MURRAY AVENUE SCHOOL PTA AFTER SCHOOL CLUBS
Fall 2009
September 30 , 2009
We are pleased to present the registration packet for the Murray Avenue School PTA Fall 2009 After School Clubs which are scheduled to begin Monday, October 19, 2009.
Debbie Hilden
20 Dimitri Place
Larchmont, NY 10538
Assume your child is in his club(s) of choice unless you are notified otherwise on or before Wednesday, October 14 . Club assignments will also be posted on the After School Clubs Bulletin Board (opposite the library) beginning Wednesday, October 14.
Scholarships are available to allow all children to benefit from the After School Clubs program regardless of financial situation. All scholarship requests are strictly confidential. Please notify Jennifer Monaco as soon as possible to request a scholarship so that your child's club choice can be included in the lottery. Scholarships are limited to one club per child per club offering.
For more information, please contact Pam Washington at 834-5936 or pwash@optonline.net
IF YOUR CHILD ENROLLS IN A CLUB --
PLEASE SAVE THIS SHEET FOR REFERENCE
RULES, REGULATIONS AND PROCEDURES
LIVE CLUB SCHEDULE & LOCATIONS
The club schedule for Fall 2009 is now available in pdf and Excel formats.
|
MONDAY |
TUESDAY |
WEDNESDAY |
THURSDAY |
FRIDAY |
|
ART OF DRAWING
G 3 - 5 |
CARTOONING
G 3 - 5
|
ART-N-ORBIT: Inventions
G 1 - 3 |
CHESS
G 1 – 5
|
ART AND FOOD
G 2 – 5 |
|
CHESS
G 1 - 5 |
CLAY WORKS
G 1 - 5 |
BEGINNING FIFE
G 1 - 3 |
MAGIC
G 1 – 5 |
EXPLORING WORLD MUSIC
G 3 - 5 |
|
COOKING & BAKING
G 1 – 5
|
FRENCH
G 1 - 5 |
DINOSAURS ROCK
1 - 5 |
MIXED MEDIA
G 2-5 |
MAD SCIENCE: LOONEY LIFE LAB
G 1 - 2 |
|
CRAFTS, CRAFTS, CRAFTS
G 1 - 5 |
MAD SCIENCE: ROCKETRY
G 3 - 5 |
JEWELRY & BEADING
G 1 – 5
|
ANIMAL SAFARI
G 1 - 3 |
TIE DYE
G 1 - 3 |
|
HOMEWORK
G 3 - 5 |
SEWING CLUB
G 1 – 5 |
MAD SCIENCE: LOONEY LIFE LAB G 3 - 5 |
PHOTOGRAPHY
G 3 – 5 |
|
|
LMC-TV: VIDEO CLUB
G 4 – 5 |
|
SPANISH Beginner & Advanced
G 1 - 5 |
YOGA FOR KIDS
G 3 – 5
|
|
|
NEEDLEPOINT: Beginner & Intermediate
G 2 – 5 |
|
|
|
|
|
Dates for Monday Clubs 10/19 10/26 11/2 11/9 11/16 11/23 11/30 12/7
Makeup 1/9 |
Dates for Tuesday Clubs 10/20 10/27 11/10 11/17 11/24 12/1 12/8 1/5
Makeup 1/26 |
Dates for Wednesday Clubs 10/21 10/28 11/4 12/9 12/16 1/6 1/27 2/3
Makeup 2/10 |
Dates for Thursday Clubs 10/22 10/29 11/5 11/12 11/19 12/3 12/10 12/17
Makeup 1/7 |
Dates for Friday Clubs 10/30 11/6 11/13 11/20 12/4 12/11 12/18 1/8
Makeup 1/29 |
|
No Clubs 12/14 |
No Clubs 11/3, 11/10, 12/15,
|
No Clubs 11/11, 11/18, 11/25, 12/2, 1/13, 1/20 |
No Clubs 11/26 |
No Clubs 10/23, 11/27 |
MONDAY 3:05 - 4:05 p.m. FALL 2009
|
ART OF DRAWING Aaron Stone |
Grades Room
Time |
3 - 5 Mr. Stone’s Art Room 3:05-4:05 |
8 Sessions – MONDAYS 10/19, 10/26, 11/2, 11/9, 11/16, 11/23, 11/30, 12/7 Makeup 1/9 |
||||
|
Cost: |
$155.00 |
NO CLUB 12/14 |
|||||
|
Each week, explore a different way of drawing. From drawing the model to on-location, the club will teach drawing but also looking at what you see, and seeing it to inspire and learn. |
|||||||
|
Minimum |
7 |
Maximum |
25 |
||||
|
CHESS Mr. Stefan Kuczinski |
Grades Room
Time |
1 - 5 233
3:05-4:05 |
8 Sessions – MONDAYS 10/19, 10/26, 11/2, 11/9, 11/16, 11/23, 11/30, 12/7 Makeup 1/9 |
