SYA and TRY 2015 FALL-Spring 2016 Program (Sudanese Youth in Action) and (Transition for Refugee Youth)

Parent Fact Sheet: SYA and TRY Fall 2015-Spring 2016 Program (Start: September 1, End: May 26th, 2016) SYA/TRY fall 2015-spring 2016: During the first week of programing, we will assign your student to the SYA or TRY site based on shared transportation and space availability. The Student Orientation Meeting/the first day of programing will be (September 1st, 2015).

Parent/Guardian Orientation Meeting: August 25, 2015 (5:30pm-7:30pm) INSCC Building, 155 South 1452 East, Room 452 Salt Lake City, UT 84112

1 [Type text] [Type text] [Type text] Student Orientation Meeting: September 1, 2015 (4:30pm-7:30pm): INSCC Building, 155 South 1452 East, Room 452 Salt Lake City, UT 84112 Schedule and Location for fall 2015 (location, duration and time is subject to change) SYA/TRY Schedule: SYA Location: Tuesday, Wednesday and Thursday 255 S 1400 E, Salt Lake City, UT 84112 4:30-7:30pm Life Science and Biology Building University of Utah campus LS building, room 102 and 107, University of Utah Campus TRY Location: *Applications must be received by September 1, 2015* 1614 E Campus Center Drive, Salt Lake City, UT 84112 Completed (original) applications only Business Classroom Building Drop off or mailed to: BU-C, room 301 and 303, University of Utah Campus 155 S 1452 E, INSCC, Room 422 Salt Lake City, UT, 84112 We follow the University of Utah’s break schedule: Fall break Sun-Sun, October 11-18, 2015 Thanksgiving break Thurs.-Fri., Nov. 26-27, 2015 Holiday recess Sat. Dec. 19 -Sun. Jan. 10, 2015 SYA/TRY Classes begin Tuesday, January 12, 2016 Spring break Sun-Sun, March 13-20, 2016 Last Day of SYA/TRY May 26th, 2016 In the SYA and TRY Fall 2015 Program your student will:  Receive tutoring from University Of Utah math and science students  College and Career Readiness advice and support  Hands-on workshops related to Science, Math and Engineering. Field trips on and off the University of Utah campus  Support for healthy development including conflict resolution and community involvement  Receive a snack/light meal during program time Please be prepared:  It is your child’s responsibility to bring homework, course books and school materials.  Please let us know on the consent form if there are any food allergies/dietary restrictions. Make sure to add any allergies (food, drug, bees etc.) and complete the medical information section.  Regular approved transportation is not guaranteed. If you apply and your child is selected, your child must attend at least 90% of program or risk loosing transportation. If your child cannot attend, you must give your cab driver 24-hour notice or risk loosing transportation privileges. No eating or drinking in cabs. Conduct: If a student is impairing the physical or emotional well being of fellow students, drivers or staff, the parent/guardian will be contacted and the student may be terminated from the program. If your child has a disability and would like to request accommodations, please notify the Director before the program starts. Contact: Tino Nywelo, REFUGES Director: [email protected] Nadia Jassim, REFUGES Site Coordinator: [email protected] or 801-214-8473 2 SYA and TRY 2015 FALL-Spring 2016 Program (Sudanese Youth in Action) and (Transition for Refugee Youth)

In partnership with The Center for Science & Mathematics Education (CSME), Sudanese Youth in Action (SYA), Transition for Refugee Youth (TRY), Planned Parenthood Association of Utah, and Refugee Services Office (RSO), we offer SYA and TRY after school program to your children. In order for your child to attend our program(s), we must have a signed release from you. The health and safety of your child is our highest priority. All sites have staff with training for basic medical emergencies. Liability insurance exists for both the sites and transportation. We will contact you by phone in the event of emergencies, issues, or changes to the scheduling. Please fill out completely. Incomplete consent forms will be rejected. All information provided is kept confidential.

3 [Type text] [Type text] [Type text] Child’s Name: ______Date of Birth: ______Age:_____School: ______Grade: ______Address of residence: ______(Street) (City) (State) (Zip) Parent/Guardians’ Names: ______Relationship to Child:______Parent/Guardians’ Phone Numbers Home: ______Work: ______Cell: ______E-mail Address:______Emergency Contact Name and Phone Number:______Student Cell Phone Number: ______Student Email Address:______Transportation Information Primary insurance coverage in the event of a vehicle accident is with the vehicle transporting the student. I understand that the Center for Science and Mathematics Education (CSME) and cooperating schools, agencies or businesses, and their employees, are not responsible for damage or personal injury as students are transported to and from, or while they are at, designated program locations. Medical Information 1. Does your child have any medical/mental condition(s) that we should be aware of in working with your child? YES____ NO____ If yes, please explain ______

2. Does your child take any medication? YES___ NO____ Please name any medication your child is taking and the dosage and times: ______

3. Does your child have any allergies to food, drink or environmental conditions such as bee stings? YES____ NO____ If yes, please list and explain______

4. Does your child have any dietary restrictions (non allergy related)? YES____ NO____ If yes, please list and explain______

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5. Does your child need regular transportation to our program? *Checking yes is not a guarantee of transportation YES____ NO____

In the event it becomes necessary for the CSME staff in charge to obtain emergency care for my child, neither he/she nor the CSME assumes financial liability for expenses incurred because of an accident, injury, illness and/or unforeseen circumstances. I authorize The CSME employees and volunteers in charge of the students to obtain all necessary emergency care and authorize any licensed physician and/or medical personnel to render necessary emergency treatment to my child.

5 [Type text] [Type text] [Type text] Please sign below if permission is given:  I give permission for my child to ride in buses, vans, cars, and bikes hired, rented, or driven by University of Utah or volunteers recruited by the program. (This includes regular transportation to site and/or field trips on or off campus).  I give permission for my child to engage in outdoor activities in close proximity to the SYA/TRY Site and off site.  I give permission for my child to engage in outdoor activities in close proximity to the University of Utah and off campus. I give permission for my child’s name and/or picture to be used in films, videos, media releases, publications by funders, written information or brochures produced to promote the program.  I give permission for my child to partake in evaluation activities related to funding and functioning of the SYA/TRY program.

I HAVE READ AND UNDERSTAND THIS FORM IN ITS ENTIRETY.

______Parent or Guardian Signature Date

OFFICE USE ONLY: STUDENT SITE ASSIGNMENT ______

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