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 1 st, 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

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:

Tuesday, Wednesday and Thursday4:30-7:30pm

University of Utah campus

SYA Location:255 S 1400 E, Salt Lake City, UT 84112

Life Science and Biology BuildingLS building, room 102 and 107, University of Utah Campus

*Applications must be received by September 1, 2015*Completed (original) applications only

Drop off or mailed to:155 S 1452 E, INSCC, Room 422

Salt Lake City, UT, 84112

TRY Location:1614 E Campus Center Drive, Salt Lake City, UT 84112

Business Classroom BuildingBU-C, room 301 and 303, University of Utah Campus

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:

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

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: tnyawelo@physics.utah.eduNadia Jassim, REFUGES Site Coordinator: njassim.utah@gmail.com or 801-214-8473

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

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

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.Child’s Name: ______________________________________________________

Date of Birth: _________Age:_____School: _________________________________________________Grade: ________

Address of residence: ________________________________________________________________________________________

(Street) (City) (State) (Zip)Parent/Guardians’ Names: ___________________________________________________________________________

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

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 InformationPrimary 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

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

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 Information1. 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____

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

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

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.

Please sign below if permission is given: 7

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

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.8

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

________________________________________________________ ________________________________Parent or Guardian Signature Date

OFFICE USE ONLY: STUDENT SITE ASSIGNMENT

_____________________9

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

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