||||
|
Cost: |
$130.00 |
NO CLUB 12/14 |
|||||
|
Let's play CHESS! Students will learn opening, middle game and endgame strategies and how to achieve a proper coordination of pieces. We will challenge each other by playing games individually and in teams. All skill levels are welcome. Let's see your strategies!!! Mr. Kuczinski is a teacher at Murray. |
|||||||
|
Minimum |
7 |
Maximum |
21 |
||||
|
COOKING & BAKING Marilyn Stahl |
Grades Room
Time |
1 - 5 Large Cafeteria
3:05-4:05 |
8 Sessions – MONDAYS 10/19, 10/26, 11/2, 11/9, 11/16, 11/23, 11/30, 12/7 Makeup 1/9 |
|||||
|
Cost: |
$160.00 |
|
NO CLUB 12/14 |
|||||
|
Mrs. Stahl, a former elementary school teacher, teaches children to cook creatively-- everything from appetizers to desserts -- through demonstration and participation. After each class everyone will take home what they’ve made and the recipe for it. Mrs. Stahl has been teaching cooking at Murray Ave. for 24 years and has a published cookbook. |
||||||||
|
Minimum |
15 |
Maximum |
23 |
|||||
|
CRAFTS, CRAFTS, CRAFTS Donna Dickerson |
Grades Room
Time |
1 - 5 Ms. Revich’s Art Room 3:05-4:05 |
8 Sessions – MONDAYS 10/19 10/26, 11/2, 11/9, 11/16, 11/23, 11/30, 12/7 Makeup 1/9 |
||||
|
Cost: |
$145.00 |
NO CLUB 12/14 |
|||||
|
We will be doing an assortment of crafts such as party piñatas, candle making, polymer clay projects, pillow making and more. Ms. Dickerson is an aide at Murray. |
|||||||
|
Minimum |
7 |
Maximum |
20 |
||||
|
HOMEWORK CLUB -
|
Grades Room
Time |
3 - 5 242
3:05-4:05 |
8 Sessions – MONDAYS 10/19, 10/26, 11/2, 11/9, 11/16, 11/23, 11/30, 12/7 Makeup 1/9 |
||||
|
Cost: |
$130.00 |
NO CLUB 12/14 |
|||||
|
Mr Rivel, a 5th grade teacher, will help with homework or a challenging concept. |
|||||||
|
Minimum |
8 |
Maximum |
15 |
||||
|
VIDEO CLUB - LMC-TV |
Grades Room
Time |
4 - 5 Auditorium Stage
3:05-4:05 |
8 Sessions – MONDAYS 10/19, 10/26, 11/2, 11/9, 11/16, 11/23, 11/30, 12/7 Makeup 1/9 |
||||
|
Cost: |
$140.00 |
NO CLUB 12/14 |
|||||
|
Teaches participants how to shoot and edit a TV news or variety show by making one. |
|||||||
|
Minimum |
6 |
Maximum |
8 |
||||
|
NEEDLEPOINT: Beginner & Intermediate Stitch by Stitch |
Grades Room
Time |
2 - 5 Game Room #1
3:05-4:05 |
8 Sessions – MONDAYS 10/19, 10/26, 11/2, 11/9, 11/16, 11/23, 11/30, 12/7 Makeup 1/9 |
||||
|
Cost: |
$120 |
NO CLUB 12/14 |
|||||
|
Beginner and returning needlepointers welcome. Learn the continental stitch and stitch a canvas suitable for framing. Instructor Kate Spader of Stitch by Stitch in Larchmont is an avid needle pointer who has been stitching almost her entire life! She is excited to share her enthusiasm and love for this art form with Murray Avenue students. |
|||||||
|
Minimum |
4 |
Maximum |
8 |
||||
TUESDAY 3:05 - 4:05 P.M. FALL 2009
|
CARTOONING Taylor Lee |
Grades Room
Time |
3 - 5 Small Cafeteria
3:05-4:05 |
8 Sessions – TUESDAYS 10/20, 10/27, 11/10, 11/17, 11/24, 12/1, 12/8, 1/3 Makeup 1/26 |
||||
|
Cost: |
$140.00 |
NO CLUB 11/3, 11/10, 12/15 |
|||||
|
Develop your own characters, comic strips, and cartoons with guidance from a pro. Cartoon history from Sponge Bob to the New Yorker will be presented. Taylor Lee is a professional cartoonist. |
