Persons Not Authorized to pick up youth:_________________________________________________________ Must have Current Court Order-(please attach court order and provide photos of unauthorized persons)

Statements of Release: *I agree to release ISD #181, Community Education employees/volunteers of all liability and medical costs related to accidents or injuries which my youth may incur while participating in the Program. Insurance Company: ___________________ *I hereby authorize the program staff to obtain the proper medical assistance as indicated in the Parent Handbook. *I give permission to Community Education to provide pictures of my youth participating in the program to the media for articles on the program and its activities. *I understand other ISD #181 school staff (i.e. teachers, social workers, special education staff, etc.) share information with the program staff regarding my youth in an effort to better serve the needs of my youth.

______________________________________________________ Date:_______________________________ Signature of parent/guardian

Please see other side!

Code of Conduct Parents/Guardians and Youth — Teaming up on Behavior

Our mission is to provide each and every member a secure and wholesome environment in which to spend his/her time. If we combine our efforts, we can make an environment that enhances the development of positive and appropriate attitude and behaviors. Please read over the following behavior expectations, rules, and consequences. Your signature indicates your support and awareness of the Code of Conduct and consequences followed. Immediate pick up required if the youth threatens, physically hurts another member or staff or endangers themselves/others. Suspension or termination will be determined by supervisors/ coordinator and shared with parent/guardian.

Member Expectations : 1. Respect for self and others 2. Respect the personal belongings of others 3. Respect the feelings of others 4. Respect the property/equipment of the program 5. Follow all rules of the program Members will not: 1. Name call, tease or threaten another member or staff

Consequences: The following consequences will be followed and upheld if one or more of the rules are broken by a member. 1. Member will be informed of inappropriate behavior and redirected and asked to correct behavior 2. Member will receive a written warning (staff will inform parents) 3. Parent/Guardian, member and staff conference 4. Member will be asked to leave program

3. Take the personal belongings 4. Swear, scream or use poor language 5. Use games/equipment inappropriately (if a youth intentionally breaks an item, they will be asked to provide fees to replace the item) 6.

Parent/Guardian Signature:______________________ Member Signature _____________________________

Helpful Information About My Youth

District #181 Community Education staff are committed to serving youth enrolled. We take pride in making reasonable accommodations adapting our environment and program so that most youth can succeed and participate. The following information will help us to better serve the needs of your youth. A family conference may be required before attending the program. 1.

Please check all of the following that apply to your youth: Takes medication _____AM _____PM Please explain: Food/Medication Allergy ______________________________ Receives Special Education Services Currently has a behavior plan in place/ IEP @ school Hearing/Sight/Physical Limitations or Delays Other:_____________________________________

____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ _

2

Does your youth have any particular fears, such as dogs, sirens, etc.? Please describe.

3.

Please note any major changes in family situation in the last year such as a move, a death, a divorce or separation, serious illness or any other factor that may affect your youth’s behavior.

4.

When angry my youth usually___________________________. When upset my youth responds best to____________________. Below add additional information that may help us get acquainted with your youth: