SPORK Application. Please return this form along with all other SPORK paperwork to Mrs. Greer NO later than July14 th.

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Download "SPORK Application. Please return this form along with all other SPORK paperwork to Mrs. Greer NO later than July14 th."

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1 SPORK Application SPORK is a program that teaches students through hands-on experience how to prepare and shop for healthy and delicious foods. The SPORK class last 8 weeks and will be on Tuesdays or Thursdays during Prime Time depending on which group you are assigned to. Only 28 students will be able to participate due to space. Only 28 kids can participate this coming semester, to apply you must answer the question below. Remember this is NOT for a grade this is just a way to see that you are interested and committed to the SPORK program Please return this form along with all other SPORK paperwork to Mrs. Greer NO later than July14 th. Please answer this question below: If you could have prepare one meal for any one person living or not, what would you serve to eat and who would you want to share the meal with you, and why? Students Name: Day you can take SPORK: (please circle) TUESDAY WEDNESDAY EITHER

2 Kids Cook! Liability Release Statement This form must be completed for every child attending any class or camp. 1. As a parent or guardian, I understand and acknowledge that: All hands-on activities and skills taught at Kids Cook! will be age-appropriate and taught under strict culinary instructor supervision at all times. Participation in any cooking class entails unanticipated risks which could result in physical injury to my child, to property or to third parties. I acknowledge that such risk cannot be eliminated without jeopardizing the essential qualities of the activity. Kids Cook! takes every reasonable precaution to insure that all culinary programs offered and all cooking activities led, run or organized by Kids Cook! are conducted by qualified and trained professional personnel in a safe environment. I have disclosed all medical conditions and all physical activity concerns on the attached Medical/Physical Concerns Questionnaire. As a parent/guardian of a school age participant I agree to provide and allow the release of current and up to date emergency care and health related information. Kids Cook! staff members will not disclose any medical conditions or concerns except as may be required in the case of an emergency. Kids Cook! may photograph and/or film my child. I hereby permit Kids Cook! to use, in whole or in part, photographs, videos and verbal comments for the purpose of illustrations and publications, including the Kids Cook! website. No names will be published without permission. 2. As a parent or guardian, I agree:

3 To hold harmless Kids Cook! and their officers, employees and agents from any claim, damage, liability, injury, expense or loss, including defense costs and attorney s fees, arising from activities under this agreement. To authorize Kids Cook! to initiate emergency evacuation or treatment in case of serious injury or illness. In case of an emergency, Kids Cook! will notify the parents, guardians or emergency contacts of the participant as soon as possible. By signing this document, I acknowledge that I have provided medical information accurately and have read and fully understood both pages of this document. The information I have provided is disclosed accurately and truthfully. Parent/Guardian s Signature Please fill out the form on the reverse completely and return to Kids Cook! with your child.

4 Kids Cook! Medical/Physical Concerns Questionnaire Liability Release Statement This form must be completed for every child attending any class or camp. Date Name of child Age Name of parent/guardian Address address for parent communication and class updates Home phone number Cell phone number Other emergency phone number Emergency Contacts: Who to call Hospital Doctor/name/phone number I understand and acknowledge that my failure to disclose relevant information may result in harm to my child and/or others during any/all culinary classes or camps at Kids Cook! Please circle either yes or no for the following questions. Does the child attending classes currently or have a history of: 1. Yes No Allergies

5 2. Yes No Diabetes or Blood sugar Problems 3. Yes No Asthma or Respiratory Problems 4. Yes No Epilepsy or Seizures 5. Yes No Other Conditions/Concerns Please explain any yes answer Allergies: Food, insect stings, poison ivy, plants, anaphylaxis, medication All information given will be held in strict confidence ]

6 PERMISSIONS FOR RELEASE OF REPORT CARDS I,, hereby authorize the release of my child s Parent/Guardian report card to estem/spork. Site s Name or Representative Parent/Guardian Signature Child s Name Date

7 Implementation Packet for the SPORK Cooking Workshop Series The SPORK program is made possible through these partners:

8 Ms. Jerusalem Greer estem Middle School 112 W. Third Street Little Rock, AR June 8, 2011 Dear Ms. Greer, Here is the description of the customized Kids Cook! series, SPORK Cooking Program to be held at estem Middle School during August and September Planned attendance is 14 students per series for a total of 28 students. SPORK Cooking Program 8 week series Tuesdays, August 2-Sepember 20 and Wednesdays, August 3-September 21, Location: TBD Time: 3:30-4:30 pm Enrollment: 14 students per series, 28 students total Take Aways: SPORK recipe book, reusable shopping bag, Eat This Not That, DHS placemat, parent incentive (1 lb pasta, 1 can tomato sauce) Logistics: Kids Cook! will bring all the baking/cooking equipment, supplies and ingredients needed. estem will provide a class space. estem will select the students and handle the registration process. Kids Cook! will provide an invitation letter to parents, enrollment, medical information and liability forms. Cooking Instructors: Faith Anaya and Kids Cook! Staff