|||||||
|
Minimum |
8 |
Maximum |
25 |
||||
|
CLAY WORKS Slavin Studios |
Grades Room
Time |
1 - 5 Mr. Stone’s Art Room 3:05-4:05 |
8 Sessions – TUESDAYS 10/20, 10/27, 11/10, 11/17, 11/24, 12/1, 12/8, 1/3 Makeup 1/26 |
||||
|
Cost: |
$135.00 |
NO CLUB 11/3, 12/15 |
|||||
|
Students will learn the basic techniques of ceramics. Using an air-drying clay, the class focuses on creativity and the fundamentals of sculpture. Slavin Studios specializes in ceramic sculpture. |
|||||||
|
Minimum |
10 |
Maximum |
30 |
||||
|
FRENCH Lingua Kids, LLC |
Grades Room
Time |
1 - 5 Game Room #1
3:05-4:05 |
8 Sessions – TUESDAYS 10/20, 10/27, 11/10, 11/17, 11/24, 12/1, 12/8, 1/3 Makeup 1/26 |
||||
|
Cost: |
$130.00 |
NO CLUB 11/3, 11/10, 12/15 |
|||||
|
Linguakids offers a fun way to learn French using songs, games, stories, arts and crafts, and much more. Native-speaking teachers create a fun, friendly atmosphere that will have your child speaking and understanding in no time. Books and worksheets are provided. Michele Heris is |
|||||||
|
Minimum |
4 |
Maximum |
12 |
||||
|
ROCKETRY Mad Science of Westchester |
Grades Room
Time |
3 - 5 Large Cafeteria
3:05-4:05 |
8 Sessions – TUESDAYS 10/20, 10/27, 11/10, 11/17, 11/24, 12/1, 12/8, 1/3 Makeup 1/26 |
||||
|
Cost: |
$140.00 |
NO CLUB 11/3, 11/10, 12/15 |
|||||
|
Building rockets and gliders is the focus of this Mad Science club. Topics will include Stunt Planes & Gliders, Air Rockets, Rocket Launches and Rocket Building. Each Rocket takes 1 to 2 weeks to complete. Children in this club will build 4 different rockets. |
|||||||
|
Minimum |
8 |
Maximum |
10 |
||||
|
SEWING CLUB Jill Parry |
Grades Room
Time |
1 - 5 Game Room
3:05-4:05 |
8 Sessions – TUESDAYS 10/20, 10/27, 11/10, 11/17, 11/24, 12/1, 12/8, 1/3 Makeup 1/26 |
||||
|
Cost: |
$155.00 |
NO CLUB 11/3, 11/10, 12/15 |
|||||
|
Students are introduced to basic sewing, construction and decorative techniques. Pillows, bags, stuffed animals are individualized with your own designs. Jill is a fiber artist and teaches for the Westchester Arts Council. |
|||||||
|
Minimum |
7 |
Maximum |
20 |
||||
WEDNESDAY 2:35 - 3:35 P.M. FALL 2009
|
ART- N- ORBIT Inventions-n-Concoctions Michael Krevlin |
Grades Room
Time |
1 - 3 Mr. Stone’s Art Room 2:35-3:35 |
8 Sessions – WEDNESDAYS 10/21, 10/28, 11/4, 12/9, 12/16, 1/6, 1/27, 2/3 Makeup 2/10 |
||||
|
Cost: |
$196.00 |
NO CLUB 11/11, 11/18, 11/25, 12/2, 1/13, 1/20 |
|||||
|
Explore the universe, create spinning robots, solve mysteries in this combination of creative art and science. New projects are featured in every class. The fee includes an instructor fee of $155, plus a $40 fee for materials ($5 per club meeting). |
|||||||
|
Minimum |
8 |
Maximum |
20 |
||||
|
BEGINNING FIFE Alice F. Miller
|
Grades Room
Time |
1 - 3 Ms. Rosen’s Rm
2:35-3:35 |
8 Sessions – WEDNESDAYS 10/21, 10/28, 11/4, 12/9, 12/16, 1/6, 1/27, 2/3 Makeup 2/10 |
||||
|
Cost: |
$160.00 |
NO CLUB 11/11, 11/18, 11/25, 12/2, 1/13, 1/20 |
|||||
|
Students will learn a simple instrument and play easy tunes. We will have fun learning how to make a sound and finger notes. We will play familiar songs together. No previous musical training or reading is needed. This instrument is a good first step on the road to learning more sophisticated instruments such as the recorder. |
