Fall 2016 PETE’s PALs Pal Application Packet 1

PETE’s PALs Fall 2016 Pal Application

“Promoting Physical Education for Everyone”

http://www.faithlafayette.org/community/programs/petes_pals

September 27, October 4, October 18, October 25, November 1, November 8, November 15

6:00-8:00 PM at Faith Community Center

Applications Due: September 9, 2016

Sunday, 1, 2008 through

Saturday, 7, 2008

Fall 2016 PETE’s PALs Pal Application Packet 2

PETE’s PALs Program Overview The PETE's PALS (Physical Education Teacher Educators Supporting Physical Activity and Life Skills) program is an aquatic and motor program offered for children with disabilities. The program is designed to help the participating children become efficient movers in a fun and safe environment. Each child in the program is assigned a trained clinician who will work one-on-one with the child for the two hour gym and swim program. PETE’s PALs is supported by Faith Community Ministries, with support of Purdue undergrad and graduate students. A child's program may include:

Physical fitness activities to improve muscular strength, endurance and flexibility.

Body awareness and spatial orientation.

Fundamental motor patterns and sport skills.

Swimming and water safety skills.

Sensory motor activities. Role of the PETE’s PALs Clinician: Children participating in PETE’s PALs will be paired one-on-one with a trained, Purdue University undergraduate or graduate student clinician. The clinicians are recruited from Purdue’s education and therapy disciplines who have shown an eagerness to work in the program and demonstrate a willingness to learn and accept an educational challenge to motivate and teach children and youth with disabilities. Interested students are interviewed and agree to the commitment of the PETE’s PALS program. Clinicians are strategically paired with their partner based on their experience and the child’s specific needs. Throughout the program, clinicians will evaluate children’s physical activity and motor development needs and will structure individualized instruction in order to help them progress toward goals and objectives that are developed by the clinicians in concert with parents and children. Parent Town Hall Meetings: Throughout the PETE’S PALs program parents will be provided with opportunities to engage with one another and with invited guest speakers. These speakers vary each semester, but include key individuals such as adapted physical education teachers, occupational therapists, special education professionals, etc. Through these meetings parents will be provided with information to help advocate for their child in the educational environment and enhance knowledge to assist their child’s motor needs at home. Time will also be provided to foster positive dialogue among the parents. Participant Eligibility: PETE”S PALs is open to children with a wide range of physical, intellectual, behavioral, and emotional disabilities ranging in age from 3 to 18 years old. We are willing to work with parents to accommodate specific concerns and can provide additional assistance for children with more severe disabilities. Application Process: Parents interested in registering their children for the PETE’s PALs Program should complete the attached application packet and send it along with a check for $45 made payable to Faith Community Ministries to Emma Werry at the address provided below. In order to ensure a spot in the program, application materials should be returned by Friday, September 9 – Late or incomplete applications may not be accepted. There are a limited number of spots in the program, so we recommend that interested families submit completed paperwork as soon as possible. Scholarships are available on a limited basis for families who are in financial need. Please contact Emma Werry (petespalspurdue@gmail.com or 812-781-1618) for information. Emma Werry Purdue University Glenwood Cooperative 503 N University St. West Lafayette, IN, 47906

Fall 2016 PETE’s PALs Pal Application Packet 3

PETE’s PALs Fall 2016 Program Schedule

PETE’s PALs is held at Faith Community Center located at 5526 State Road 26 E, Lafayette, IN 47905. Driving Directions to Faith Community Center can be found at: http://www1.faithlafayette.org/about/visiting_faith/location_and_directions/ PETE’s PALs will be held on seven Tuesday evenings in Fall 2016. The specific dates are September 27, October 4, October 18, October 25, November 1, November 8, and November 15. There will also be a required training session on Tuesday, Septermber 20 at Faith Community Center for the clincians. The children will be divided into two groups (designated by the names Flynn and Harper). The Harper group (older participants) will swim first while the Flynn group (younger participants) is in the gym and then they will switch at 7:00. On the first night of the program please arrive around 5:45 in order to meet and communicate with your child’s clinician. On all other nights plan to be at Faith around 5:55 to allow a couple of minutes for check in. Please understand that the nightly schedule is tentative and may change prior to the beginning of the program. Clinicians who volunteer for the program will be notified in advance of schedule changes.

Time September 27 October 4 October 18 October 25 November 1 November 8 November 15

5:45

Check in at Faith and

meet parents

Check in at Faith

and meet parents

Check in at Faith

and meet parents

Check in at Faith

and meet parents

Check in at Faith

and meet parents

Check in at Faith

and meet parents

Check in at Faith

and meet parents

6:00

Harper

Group –

Swim

Flynn

Group –

Gym

Harper

Group –

Swim

Flynn

Group –

Gym

Harper

Group –

Swim

Flynn

group –

Swim

Harper

group –

Swim

Flynn

Group –

Gym

Harper

group –

Swim

Flynn

Group –

Gym

Harper

group –

Swim

Flynn

Group –

Gym

Harper

group –

Swim

Flynn

Group –

Gym

Parents’ Meeting Parents’ Meeting

6:45 Change to/from pool Change to/from pool Change to/from

pool

Change to/from

pool

Change to/from

pool

Change to/from

pool

Change to/from

pool

7:00

Harper

Group –

Gym

Flynn

Group –

Swim

Harper

Group –

Gym

Flynn

Group –

Swim

Harper

Group –

Gym

Flynn

Group –

Gym

Harper

Group –

Gym

Flynn

Group –

Swim

Harper

Group –

Gym

Flynn

Group –

Swim

Harper

Group –

Gym

Flynn

Group –

Swim

Harper

Group –

Gym

Flynn

Group –

Swim

7:50 Change from pool

and clean gym

Change from pool

and clean gym

Change from pool

and clean gym

Change from pool

and clean gym

Change from pool

and clean gym

Change from pool

and clean gym

Change from pool

and clean gym

8:00 Parent pick up and

check out

Parent pick up and

check out

Parent pick up and

check out

Parent pick up and

check out

Parent pick up and

check out

Parent pick up and

check out

Parent pick up and

check out

8:10 Short clinician

meeting

Short clinician

meeting

Short clinician

meeting

Short clinician

meeting

Short clinician

meeting

Short clinician

meeting

End of program

party

Fall 2016 PETE’s PALs Pal Application Packet 4

Preparing for PETE’s PALs In order to best prepare for PETE’s PALs, we ask that you complete the attached forms and registration materials. Completed applications will be accepted in the order in which they are received and an application will only be considered completed when all materials are received. Required materials include the following:

- Student Information Form - Technology and Information Release Form - Parental Authorization Form (which includes a physician’s signature or recent school physical form) - Non-Parental Pick Up Authorization - Waiver, Release, and Hold Harmless - A check for $45 made payable to Faith Community Center

In order for us to hold your spot in the program, all of these forms must be completed and returned to Emma Werry (Glenwood Cooperative, 503 N University, W Lafayette, IN, 47906) by September 9th, 2016. This includes the parental authorization, which must be accompanied by a physician’s signature or a recent school physical form (completed within the last 12 months). Children for whom we have current paperwork on file will not need a physician’s signature to participate during the Spring, 2016 session. If you have questions about the parental authorization, please email Emma Werry (petespalpurdue@gmail.com). Please note that failure to complete all of the enclosed materials will delay the registration process. WHAT IS NEEDED FOR PETE’s PALs In order to be prepared for the program, children should bring the following items along with them each night:

Backpack/duffel bag to hold belongings

Sneakers or tennis shoes

Comfortable clothes for physical activities

Swimsuit

Towel

Lock for changing room locker (optional)

Anything else that is required to make the experience enjoyable

We discourage children from bringing items such as toys that may become a distraction CLINICIAN-PARENT COMMUNICATION In order to help personalize the PETE’s PALs program to the needs of the children, we encourage our clinicians to foster a positive relationship with parents. As a part of this relationship, we will ask our clinicians to communicate with you on a regular basis and will provide them with your email address so they can contact you prior to the start of the program. This pre-program communication is critical as it helps clinicians to plan for the first session and outline their objectives for the program. QUESTIONS, COMMENTS, OR CONCERNS Parents are welcome to ask questions about registration materials or the program more generally. Please direct all questions to Emma Werry at (petespalspurdue@gmail.com or 812-781-1618) or Alec Werry at awerry@purdue.edu

