Dear Parent(s) and Students

TOWN OF CHESHIRE
DEPARTMENT OF HUMAN SERVICES
84 SOUTH MAIN STREET, CHESHIRE, CONNECTICUT 06410
Telephone (203) 271-6690 FAX (203) 271-6626
Email: [email protected] OR [email protected]
6TH GRADE YELLOW HOUSE ACTIVITIES ~ SPRING 2015 ~ REGISTRATION FORM (Part 1)
Spring is almost here and the Yellow House is ready to enjoy the warmer weather ahead of us! Check below to see what Cheshire Youth Services is planning for
the months ahead. Activities will be held on designated Friday & Saturday evenings at the Yellow House (554 South Main Street). Trip times may vary. A
completed registration form AND a confirmation email are required EACH week in order to be placed on each event’s sign in sheet. There is no registration fee
associated with any of the activities listed below unless it is a trip, a suggested monetary or item donation for local charities and organization are requested but
not required to attend the events. All activities will be supervised by Yellow House staff members. To register please place a check mark in the box next to each
event(s) you would like your child to attend and fill out the part 2 on the reverse side. Each week you will receive a confirmation email requesting you to RSVP
for your child to attend by a requested date. Space is limited based on the activity planned.
Visit our website soon to see our upcoming Summer programs & trips: http://www.cheshirect.org/youth-services
CHECK THE EVENT(S) YOU WISH TO TENTATIVELY REGISTER FOR:
PLEASE NOTE: Select ALL events your child may be interested in attending, this does not mean your child HAS to attend all events selected.
Please return this form to: Cheshire Youth Services, 84 South Main Street, Cheshire, CT 06410 or fax forms to (203) 271-6626.
A registration confirmation will be sent to your email upon receipt of this form to hold your child’s spot.
For office use only: Child’s Name: __________________________________________________
Lucky Leprechaun Night: Saturday, March 14th
Time: 6:00-9:00pm
Max. Participants: 35 kids (6th graders only)
Donation: Used books for Read to Grow, Inc.
3/14
Free Event!
Free Event!
Waitlist #: ________
Fun Fiesta & Nachos Night: Friday, May 8th
5/8
Time: 6:00-9:00pm
Free Event!
Max. Participants: 30 Kids (6th graders only)
Donation: Items for Care Packages for our troops (list will be emailed)
Come dressed head to toe in your favorite green clothes
and St. Patrick’s Day attire. Pins, hats, wigs, and green socks
are all welcome! Enjoy a lime sherbet float or mint chocolate
chip ice cream cone. If the weather is nice we’ll be outdoors
playing team games & relays. We’ll even have some fun St.
Patrick’s day crafts to help us celebrate.
Hollywood Night: Saturday, March 28th
Date Received ________________
3/28
Nickelodeon Kids’ Choice Awards viewing party
Take your pick of toppings at our loaded nacho bar;
complete with tortilla chips, salsa, melted cheese,
sour cream, guacamole, and hot sauce! Decorate wooden maracas
or make a fiesta themed frame. Enjoy sipping lemon-lime punch
after a few games outside and take your best swing at the treat filled piñata. If
it’s rainy we’ll watch a movie inside.
Duck Tape Mania & Pizza Party: Friday, May 15th
5/15
Time: 6:00-9:00pm
Free Event!
Max. Participants: 20 Kids (6th graders only)
Donation: Baby Items – diapers, wipes, onesies, baby food, pacifiers, etc.
Time: 7:00-10:00pm
Max. Participants: 35 Kids (open to 6th-8th graders)
Donation: Non-perishable food items – Cheshire Food Pantry
The Yellow House will be transformed into an orange carpet event for the night.