|||||||
|
Minimum |
3 |
Maximum |
20 |
||||
|
DINOSAURS ROCK Dinosaurs Rock |
Grades Room
Time |
1 - 5 Auditorium Stage
3:05-4:05 |
8 Sessions – WEDNESDAYS 10/21, 10/28, 11/4, 12/9, 12/16, 1/6, 1/27, 2/3 Makeup 2/10 |
||||
|
Cost: |
$143.00 |
NO CLUB 11/11, 11/18, 11/25, 12/2, 1/13, 1/20 |
|||||
|
NEW ACTIVITIES ADDED! The museum comes to Murray with hands-on exploration of the prehistoric world. Topics covered include Fascinating Fossils, The Miracle of Minerals, Paleontologist for a Day, the Ice Age, Prehistoric Sharks, and more. Weekly take-home projects with real fossils and minerals such as Fossil Excavation, Tar Pit Discover, Crystal-Filled Geode Opening, Dinosaur Model-Building, Gemstone Panning, Shark Tooth Necklace Making, and Trilobite Excavation. |
|||||||
|
Minimum |
15 |
Maximum |
25 |
||||
|
JEWELRY & BEADING Melanie Rose |
Grades Room
Time |
1 - 5 Small Cafeteria
2:35-3:35 |
8 Sessions – WEDNESDAYS 10/21, 10/28, 11/4, 12/9, 12/16, 1/6, 1/27, 2/3 Makeup 2/10 |
||||
|
Cost: |
$176.00 |
NO CLUB 11/11, 11/18, 11/25, 12/2, 1/13, 1/20 |
|||||
|
Necklaces, bracelets, hair wraps, and more … jewelry galore!! Each week students will create at least one new beaded item to take home. Students will be introduced to many stringing materials: charms, pendants and tons of beautiful beads. Both younger and older students will be accommodated and a few new projects will be introduced for returning students. Melanie Rose is the owner of Beadz, a bead boutique/party store in Larchmont. |
|||||||
|
Minimum |
8 |
Maximum |
25 |
||||
|
LOONEY LIFE LAB Mad Science of Westchester |
Grades Room
Time |
3-5 Large Cafeteria
2:35-3:35 |
8 Sessions – WEDNESDAYS 10/21, 10/28, 11/4, 12/9, 12/16, 1/6, 1/27, 2/3 Makeup 2/10 |
||||
|
Cost: |
$125.00 |
NO CLUB 11/11, 11/18, 11/25, 12/2, 1/13, 1/20 |
|||||
|
Join our mad scientist for an hour of educational, hands-on, cool science experiments. Looney Life Lab focuses on animals, food, weather and the earth. Mad Science classes spark imaginative learning about science-related phenomena while having lots of fun. |
|||||||
|
Minimum |
8 |
Maximum |
30 |
||||
|
SPANISH, Beginner and Advanced Lingua Kids, LLC |
Grades Room
Time |
1 - 5 Game Room
2:35-3:35 |
8 Sessions – WEDNESDAYS 10/21, 10/28, 11/4, 12/9, 12/16, 1/6, 1/27, 2/3 Makeup 2/10 |
||||
|
Cost: |
$130.00 |
NO CLUB 11/11, 11/18, 11/25, 12/2, 1/13, 1/20 |
|||||
|
Through activities such as singing, arts and crafts, games, and other multi-sensory teaching techniques, your child will learn basic Spanish vocabulary words and phrases. The teacher, a native speaker, is friendly, energetic, and enthusiastic and will help everyone have fun learning. In the event of under enrollment, beginner and advanced will be combined. Depending on the experience levels of the children, the group may be split. |
|||||||
|
Minimum |
4 |
Maximum |
12 |
||||
THURSDAY 3:05 - 4:05 P.M. FALL 2009
|
CHESS Stefan Kuczinski |
Grades Room
Time |
1 - 5 233
3:05-4:05 |
8 Sessions – THURSDAYS 10/22, 10/29, 11/5, 11/12, 11/19, 12/3, 12/10, 12/17 Makeup 1/17 |
||||
|
Cost: |
$130.00 |