9 Financial Agreement: This program is funded from a Pulaski County Youth Services grant. The program is free to Pulaski County 6 th graders in selected schools. SPORK is very excited about this program! Thank you for providing this opportunity to students at estem Middle School. Sincerely, Faith Anaya, Owner, Kids Cook! on behalf of SPORK 58 Valley Estates Ct. Little Rock, AR phone fax

10 Facility Requirements: estem Middle School Requirements for Participation Space for 14 children and at least 3 adults to work in. Ready access to hot and cold water. Sinks suitable for dishwashing. Properly functioning electrical outlets. Tables at height suitable for 6 th grade children. An area separate from the students cooking space for the parents discussion with Arkansas Children s Hospital nutritionists and for the finale dinner--the first and final workshops. Access to building for loading and unloading equipment. School/Administrator Requirements: Select 14 sixth-grade students and their parents to attend the series of workshops. Strive to have male and female representation as equal as possible. Diversity is always encouraged. Support completion of all paperwork on student s behalf by parents. No student may participate if his or her guardian has not completed and returned the enrollment packet. Provide allergy information for participating students to SPORK staff. Allow reasonable access for the staff of SPORK, Arkansas Children s Hospital, and Pulaski County Youth Services; and members of the press during workshops. Grant access to school computers for parents and students to complete online preand post- workshop surveys. 15 minutes before the first workshop and 15 minutes after the last workshop have been scheduled for this purpose. Survey links will be provided prior to the start of the workshop series. Participant Requirements: Students may not participate in this program without the involvement of their parent or guardian in both the ACH workshop and the finale dinner. Students must be able to attend the entire series of workshops, barring any unforeseeable circumstances.

11 All participants and their parents must complete online pre- and post- surveys as this helps SPORK measure its impact and inform future programs. All students must provide the following paperwork to SPORK before the series of workshops begins. 1. Medical Information/Liability Waiver completed and signed by parent/guardian. Must include an address for parent communication. 2. PCYS Enrollment Form completed and signed by parent/guardian. 3. PCYS Report Card Release Form completed and signed by parent/guardian.

12 Dear Parent, estem Middle School has been selected to participate in an after-school program called SPORK. SPORK is a nutrition-based cooking program that teaches students how to cook nutritious, kid-friendly recipes and how to make healthier eating choices, all in a hands-on, fun and safe environment. This program also engages parents and guardians of participating students by inviting them to (1) attend two forty-five minute workshops led by a nutritionist from Arkansas Children s Hospital at the beginning and end of the program and (2) to attend a graduation dinner cooked by the students. The parent/guardian workshop includes household tips that you can use prepare healthier foods in your home and information on the nutrition needs of growing students. There is no cost to participate in the SPORK program. This series will accommodate up to 28 students, 14 on Tuesdays and 14 on Wednesdays. Your child has been selected for an invitation to participate in the series. In order to participate in the SPORK program, students must be able to attend all 8 classes. Parent/guardian attendance at both parent/guardian sessions is also required for students to participate. In order to measure the impact of the SPORK program, parents and students are required to complete pre- and post- surveys about their experience. The SPORK workshop at estem Middle School will last for a total of 8 weeks, starting on August 2 nd and concluding on September 21 st. The program will take place on Tuesdays and Wednesdays from 3:30-4:30 pm during Prime Time. Your child will attend either the Tuesday or the Wednesday series. The parent/guardian workshop with the Arkansas Children s Hospital nutritionist will take place on either Tuesday, August 2 nd or Wednesday, August 3 rd from 3:30-4:30 pm and includes a snack prepared by the kids. The family graduation dinner will take place on Tuesday, September 20 th or Wednesday, September 21 st from 3:30-4:45 pm. If you and your child would like to participate in the SPORK workshops, please fill out, sign and return the three attached forms to Ms. Jerusalem Greer at estem. If you have any questions or concerns about participating in SPORK, please contact Ms. Greer at This opportunity is made possible by Pulaski County Youth Services. SPORK is a partnership between Kids Cook!, Clinton School of Public Service students, Pulaski County Youth Services, and Arkansas Children s Hospital. Sincerely, Jerusalem, Greer, estem Middle School Hilary Trudell, SPORK Program Coordinator Faith Anaya, Kids Cook! Kalena Jones, Pulaski County Youth Services

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