Where youth & teens with unique & special needs can develop relationships and. experience social growth through recreation.

Transcription

1 The Afterschl Prgram... Where yuth & teens with unique & special needs can develp relatinships and experience scial grwth thrugh recreatin. A partnership f The Rchester Parks & Recreatin Department and Bear Creek Services Inc. This prgram ffers a fun recreatinal after schl experience designed specifically fr yuth ages 5-21 with a variety f unique & special needs wh are in a schl-based prgram. Participants benefit frm activities invlving fine & grss mtr skills, individual & grup activities, music therapy, dramatic play, and sensry stimulatin while emphasis is placed n scializatin and cmmunicatin. Transprtatin frm a Rchester Public/Private schl t Bear Creek Services and an afterschl snack are als ffered! The 2015/16 Afterschl Prgram is currently full. If interested in the prgram, please cntact Karen Meyer at ( =2539 r via with inquiries r t be placed n a Waiting List. DATES: Tuesday, September 8, 2015-June 2, 2016 Clsed n hlidays and Rchester Public Schl District Days see RPS District Calendar prvided. WHO: Individuals ages 5-21 years f age with an Intellectual and/r Physical Challenge wh are in a schl-based prgram. TIME: Prgram hurs are 2:00-6:00 p.m. FACILITY: Bear Creek Services, 3108 Hwy 52 N. Rchester, MN COST: $ PROGRAM SERVICES *Experienced and well-trained staff will supervise and facilitate all activities. *Music Therapy class, an afterschl snack, and bussing t the prgram prvided. *PECs and Visual Schedules used. *Accessible utdr playgrund and utdr activities available. *Open activity area and classrms. *Individual & grup time activities. *Open frm 12:30-6:00 p.m. n EARLY RELEASE days (based n the Rchester Public Schl District calendar)

2 THE AFTERSCHOOL PROGRAM 1. TRANSPORTATION Please cmplete and return the attached Day Care Transprtatin frm t the Rchester Public Schl District s Transprtatin Office at Edisn if yu plan t have yur child bussed t the prgram afterschl. Transprtatin hme will be up t families. Pick up is scheduled at 6:00 p.m. daily. See Late Pick Up plicy belw. 2. STAFFING Supervisin & assistance is based n a 1:4 (staff t child) rati and will be prvided by experienced and well-trained staff. We d nt ffer 1:1 staffing. 3. Days / Times Offered The prgram will be pen Mndays-Fridays, 2:00 6:00 p.m. schl days nly. We will be pen frm 12:30-6:00 p.m. n Early Release Days (Rchester Public Schl Calendar). 2. Facility The prgram will be hsted in the center space at Bear Creek Services, lcated at 3108 Hwy 52 N. Rchester, MN Prgram Cst Cst f the prgram is $ fr the schl year (September 2015-June 2016). We will bill in quarterly installments as fllws: August 1, $ Nvember 1, $ February 1, $ Absences due t illness/appintments/etc.: If yur child is sick r will nt be attending the prgram fr any reasn, please make ntificatin t Karen Meyer at (507) r t kmeyer@rchestermn.gv. 6. Late Pick Ups: There will be a $9.00 late fee per child charged fr late pick up AFTER 6:00 p.m. The fee will increase an additinal $9.00 every 15 minutes and must be paid befre yur child can attend the next prgram day. Participatin will resume nce the balance is paid t the Parks & Recreatin Department at th Street SE #150, Rchester, MN *If running late, please call staff at (507)

3 7. Registratin Infrmatin & Prcess: Registratin can be dne upn receipt f this frm and until Friday, May 22, 2015 by cmpleting and returning the registratin frm ne f the fllwing ways belw: 8. Frms can be submitted as fllws: Brught r Mailed t: The Parks & Recreatin Department Adaptive Recreatin Divisin th Street SE #150 Rchester, MN FAX: SCAN/ kmeyer@rchestermn.gv 9. Questins? Call Karen Meyer, Directr f Adaptive Recreatin at (507) r kmeyer@rchestermn.gv Prgram Staff Lead: Sctt Zemb 3-6 p.m. Assistant: Katie Wiskw 3-6 p.m. Assistant: Amanda Christian 2-5 p.m. Prgram Cell Phne: (507) Prgram Address: Bear Creek Services Inc Hwy. 52 Nrth