Fall 2016 PETE’s PALs Pal Application Packet 5

Fall 2016 Child Information Packet GENERAL INFORMATION Child’s Name: ___________________________ Male / Female T-Shirt Size (circle one): YS YM YL AS AM AL AXL Parent Name(s): ___________________________________________________________________________ Address: ____________________________________________________________________________________ City: _________________________________________ State: _________________ Zip Code ______________ Email Address(es): ___________________________________________ ________________________________ Phone Number(s): _________________________________________ __________________________________ Child’s Age: _____________________________________ Date of Birth: ______________________________ Person to contact in case of emergency (available during program hours): __________________________ Phone number(s) of person who is to contacted: ________________________________________________ Are there any dates this session you anticipate not being able to make it to PETE’s PALS: _____________ __________________________________________________________________________________________ BACKGROUND INFORMATION (Will be used to help pair child with appropriate partner) School Child Attends: _____________________________________________________________________ Has the child participated in PETE’s PALs in the past? _________________________________________ Is there a particular clinician you would like to request? ________________________________________ SWIMMING Does the child enjoy being in the water? Explain: _______________________________________________ __________________________________________________________________________________________ Describe the child’s swimming ability: _________________________________________________________ __________________________________________________________________________________________ ALLERGIES Does your child have any allergies of which we need to be aware? _____________________________________ COMMUNICATION How does your child communicate (please check all that apply)?

Fall 2016 PETE’s PALs Pal Application Packet 6

___ Verbally ___ Sign Language ___ See Sign ___ Language Board ___ Electronic Device Does your child wear hearing aids? ___ Yes ___ No If yes, please provide a container for them while swimming and daily care instructions Is your child’s primary language something other than English? If so, please list _____________________ DISABILITY INFORMATION (Please attach another page if necessary) What is the name of the child’s disability or condition? _______________________________________________ Please provide a detailed explanation of the way in which the disability or condition presents (additional information can be provided on the back on this sheer or an attached sheet): _____________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Does your child have any contraindications (i.e., things he/she should not do) in a physical activity setting? If so, please explain: _____________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Is there anything else we need to know about the child? _____________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Is there anything else we need to know about the child? _____________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Is there anything specific that the child’s clinician should work on with him/her during the program? ___________ __________________________________________________________________________________________ __________________________________________________________________________________________

Fall 2016 PETE’s PALs Pal Application Packet 7

__________________________________________________________________________________________ BEHAVIOR ISSUES Describe any behavior challenges the child may have and effective discipline techniques: _________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Does the child have aggressive behavior and/or Oppositional Defiant Disorder (ODD)? If yes, how is it displayed? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

Fall 2016 PETE’s PALs Pal Application Packet 8

TECHNOLOGY INFORMATION & RELEASE FORM

FALL 2016

To the Parents/Guardians of PETE’s PALs Participants:

The future of the PETE’s PALs Program is due in part to successful promotion by our participants and families.

We are therefore requesting your assistance by granting us permission to use any photographs, videotape or

audio tape for our publications, videos or web pages. Please review and sign the form below if you will consent

to our use of the photographs, videotapes or audio tapes.

Thank you for your assistance.

PHOTOGRAPHY/ VIDEO

Date: __________________________

I hereby authorize and consent to the use and reproduction by the PETE’s PALs Program at Faith Community

Ministries, of any and all photographs, video tape recordings, or audio tape recordings in which I appear. I

understand that I am not to receive payment for the photographs, video tape recordings, or audio tape

recordings, and that the photographs, video tape recordings or audio tape recordings will not discredit or distort

my person in any way. All negatives and positives, and tapes, together with the prints shall be solely the

property of the PETE’s PALs Program.

Student’s Name: __________________________________________

Student’s Signature: _______________________________________

I hereby certify that I am the parent or guardian of _____________________________ and I do give my consent

to the forgoing on behalf of him/her.

Printed Name of Parent/Guardian: __________________________________________

Signature of Parent/Guardian: _____________________________________________

Fall 2016 PETE’s PALs Pal Application Packet 9

PETE’s PALs Parental Authorization

All information on this form MUST be completed in order to guarantee a place

in the program.

Faith Community Center Medical Authorization for Treatment of a Minor (persons under 18 years) Pursuant to Indiana Code Paragraph 16-36-1-6, I request and authorize the Purdue University Student Health Center, Tippecanoe Ambulance Service, St. Elizabeth East and Clarian Arnett Hospital, medical personnel, agents, and employees to provide all reasonably necessary medical care advisable for the health of my child, including surgery, and prescription drugs. I acknowledge that no representations, warrants, or guarantees can be made with respect to any medical care or treatment provided. I also understand that, as a result of my child’s participation in this program, it will be necessary for supervisors, clinicians, and others involved with the program to have access to relevant medical information pertaining to my child, and I authorize the use and disclosure of my child’s medical information to promote a safe and healthy experience for my child. Further, I hereby grant permission for my child:

