South Royalton One Planet Participant Information Sheet ...



One Planet Afterschool Program

Bethel, Chelsea, Newton, Rochester, Royalton,

Sharon, Stockbridge, Tunbridge

Dear Families,     February 18, 2019

Wow, what a winter! Even for those of us who love snow and cold, spring sounds pretty appealing right now. Bring on the longer days and the milder temps! In addition to our Session III programming, all of our sites will be offering opportunities for students to develop their social and emotional awareness and skills this spring. Many of our site coordinators and/or head teachers have been involved in a year-long Community of Practice focused on social and emotional learning. We believe that supporting our students in this way is one of most important things we can do. We hope you will see a difference in your children too. Session III will begin on Wednesday, March 6 and run thru Tuesday, June 11.

PLEASE NOTE: Our special enrichment programming will start Monday, March 11 and finish up on Friday, May 31. If you want to enroll your child for only the weeks we run enrichments, you may adjust the fee sheet and pay accordingly.

FINANCIAL ASSISTANCE: We want ALL families who are interested in One Planet to be able to use this valuable resource. If you have a childcare need and qualify for free or reduced lunch, PLEASE consider applying for child care subsidy through DCF.  Contact the Family Place for an application at 802-649-3268 or at .

If you are interested in enrolling your child(ren) in Session III, please be sure to complete and return the following forms to your Site Coordinator by Friday, February 22nd.  

1. General Registration Form 2018-19 (unless you already completed one for the 18-19 year)

2. Session III Enrollment Form

3. Payment Worksheet + Payment

Warm Regards,

Carrie McDonnell Bill Bonsignore Kiersten Harlow Jola Labejsza

Program Director Lead Site Coor. Newton Site Coor. Rochester Site Coor

(802) 763-7775, ext 4 (802) 763-7775, ext 5 (802) 765-4351 802-767-3161

CMcDonnell@ bbonsignore@ skharlow2@ jlabejsza@

Tara Tucker Blythe Bates Amy Gray Leila LaRosa

Royalton Site Coor. Stockbridge Site Coor. Bethel Site Coor. Chelsea Site Coor.

(802) 236-4882 (802) 234-9248 (802) 234-6607 (802) 685-4551

ttucker@ bbates@ agray2@ llarosa@

Jackson Howe Lindsey Cole

Sharon Site Coord. Tunbridge Site Coor.

(802) 763-7425 (802) 889-3310

jhowe@ lcole@

SESSION III Special Program Schedule – Tunbridge

| |K-2nd |3rd-6th |

|Monday |Phoenix Russell |Phoenix Russell |

| |Minecraft World Design |Minecraft World Design |

|Tuesday |Susie Gray |Susie Gray |

| |Shh, Don’t Tell Anyone It’s Math |Shh, Don’t Tell Anyone It’s Math |

|Wednesday |Lindsey Cole |Lindsey Cole |Chelsey Hook |

| |Dungeons & Dragons |Dungeons & Dragons |Girls on the Run |

|Thursday |Matt Aucoin |Matt Aucoin |Chelsey Hook |

| |Crafty Hands |Crafty Hands |Girls on the Run |

|Friday |Core Staff |Core Staff |

| |Free Choice |Free Choice |

ACTIVITY DESCRIPTIONS

Minecraft World Design: Minecraft is all about being creative.  Students will get to really take it to another level with this activity.  Using the free program WorldPainter they will design and present their very own Minecraft worlds.

Shh, Don’t Tell Anyone It’s Math: Can you guess what games, buildings, art and map making have in common?  They all have their origins in the math of ancient civilizations. During this enrichment we will learn about different cultures, and play various games that have their roots in ancient Egypt, Babylon and Rome.  We will create art using frometri shapes and patterns, look at architecture through the ages and create a simple model of an early dwelling and learn make some maps and board games.

Dungeons & Dragons:

Girls on the Run: GOTR inspires girls to take charge of their lives and define the future on their terms. It’s a place where girls learn that they can. No limits. No constraints. Only opportunities to be remarkable.  We start with helping the girls get a better understanding of who they are and what's important to them. Then we look at the role of teams and healthy relationships. And, finally, we explore how girls can positively connect with and shape the world.  This enrichment is taught by licensed teachers and will culminate in a 5K race open to the girls and their families.

Crafty Hands: Students will get the opportunity to try out many different mediums. We will focus on midground and background, lines and shapes, and narrative elements. We will use various paints, markers, pencils, and paper crafting. Taught by licensed teacher.

Free Choice: This intentionally designed time allows students to have voice and choice. At the beginning of the session, kids will help brainstorm activities that they would like to do and these options will be integrated into our Free Choice days. In addition, we will have “stations” that kids can choose from, including open-ended arts/crafts, LEGOS, dress up, board games and more.

One Planet Program Enrollment Form

Session III 2018-2019 Tunbridge

(Please use one form per family.)

Name of Student(s): ____________________________________________ Grade(s): ______________

Parent or Guardian Printed Name: ____________________________________________

Please check off the sections that you desire for Session III.

SESSION III (March 6 – June 11)

___ Section One: Mondays

___ Section Two: Tuesdays

___ Section Three: Wednesdays

___ Section Four: Thursdays

___ Section Five: Fridays

___Section Six: HALF DAYS

Payment Worksheet

Please complete Section 1 or 2. If FINANCIAL ASSISTANCE is needed, please speak to your Site Coordinator about options.

1) If your child is eligible for Free or Reduced lunch: $4/day (or $8/day for HALF DAYS)

Section One: Mondays (12 days x $____) = $_______

Section Two: Tuesdays (13 days x $____) = $ _______

Section Three: Wednesdays (13 days x $____) = $ _______

Section Four: Thursdays (13 days x $____) = $ _______

Section Five: Fridays (11 days x $____) = $ _______

Section Six: HALF DAYS (2 days x $____) = $________

Total Sum= $ ___________

2) If your child is NOT eligible for Free/Reduced lunch: $8/day (or $16/day for HALF DAYS)

Section One: Mondays (12 days x $____) = $_______

Section Two: Tuesdays (13 days x $____) = $ _______

Section Three: Wednesdays (13 days x $____) = $ _______

Section Four: Thursdays (13 days x $____) = $ _______

Section Five: Fridays (11 days x $____) = $ _______

Section Six: HALF DAYS (2 days x $____) = $________

Total Sum= $ ___________

Payment Options (Please make check payable to WRVSU - One Planet):

1. Enclose a check or money order for the full amount OR

1. Enclose a check for 50% of the program costs. The remaining 50% is due by April 12, 2019.

SECTION 3: Scholarship Request

Payment options are available for families who qualify for free or reduced lunch. If you wish to receive financial assistance or a scholarship to attend the GAP or One Planet Program, please check the appropriate box below:

My child(ren) qualify for

□ Free Lunch

□ Reduced Lunch

Step 1: Apply for Child Care Financial Assistance

We ask families to seek out Child Care Financial Assistance through the Family Place first as this allows your child to attend for free or at a reduced rate, and our program receives reimbursement from the state. To apply, parents/guardians must contact the Family Place at 802-649-3268 or go to . If you don’t qualify for child care assistance from the state, please go to Step 2.

Step 2: Scholarship Request

If you do not qualify for Child Care Financial Assistance, please complete the following statement:

“I am requesting scholarship funds for my child(ren) for the following reasons:”

____________________________________________________________________________

__________________________________________________________________________________

We can pay $_______/day.

Signature:_____________________________________ Date:________________________

One Planet Afterschool Program

GENERAL REGISTRATION FORM – Part I

One form per student, please.

Student name: ___________________________________Birth Date______________________

School ________________  Grade __________________ Teacher_________  Gender________

Home Address__________________________________________________________________

Street Town State Zip

Mailing Address__________________________________________________________________

Street Town State Zip

Email (a MUST!) ______________________________________________________________

Parent Contact Information

Name Home Phone Work Phone Cell Phone

Parent/Guard. #1 ________________ _______________ ________________ ____________

Parent/Guard #2 ________________ _______________ ________________ _____________

Is there anyone documented by a court order that your child should not be released to?

_________________________

Pick Up Information

Safety is a top priority; no child will be released from program without a signature of one of the individuals below.  List parents/guardians as appropriate and all individuals listed must be 16 years or older.

Do both parents have permission to pick up child at the end of program activities? _______________

Who else has permission to pick up your child at the end of program activities?

1. ____________________________   Relationship:  _____________ Phone: _____________

2. ____________________________    Relationship:  _____________ Phone: _____________

3.  _____________________________ Relationship:  _____________ Phone: _____________

Emergency Contact Information

List 2 local contacts who can be reached in case of an emergency if parents are unable to be reached.

Name___________________________ Phone_________________ Relationship____________

Name___________________________ Phone_________________ Relationship____________

(Please turn to complete back page)

One Planet Afterschool Program

GENERAL REGISTRATION FORM – Part II

Medical Information

Health/Emotional Issues___________________________________________________________

Does your child have an IEP ___yes ____no?   Does your child have a 504 plan? ___yes ___no?

Allergies________________________________________________________________________

Medications______________________________________________________________________

Physician__________________________ Phone_____________________

Dentist____________________________ Phone_____________________

Swim Level: Please check one

□ My child is a beginner swimmer

□ My child has completed swim level: ____________(please provide a certificate of completion)

Permissions Please check the boxes for which you give permission

□ I give permission to One Planet to treat my child medically in the event I cannot be reached.

□ I give permission for photographs and/or videos to be taken of my child as part of the program for newsletters, Vermont Afterschool Inc., the media or any other positive and wholesome portrayal of the program to the public.  

□ I give my permission for my child to swim when taken to swimming areas where a lifeguard is on duty.

□ I give my permission for One Planet staff to give □ Tylenol or □ Ibuprofen for fever or headache as needed.

□ I give my permission for One Planet staff to give Benedryl as needed

□ I give my permission to the Family Place to share information with One Planet regarding my Child Care Financial Assistance application status and details (if applicable).

In order for your child(ren) to participate, parent/guardians must read following statement and sign below.

I give consent to One Planet to gather information pertaining to my child for statistical purposes including:  Free and Reduced Lunch Status, grades, standardized test results, school behavior and academic records, special education plans, health records and attendance records.  I understand that this information will only be seen by individuals with a strict “need to know” and otherwise will remain confidential. I also grant permission to the program to survey my child to fulfill requirements of the grant.

Signature of Parent/Guardian _______________________________ Date ___________________

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