4 2015/2016 Afterschl Prgram Participant Frm CONTACT INFORMATION Participant Name: DOB: / / Age: Mther s Name: Cell Phne: ( ) Father s Name: Cell Phne: ( ) Hme Phne: ( ) *Emergency Cntact Name & Phne: ( ) *Required infrmatin. Hme Address: (Street, City, State, ZIP) Address: Check all that apply MEDICAL INFORMATION Allergies t: Atlant-axial Subluxatin and restrictins fr persns with Dwn syndrme: Cyansis Diabetes Headaches/Migraines Heart Cnditin and restrictins: Hepatitis Seizures: what are signs t be watching and what prcedures yu direct staff t take shuld an episde ccur? ADHD/ADD Mental Health Nn-ambulatry Autism/PDD Autism/PDD Nn-verbal Brain Injury Mental Retardatin Mild Prader-Wili Cerebral Palsy Mental Retardatin Mderate Rhetts-Syndrme Deaf/Hearing Impaired Mental Retardatin Severe Speech Delay Dwn Syndrme Mbility Impairment Spina Bifida Epilepsy Muscular Dystrphy Turettes Syndrme Learning Disability Multiple Sclersis William s Syndrme Visual Impairment Please specify ther diagnsis if nt listed:.

5 COMMUNICATION Check all that apply Gd Shy Limited Cnversatin Signs Interpreter Dminates Inapprpriate Needed Cnversatin Tpics Check all that apply RESTRICTIONS Behavir (explain): Physical Limitatins (explain): Dietary Restrictins (explain): Tileting (explain): Medicatin (explain): List any ther infrmatin yu feel we shuld have t prvide prper and well-infrmed care t yur child:

6 2015/16 Afterschl Prgram Waiver/Release The City f Rchester and Bear Creek Services Inc., their fficers and emplyees hereby agree t allw t participate in the Afterschl Prgram cllabrative with Bear Creek Services, Inc. and the Parks & Recreatin Department frm the mnths f September 2015-June 2016 and agree t prvide transprtatin in Bear Creek Services/Parks & Recreatin vehicles driven by said agencies staff frm a specified schl r ther specified lcatin within Rchester, t the prgram site f Bear Creek Services, Inc. as well as any activities assciated with the Afterschl Prgram during Afterschl Prgramming. In rder t participate in this activity, I agree n behalf f the participant named abve t hld the City f Rchester and Bear Creek Services, Inc. their emplyees and agents harmless and waive any right t make claims r lawsuits against the City and/r Bear Creek Services Inc., r anyne wrking n behalf f the City and/r Bear Creek Services Inc. r anyne wrking fr Bear Creek Services, Inc. fr any injuries r damages related t the alleged negligence f the City and/r Bear Creek Services, Inc. This waiver des nt apply t any injuries r damages that are the result f any willful, wantn r intentinal miscnduct. Participatin in this activity is vluntary and I understand the effect f this waiver n my legal rights and thse f the participant named abve. PHOTOGRAPHS My permissin (circle ne) is given is NOT given fr my child s picture t be taken and image used in the media and/r fr purpses assciated with the Parks & Recreatin Department & Bear Creek Services Inc. Medicatin/Sunscreen Administratin We must have written permissin t administer all frms f medicatin: Sunscreen: Yes N The fllwing medicatins: Yes N Name f Medicatin Amunt t be Given Time t be Given Please nte: if there are any changes r adjustments t yur child s medicatin r the way it is administered, yu must make written updates n a new frm.

7 / / Signature Date Relatinship t Participant