NO CLUB 11/26 |
|||||
|
Let's play chess! Students will learn opening, middle game and endgame strategies and how to achieve a proper coordination of pieces. We will challenge each other by playing games individually and in teams. All skill levels are welcome. Let's see your strategies!!! Mr. Kuczinski is a teacher at Murray. |
|||||||
|
Minimum |
7 |
Maximum |
21 |
||||
|
MAGIC Joe Fields
|
Grades Room
Time |
1 - 5 Small Cafeteria
3:05-4:05 |
8 Sessions – THURSDAYS 10/22, 10/29, 11/5, 11/12, 11/19, 12/3, 12/10, 12/17 Makeup 1/17 |
||||
|
Cost: |
$120.00 |
NO CLUB 11/26 |
|||||
|
A perennial favorite and Murray’s longest-running club! If magic is your bag, you’ll want to join magician Joe Fields and learn to do magic with coins, cards, ropes, cups, and balls, as well as impromptu magic with everyday objects. Every class is mystifying, funny, and entertaining. At the end, you will have your own bag of tricks for performing. |
|||||||
|
Minimum |
10 |
Maximum |
24 |
||||
|
MIXED MEDIA ART Jenny Lee |
Grades Room
Time |
2 - 5 Ms. Revich’s Art Room 3:05-4:05 |
8 Sessions – THURSDAYS 10/22, 10/29, 11/5, 11/12, 11/19, 12/3, 12/10, 12/17 Makeup 1/17 |
||||
|
Cost: |
$153.00 |
NO CLUB 11/26 |
|||||
|
Students will have fun exploring a variety of techniques and materials while using the most important tool of all – imagination! If you enjoy using different art materials, this is the class for you!. NEW PROJECTS! Instructor Jenny Lee is a Murray mom and local artist who has received numerous awards for her works on paper and has taught courses in oil painting, drawing, and clay. |
|||||||
|
Minimum |
6 |
Maximum |
20 |
||||
|
ANIMAL SAFARI Jim Bingham |
Grades Room
Time |
1 - 3 Mr. Stone’s Art Room 3:05-4:05 |
8 Sessions – THURSDAYS 10/22, 10/29, 11/5, 11/12, 11/19, 12/3, 12/10, 12/17 Makeup 1/17 |
||||
|
Cost: |
$130.00 |
NO CLUB 11/26 |
|||||
|
Each week, travel to a different region of the world and get a visit from a real LIVE animal. Students hold and pet the animals as they learn. Safe and fun animals like chinchilla, tortoise, blue-tongued skink, hedgehog, bearded dragon, snake and more will be seen. Students will also keep a safari journal and do a craft project each week. |
|||||||
|
Minimum |
8 |
Maximum |
16 |
||||
|
PHOTOGRAPHY Shirley Zeiberg |
Grades Room
Time |
3 - 5 Game Room
3:05-4:05 |
8 Sessions – THURSDAYS 10/22, 10/29, 11/5, 11/12, 11/19, 12/3, 12/10, 12/17 Makeup 1/17 |
||||
|
Cost: |
$125.00 |
NO CLUB 11/26 |
|||||
|
Welcome to the world of photography, where students will learn the components of a good photograph and how to get them. This includes: lighting, reflection, posing, composition, action photos and more. Students are asked to supply their own cameras -- can be a simple 35 mm, digital, or disposable. Instructor Shirley Zeiberg is a well-known portrait, commercial and news photographer in the area. |
|||||||
|
Minimum |
8 |
Maximum |
12 |
||||
|
YOGA FOR KIDS Kyle Greenberg |
Grades Room
Time |
3 - 5 Small Gym
3:05-4:05 |
8 Sessions – THURSDAYS 10/22, 10/29, 11/5, 11/12, 11/19, 12/3, 12/10, 12/17 Makeup 1/17 |
||||
|
Cost: |
$130.00 |
|
NO CLUB 11/26 |
||||
|
