1. Healthcare

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 ~ WINTER
2014-2015 ~ REGISTRATION FORM (Part 1)
It may be getting chilly outside but the Yellow House has planned some cool events for the Winter months ahead to keep you happy!
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 for upcoming Spring programs: http://www.cheshirect.org/youth-services
CHECK THE EVENT(S) YOU WISH TO REGISTER FOR:
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: __________________________________________________
Hot Chocolate & Movie Night: SAT. December 6th
12/6
Time: 6:00-9:00pm
Free Event!
Max. Participants: 35 Kids (6th grade event)
Donation: Gloves & hats for kids ages 1-16 years old.
*Please Note: This is NOT a peanut/tree nut free event, snacks may contain nuts*
12/13
Max. Participants: 40 people (6th -8th graders and their families)
Donation: $10.00 per family – For Cheshire’s Adopt a Family
Sneak away a few hours during the hectic holiday season to gather
with your friends and family to create something sweet! Each
family begins with a box of graham cracker and constructs it into a
candy covered work of art. The family with the most creative graham cracker
house will win a Winter themed gift package for the whole family to enjoy. Enjoy
some of your favorite holiday music and movies while sipping hot cocoa. Every
child will leave with a winter treat bag. Themed snacks, drinks, and pizza will be
served. Winners will be announced on Monday, 12/22/14.
Please Note: * This is NOT a peanut/tree nut free event, snacks may contain nuts*
Free Event!
Winter Luau & Ice Cream Social: SAT. January 24th
1/24
Come dressed in your Hawaiian shirts and festive hibiscus dresses and
get ready to have fun with your friends at the Yellow House tropical
get-a-way! Decorate beach themed cupcake to take home, make your
own colorful leis and sand art. Create the ice cream sundae of your
dreams with your favorite candy toppings and whipped cream!
*Please Note: This is NOT a peanut/tree nut free event, snacks may contain nuts*
Winter Festival & Graham Cracker House Decorating Contest
Frozen Friday: FRI. December 19th
Waitlist #: ________
Time: 6:00-9:00pm
Free Event!
Max. Participants: 35 Kids (6th grade only)
Donation: Paper goods & cleaning supplies - Cheshire Food Pantry
Sip hot cocoa and enjoy a night inspired by Tim Burton’s
‘Nightmare Before Christmas’ (PG) movie. Play some of your
favorite board games like Yahtzee, Monopoly and Operation with
a movie themed twist. We’ll have fun snacks and get to make a hot chocolate jar
to take home. This is a night you don’t want to miss out on.
Family Fun Night: SAT. December 13th 5:00-8:00pm
Date Received ________________
12/19
Time: 6:00-9:00pm
Max. Participants: 35 Kids (6th grade event)
Donation: Socks & slippers – For local Senior Centers
TRIP: Tubing at Woodbury Ski – FRI. January 30th
1/30
Snow date: Saturday 1/31/15 (5:45-10:00pm)
Time: 5:45-10:00pm
Max. Participants: 40ppl. /Min.: 15ppl. (open to 6th-8th graders)
Cost: $40.00 per child (pizza dinner, bus, tubing & helmet included)
Imagine the feeling of flying down the mountain in your own snow tube - there is
nothing like it in the world. At Woodbury there are 3 very different snow tubing
trails for your enjoyment. Trails are lighted for night use!
***NOTE: You MUST fill out and return 2 separate forms by Monday, January 12th to attend:
The Cheshire Youth Services Permission Form AND Woodbury Ski Area Waiver
will both be emailed and can also be downloaded directly from our website.
*Financial assistance is available to those who need it, please call our
Office at 203.271.6691 to see if you are eligible for a discounted rate.
Valentine’s Day Pizza Party: Fri. February 13th
2/13
Snow date: Saturday 2/14/15 (6:00-9:00pm)
Free Event!
Time: 6:00-9:00pm
Max. Participants: 35 Kids (6th-8th grade)
Donation: Toiletries & personal grooming items - Cheshire Food Pantry
Brrrr! The night where everything is frozen! Watch Disney’s
‘Frozen’ (PG) movie, make a snowflake bracelet, key chains or
picture frame and enjoy snow cap punch and frosty ‘Frozen’
movie inspired treats. Bring your warm clothes & gloves, if there’s snow on the
ground we’ll head outside and make our own Olaf.
Have fun this Valentine's Day with your friends at the Yellow House.
Wear red in support for American Heart Health Awareness Month.
Make a card or craft for a special friend or loved one and play some fun
Minute-to-Win-it challenges. Enjoy healthy yummy V-day snacks and make a
mason jar treat to take home. Please Note: * This is NOT a peanut/tree nut free event*
Please Note: * This is NOT a peanut/tree nut free event *
Taste of Cheshire Pizza Battle: FRI. January 9th Free!
Snow date: Saturday 1/10/15 (6:00-9:00pm)
Time: 6:00-9:00pm
Max. Participants: 40 Kids (6th-8th grade)
Donation: $5-$10 Donation - Winner of Best Overall Pizza’s charity of choice.
1/9
Games & Trivia Night: FRI. February 27th
Free Event!
Time: 6:00-9:00pm Max. Participants: 35 Kids (6th grade only)
Suggested Donation: Non-Perishable Item - Cheshire Food Pantry
2/27
Come hang out with your friends and make a
few new ones playing classic games such as
UNO, SKIP-BO, CLUE, Sorry and Monopoly.
If you love pizza then this is the event for you!!! Dig into some of the tastiest pizzas
Then try your best with a game of charades and
around town then cast your vote for The Best Crust; Best Sauce; Cheesiest; and
challenging Yellow House Jeopardy style trivia on categories
Best Overall Pizza. We’ll have pizza themed crafts and watch the ‘Teenage Mutant
about popular movies, music, TV, and famous people. Enjoy fresh popped popcorn,
Ninja Turtles’ (PG-13) movie to keep you entertained. Please note that the movie is
cookies and fruit punch in between the games.
rated PG-13. Visit commonsensemedia.org to find more detailed information on the rating.
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) - WINTER
2014-15
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 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).
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.*