| Community Connections Program Sponsored by Sweetwater County School District Number One and 21st Century Community Learning Center Grant Project P.O. Box 1089 Rock Springs, Wyoming 82902-1089 (307) 352-3474 office (307) 389-4942 cellular Be a part of the community this year and have fun helping others by becoming a part of the Community Connections Program. This exciting volunteer program is available to all students between the ages of 12 to 18. Although this program is voluntary, you the student, will benefit by being involved. You will experience personal growth, have more to add to your resumes, scholarship and college applications, and a volunteer experience may turn into a paying job at a later date. This program is designed to help connect the student with the community by participating in volunteer activities within the community. The program runs from 2:45 p.m. to 4:30 p.m. Monday through Thursday. There is no cost to participate. The program is strictly on a volunteer basis. The student will not be punished or dismissed from the program for not participating daily. Activities may include performing various tasks with the elderly at Sage View Care Center, volunteering at the Chamber of Commerce, the Recycling Center, the Humane Society, the YWCA, and at other non-profit organizations throughout the community. Transportation will be provided. This program is not only a great confidence builder for teens, but it also benefits the community. If you are highly enthusiastic, energetic, committed to success and looking for a fun and exciting activity, this is the one for you! Thank you, Lisa Plant, Program Coordinator Rechelle Knezovich, Progam Evaluator Lori Moses, Activity Instructor Alyssa Stenstock, Activity Instructor Sweetwater County School District Number One Emergency Information and Release Name___________________________________________Birth Date_______________ Address________________________________________Home Phone______________ Parent/Guardian________________________________Work Phone_______________ Phone number of parent during the day_______________________________________ Mother__________________________Father__________________________________ In an emergency if parents cannot be contacted: Notify________________________________________Phone Number______________ Doctor_______________________________________Phone Number______________ Allergies________________________________________________________________ Insurance Company_______________________Policy Number____________________ List any medical conditions or medications that we should be aware of: _______________________________________________________________________ The Program Coordinator, Activities Instructors, and Supervisors may apply first aid treatment until the parent/guardian, emergency contact, and/or medical doctor can be notified. Yes___No____ We give our consent for the Director, Activities Instructors, and/or Supervisors to use their own judgment in securing medical aid and ambulance service in case parent/guardian cannot be reached. Yes_________No__________ Does your child receive free or reduced lunch? Yes ___No___ Does your child receive Title I benefits? Yes____No ____ If we offered an adult literacy program would any adult in your family be interested in attending? Yes_____No_____ Parent/Guardian Signature________________________________Date____________ Ethnic Origin: White___ Black/African American___ Hispanic/Latino ___ Asian/Pacific Islander___Native American___ Unknown___ This is a school sponsored violence-free, alcohol-free, tobacco-free, and other drug-free program. These items, or any types of weapons, will not be allowed on the premises of any site, at any time. If anything is found in the possession of any student, or any student is under the influence, then he/she will not be allowed to continue the program. Parents will be contacted and expected to come to the site their child is at and take their child home. If other offensive behavior is exhibited by a student, the parents will also be called and expected to pick up their child immediately. I acknowledge that I have read and understand the above guidelines and hold harmless Sweetwater County School District Number One and this program for any damages or injuries to my child while attending this program. Student Signature__________________________________________Date__________ Parent/Guardian Signature__________________________________Date__________
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