Get dressed up and feel like a celebrity for the Nickelodeon Kids’ Choice Awards
viewing party. Enjoy fresh popcorn, pizza, and punch while you watch celebrities
get slimed with green goo. Cheer on your favorites when they accept their coveted
orange blimp award. Don’t forget to vote for all your favorites during the month of
March at www.nick.com/kids-choice-awards
Get crafty with colored and patterned Duck tape. We’ll provide the tape
and the tutorials on how to make; a wallet, pencil case, key ring
wristlet, flower ring, book mark, frames, hair bows…the ideas are
endless! Have your own idea you want to try?...no problem, just bring the
tutorial along and share with your friends. We’ll take a break from crafting to enjoy
some pizza, and treats. Hurry and sign up, there’s only 20 spots for this fun night of
Duck Tape crafting.
Super Hero & Heroine Night: Friday, April 10th
Outdoor Games & Sundaes: Friday, May 29th
4/10
Time: 6:00-9:00pm
Max. Participants: 30 Kids (6th graders only)
Donation: $10.00 for the Children’s Burn Camp of CT
We’ll watch the animated movie ‘The Incredibles’ (Rated PG).
Make a fun super hero craft, design your own super hero t-shirt and play fun group
games & challenges to win prizes. Make your own hero sandwich and enjoy chips, a
cookie and an action packed fruit punch! Movie Summary: A family of undercover
superheroes, while trying to live the quiet suburban life, are forced into action to save the
world. Visit commonsensemedia.org to find more detailed information on the rating.
Penguin & Pretzel Celebration: Saturday, April 25th
Free Event!
5/29
Time: 6:00-9:00pm
Max. Participants: 35 Kids (6th graders only)
Donation: New Soccer Balls – Kick for Nick charity
4/25
Time: 6:00-9:30pm
Free Event!
Max. Participants: 35 Kids (6th-8th grade)
Donation: Cat/Dog food, treats, blankets, He Laundry Detergent
Come hang out with your friends and celebrate World Penguin
Day (4/25). Watch ‘The Penguins of Madagascar’ (Rated PG), drink
punch & enjoy a soft pretzel with your choice of sides; mustard,
cheese, salt, caramel, cinnamon & sugar in honor of National Pretzel
Day (4/26). You can even make a penguin craft to take home.
Here’s a sneak peak at the Summer day trips we are planning . . .
Roger Williams Zoo, RI - Brownstone Discovery Park Misquamicut Beach, RI & Water Park – Bowling & Movies
- Nomad’s Adventure Quest - Lake Compounce –
To learn more about this charity please visit http://www.kickfornick.org/
Now that the weather has warmed up its time to go outside and have
some fun! We’ll spend the night outside playing soccer, kickball,
volleyball, and Wiffle ball. Then you can cool off with a delicious ice
cream sundae and a water balloon toss.
Summer youth activities & trips flyer
for June – August coming soon!
Outdoor Movie Night - Friday – June 5th (rain date: Sat. 6/6) 7:00-10:00p.m.
Come hang out with your friends and watch a movie under the stars. Free Event!
End of School Bash - Friday – June 19th (rain date: 6/20) 3:00-8:00p.m.
Don’t miss out on all the fun! We’ll have a DJ, inflatables, outdoor games, tie dying
station, crafts, dance contest & prizes. Enjoy FREE pizza (served at 6:00pm), soda,
popcorn, and refreshing treats to keep you cool! Free Event!
Visit our website for recent posts and forms for upcoming youth activities & trips:
http://www.cheshirect.org/youth-services/youth-programs-publications-and-forms
TOWN OF CHESHIRE
DEPARTMENT OF HUMAN SERVICES
84 SOUTH MAIN STREET, CHESHIRE, CONNECTICUT 06410
Telephone (203) 271-6690 FAX (203) 271-6626
Email: [email protected] OR [email protected]
6TH GRADE YELLOW HOUSE ACTIVITIES - REGISTRATION FORM (Part 2) – SPRING 2015
Please complete this form and return it to Cheshire Youth Services. No child will be allowed into Yellow House events without a permission
form. A separate Trip Permission Form MUST be filled out and handed in with payment 10 days prior to a scheduled off premises trip – these will
be emailed to you separately. Space for event and trips are on a first-come, first-serve basis (those who have NOT participated in the previous
session will be offered spots first). A limited number of spots are available for each Yellow House activity (please refer to specific event for the
maximum number of participants). Once your registration form is processed, you will receive a confirmation email with more information on how to
RSVP for each weekly event to guarantee your child’s spot to participate. All events are from 6:00 p.m. – 9:00 or 9:30 p.m. unless otherwise stated,
trip times vary. If your child cannot attend an event you’ve previously signed up for please email us as soon as you are aware so that we may allow
another child to attend in your child’s absence. Thank you. This form may be mailed to Cheshire Youth Services, 84 S. Main St, Cheshire,
CT 06410, faxed to (203) 271-6626, or turned in at the Human Services Department at Cheshire Town Hall.
Child’s Name: ______________________________________
Grade: ______ Age: _______ Gender: _______
School: Please put a check next to the school your child currently attends.
____ Chapman
____ Doolittle
____ Highland
____ Norton
____ Other: ___________________________________
***Does your child have and food/drug allergies or dietary restrictions? _______________________________________
Please Note: While we try our best to accommodate food allergies and offer alternative snacks during our events, we are not a gluten/dairy/egg free, or a peanut/tree nut free facility.
***Please list any behavioral problems AND/OR medical conditions that would assist our staff while your child is in our care:
___________________________________________________________________________________________
Parent/Guardian Name(s): ______________________________________________________
Home Address: _________________________________________________ Home Phone #:____________________
***Email Address (for registration confirmation): .___________________________________________________________
MUST HAVE A CURRENT & REGULARLY CHECKED EMAIL ADDRESS- This is how we will confirm your child’s participation EACH event…RSVP’s ARE REQUIRED TO ATTEND.
Mom’s Cell Phone #:_____________________________
Dad’s Cell Phone #: __________________________
Emergency Contact Name: ________________________________ Relationship to Child: ____________________
(Must be someone NOT living at the residence listed above, someone other than their legal guardian in case we are NOT able to contact a parent).
Home Phone #: __________________________
Cell Phone #: __________________________
I/WE, ____________________________________ (parent) give permission for ____________________________ (child) to
participate in the Cheshire Youth Services Activity Night(s) at the Yellow House. I/WE are aware of the purpose and scope of
these activities and accept responsibility for the normal and general risks involved an release Cheshire Youth Services a
division of Human Services, its employees and agents of liability for any injury or losses which may occur by way of our son’s
or daughter’s participation in such activity. If it is necessary for my child’s health to have emergency transportation or
medical care administered, I give permission for the Program Supervisor/Coordinator to authorize this care for my
son/daughter if I am unable to do so.
X
(Parent or Guardian’s Printed Name)
(Parent or Guardian’s Signature)
(Date)
Image Use and Release Statement:
In consideration of your child’s participation in Cheshire Youth Services’ and Yellow House Programs, occasionally
pictures and/or video are taken during trips and events. Some of these pictures and/or videos may contain images of your child. *The images taken on occasion are used
for our program advertisements, department newsletters, submitted for content on the official Cheshire Youth Service or Town of Cheshire website and
official Facebook & Shutterfly websites (password protected), or used in local newspapers. For more information regarding these images please contact
Cheshire Youth Services at (203) 271-6690.
____ I DO give permission for my child’s picture/video to be taken for use for the purposes mentioned above.*
____ I DO NOT give permission for my child’s picture/video to be taken for use for the purposes mentioned above.*
IMAGE USE DISCLAIMER: While your child’s safety and privacy are of the utmost importance to our department, there may be an occasion your child’s image will appear in
group pictures or in the background of photos taken during our programs and activities. Our staff will try our best to prevent this from occurring, on the occasion that a local
reporter visits our events, there may be group images taken that your child may be used in the local newspapers and on their website.