Minor’s Name Date To attend the Fall 2016 PETE’s PALs Program at Faith Community Center by signing below. A signature from one or both parents/legal guardians and a witness signature is required. _______________________________________________________ Signature Parent/Legal Guardian (required) _______________________________________________________ Signature Parent/Legal Guardian/Witness (required) PHYSICIAN APPROVAL I have examined _____________________________________________ and found him/her to be healthy to attend and participate in activities during the Fall 2016 PETE’s PALs program. Medical Conditions _________________________________________________________________________________________ Current Medications _______________________________________________________________________________________ Allergies______________________________________________________________________________________________________

Fall 2016 PETE’s PALs Pal Application Packet 10

Date of Last Tetanus Shot _________________________________________________________________________________ If date not supplied, child may be required to obtain a tetanus shot if injured Physician’s Signature______________________________________________________________________________________ Phone ________________________________________________________________________________________________________

PETE’s PALs Fall 2016 Pick – Up People

For the safety and security of your child/ren, we at PETE’s PALs would like a list of eligible “Pick-up People”. A “pick-up person” is a person/s that you authorize to pick up your child/ren from the program each night. We would like to ensure all your children’s safety and security by creating an authorized list of people that you (parents/guardians) designate as the only people allowed to pick up your child/ren from PETE’s PALs. THIS FORM ONLY NEEDS TO BE COMPLETED IF THE PARENTS/GUARDIANS WHO COMPLETED THIS REGISTRATION PACKET IS NOT GOING TO BE PICKING UP THE CHILD/REN. We will ask for identification from everyone (including parents/guardians) who picks up a child each night, so please inform anyone who may be picking up your child/ren that they will need photo identification (and so will you!). If you have any questions, please contact Emma Werry (petespalspurdue@gmail.com or 812-781-1618). Child/ren’s Name(s): ________________________________________________________________________________________

_________________________________________________________________________________________ Pick up Person #1: ___________________________________________________________________________________________ Relationship to child: ________________________________________________________________________________________ Telephone #: _________________________________________________________________________________________________ Drivers License #: ___________________________________________________________________________________________ Pick up Person #1: ___________________________________________________________________________________________ Relationship to child: ________________________________________________________________________________________ Telephone #: _________________________________________________________________________________________________ Drivers License #: ___________________________________________________________________________________________

Fall 2016 PETE’s PALs Pal Application Packet 11

Waiver, Release, and Hold Harmless Agreement

Fall 2016

In consideration of permission granted by Faith Community Center allowing me to participate in PETE’s PALs (“The Activity”), which will occur on September 27, October 4, October 18, October 25, November 1, November 8, and November 15, which is sponsored by the Faith Community Center, I (together with my parent, guardian, if I am under the age of eighteen or under a legal disability) represent, covenant and agree, on behalf of myself and my heirs, assigns, and any other person claimed by, under or through me, as follows:

1. I acknowledge that participating in the Activity involves certain risks (some of which I may not fully appreciate) and that injuries, death, property or other harm could occur to me or others. I accept and voluntarily incur all risks of any injuries, damages, or harm which arise during or result from my participation in the Activity, regardless of whether or not caused in whole or in part by departments, trustees, affiliates, employees, officers, agents or insurers, and Faith Community Ministries (“Released Parties”).

2. I waive all claims against any of the Released Parties for any injuries, damages, losses or claims, whether known or unknown, which arise during or result from my participation in the Activity, regardless of whether or not caused in whole or part by the negligence or other fault of any of the Released Parties. I release and forever discharge the Released Parties from all such claims. 3. I agree to indemnify and hold the Released Parties harmless from all losses, liabilities, damages, costs or expenses (including but not limited to reasonable attorneys’ fees and other litigation costs and expenses) incurred by any of the Released Parties as a result of any claims or suits that I (or anyone claiming by, under or through me) may bring against any of the Released Parties to recover any losses, liabilities, costs, damages, or expenses which arise during or result from my participation in the Activity, regardless of whether or not caused in whole or part by the negligence or other fault of any of the Released Parties.

4. I have carefully read and reviewed this Waiver, Release and Hold Harmless Agreement. I understand it fully and I execute it voluntarily.

EXECUTED this _________________________ day of _______________________, 20___

Fall 2016 PETE’s PALs Pal Application Packet 12

______________________________________________ ____________________________________________________ Participant Signature Participant Printed Name ______________________________________________ _____________________________________________________ Parent/Guardian Signature Parent/Guardian Printed Name (if participant is under 18)