A fun way to increase flexibility and strength in safe, non-competitive atmosphere. Children learn basic yoga poses, breathing and relaxation. Students work at their own pace. Games are included as a way to learn yoga poses. |
|||||||
|
Minimum |
8 |
Maximum |
14 |
||||
FRIDAY 3:05 - 4:05 P.M. FALL 2009
|
ART AND FOOD Aaron Stone |
Grades Room
Time |
2 - 5 Mr. Stone’s Art Room 3:05-4:05 |
8 Sessions – FRIDAYS 10/30, 11/6, 11/13, 11/20, 12/4, 12/11, 12/18, 1/8, 2/3 Makeup 1/29 |
||||
|
Cost: |
$165.00 |
NO CLUB 10/23, 11/27, 1/15, 1/22 |
|||||
|
Each week, we will use food as a tool to create art. From mosaics to painting, food will be our medium to create interesting, yummy and fun art. |
|||||||
|
Minimum |
7 |
Maximum |
15 |
||||
|
EXPLORING WORLD MUSIC Alice F. Miller
|
Grades Room
Time |
3 - 5 Game Room
3:05-4:05 |
8 Sessions – FRIDAYS 10/30, 11/6, 11/13, 11/20, 12/4, 12/11, 12/18, 1/8, 2/3 Makeup 1/29 |
||||
|
Cost: |
$168.00 |
NO CLUB 10/23, 11/27, 1/15, 1/22 |
|||||
|
Listen to the music and learn about the instruments and culture of other countries. We will explore a different country each week, listening to its music and learning about its people and customs. There will also be related hands-on activities. Music is a great way to make a connection between ourselves and people living in different parts of the world. Come and learn about the rhythms of Africa, Latin America and the USA among others. |
|||||||
|
Minimum |
3 |
Maximum |
20 |
||||
|
LOONEY LIFE LAB Mad Science of Westchester |
Grades Room
Time |
1 - 2 Large Cafeteria
3:05-4:05 |
8 Sessions – FRIDAYS 10/30, 11/6, 11/13, 11/20, 12/4, 12/11, 12/18, 1/8, 2/3 Makeup 1/29 |
||||
|
Cost: |
$125.00 |
NO CLUB 10/23, 11/27, 1/15, 1/22 |
|||||
|
Join our mad scientist for an hour of educational, hands-on, cool science experiments. This Fall’s topics focus on animals, food, weather and the earth. Mad Science classes spark imaginative learning about science-related phenomena while having lots of fun. |
|||||||
|
Minimum |
8 |
Maximum |
16 |
||||
|
TIE DYE Robyn Dempsey |
Grades Room
Time |
1 – 3 Ms. Revich’s Art Room 3:05-4:05 |
8 Sessions – FRIDAYS 10/30, 11/6, 11/13, 11/20, 12/4, 12/11, 12/18, 1/8, 2/3 Makeup 1/29 |
||||
|
Cost: |
$160.00 |
NO CLUB 10/23, 11/27, 1/15, 1/22 |
|||||
|
Tie dye shirts, socks, pillowcases and towels. Lots of color and fun!! Ms. Dempsey is a Murray aide. |
|||||||
|
Minimum |
3 |
Maximum |
20 |
||||
AFTER SCHOOL CLUBS - APPLICATION FOR CLUB
REGISTRATION AND CHECKS ARE DUE IN DRAWER BY FRONT DOOR
OR AT DEB HILDEN’S 20 DIMITRI PLACE BY THURS, OCT 8
LATE FORMS WILL NOT BE ACCEPTED
|
CLUB NAME |
DAY |
ALTERNATE |
DAY |
1st |
|
|
|
|
|
CLUB NAME |
DAY |
ALTERNATE |
DAY |
2nd |
|
|
|
|
NOTE: A SEPARATE check for each club & alternate must be attached to be considered in lottery. All checks should be made out to MURRAY AVENUE PTA. Unused checks will be destroyed.
CHILD’S NAME:
CHILD’S GRADE: _____ HOME PHONE:
TEACHER: _____ CELL PHONE:
PARENT NAME: _____ WORK PHONE:
EMAIL: _ _____ ______________:
LOCAL EMERGENCY CONTACT:
PHONE#: CELL:
SPECIAL MEDICAL INFORMATION / PROBLEMS:
DISMISSAL INSTRUCTIONS:
Is child permitted to leave club on his/her own? YES NO
______________________________
(Parent signature)
If NO, list all adults your child may be dismissed to: