Teen Thursdays
Partnership of Community Resources, 1517 Church Street, Gardnerville, NV
Tel: (775)-782-8611
Facilitator: Christina 775-230-xxxx
DROP OFF: 9:30am-10:00am
PICK UP: June 23 ONLY 4:00pm-4:30pm ** June 30, July 7 & 14 3:00pm-3:30pm
Teens must be dropped off and picked up within times allotted. Teens who arrive earlier or do
not get picked up in time will NOT be Partnership of Community Resources’ responsibility.
CODE OF CONDUCT
All participants have the right to be respected and to feel welcome in all activities.
All participants have the responsibility to:
Be respectful
Participate and interact with a positive attitude
Refrain from swearing
Listen to and follow instructions of adult leaders
Allow other teens to express their thoughts and ideas without interrupting
Acknowledge others’ ideas, personal challenges and life choices
Be honest and do not falsely represent yourself or someone else through gossip or rumors.
Be helpful, polite and kind to others
DO NOT touch another person’s body inappropriately; make inappropriate, racial or sexual references or
comments; or bully another participant by isolating, teasing or physically hitting.
Refrain from discussing religion, politics, sexual orientations, race or any other matters of affiliation.
Teen Thursdays is about teaching life skills applicable to teens of all backgrounds.
If a participant is found violating the Code of Conduct and disrupting the flow of activities, the participant will
be removed from all activities and a parent/guardian is required to pick up the participant immediately.
This publication was supported in whole or in part by Nevada Division of Public and Behavioral Health. Its contents are solely the responsibility of the
authors and do not necessarily represent the official views of the U.S. DHHS, SAMHSA, or the State of Nevada.
Teen Thursdays
Send registrations by:
Mail/In-person: 1517 Church Street, Gardnerville, NV 89410
Email: [email protected]
Fax: 775-782-xxxx
Note: All workshop sessions are first come first-served until June 22nd or until full.
Contact us at 775-782-8611.
TEEN PARTICIPANT
Name: __________________________________________
Grade (Fall 2016): ________
Age:_____
Must not turn 18 years old before July 15, 2016
Birthday: __________________________
Home Phone: ____________________________________
Sex: [ ]Male [ ]Female
Cell Phone: ______________________________________
Address: ____________________________________________________________________________________________
City/State/Zip: ________________________________________________________________________________________
Only the following parents or guardians will be acknowledged to pick up the above teen participant during pick up times.
PARENT/GUARDIAN
Parent/Guardian Name: ________________________________________________________________________________
Work/Cell Phone: _________________________________
Email: __________________________________________
What is the best way to reach you (call/text/other?)__________________________________________________________
PARENT/GUARDIAN
Parent/Guardian Name: ________________________________________________________________________________
Work/Cell Phone: _________________________________
Email: __________________________________________
What is the best way to reach you (call/text/other?)__________________________________________________________
REGISTER FOR THE FOLLOWING WORKSHOPS:
Since spaces are limited, please register for workshops that you are most sure to attend for its entirety.
[ ] June 23, 2016 - Health and Wellness
[ ] July 7, 2016 - Leadership and Volunteerism
[ ] June 23, 2016 - Health and Wellness
[ ] July 14, 2016 - Advocacy
ATTENDANCE
I, the participant, and I, the parent/guardian, understand that the participant must participate in the entirety of the workshops
we are registering for.
Participant Initial_____ Parent Initial______
Teen Thursdays
TRAVEL
All workshop sessions will start and end at the Partnership of Community Resources. We will only provide transportation to and
from designated activities per workshop day.
Participants will travel in a vehicle operated by or provided by Partnership of Community Resources. By signing this document, I
permit my child to travel. In consideration of my child’s participation, I, as a parent/guardian of the named minor below, waive,
release and agree to hold harmless the Partnership of Community Resources, its sponsors, staff members, or contracted
individuals for all claims arising from traveling to or from participation in and /or being involved in its activities.
Participant Initial_____ Parent Initial______
MEDIA/PHOTO
I give permission for my son/daughter’s picture to appear in the media i.e., newspapers, posters, website, facebook, etc.
Participant Initial_____ Parent Initial______
TEEN PARTICIPANT RESPONSIBILITY / CODE OF CONDUCT
All participants have the right to be respected and to feel welcome in all activities.
All participants have the responsibility to:
Be respectful
Participate and interact with a positive attitude; Refrain from swearing; Listen to and follow instructions of adult
leaders; Allow other teens to express their thoughts and ideas without interrupting; Acknowledge other’s ideas,
personal challenges and life choices.
Be honest and do not falsely represent yourself or someone else through gossip or rumors;
Be helpful, polite and kind to others
DO NOT touch another person’s body inappropriately; make inappropriate, racial or sexual references or comments; or bully
another participant by isolating, teasing or physically hitting.
Refrain from discussing religion, politics, sexual orientations, race or any other matters of affiliation.
Teen Thursdays is about teaching life skills applicable to teens of all backgrounds.
PARENT/GUARDIAN RESPONSIBILITY
If a participant is found violating the Code of Conduct and disrupting the flow of activities, the participant will be removed from
all activities and a parent/guardian is required to pick up the participant immediately.
Participants who arrive earlier or do not get picked up in time will NOT be Partnership of Community Resources’ responsibility.
DROP OFF: 9:30am-10:00am
PICK UP: June 23 ONLY 4:00pm-4:30pm ** June 30, July 7 & 14 3:00pm-3:30pm
My signature below acknowledges that I have read and accepted the policies of Teen Thursdays.
Student Signature: ____________________________________________
Date:____________________
Parent/Guardian Signature: _____________________________________
Date:____________________
Teen Thursdays
PARENTAL PERMISSION/ ASSUMPTION OF RISK/
MEDICAL TREATMENT AUTHORIZATION/
MEDICAL CONDITIONS/ MEDICAL INFORMATION
Please provide a copy of your medical insurance card and a copy of your valid Drivers License.
Consent to Treat
In the event of illness or injury, I The undersigned does hereby give consent for our (my) child
_________________________________________________to receive whatever x-ray examination, anesthetic,
medical, surgical or dental diagnosis or treatment and hospital care and emergency transportation considered
medically necessary in the best judgment of the attending physician, surgeon, or dentist be performed under the
supervision of a member of the medical staff of the hospital or facility providing medical or dental services. I hereby
agree to waive all claims against the Partnership of Community Resources, its officers, agents, and/or employees and
hold them harmless from any and all liability or claims that may arise out of/or in connection with my child’s
participation in this activity. The Partnership of Community Resources provides o medical insurance for such
treatment, and that the cost thereof will be my sole responsibility.
Parent Name:________________________________
Signature: ___________________________________
Child Name: _________________________________
Date: _______________________________________
Emergency Medical Information:
Parent/Guardian: ____________________________ Parent/Guardian: ______________________________
Home Phone: __________________________
Cell Phone: ____________________________
Insurance Company: _______________________________________________________________________
Group # __________________________
Policy # _____________________________
Doctor: __________________________
Phone: _____________________________
Any known Allergies, Illnesses, Injuries or Disabilities:
________________________________________________________________________________________________
Medications participant will bring (please include prescribed dose/frequency:
________________________________________________________________________________________________
Emergency Contact if unable to contact above Parent/Guardian
Name ______________________________________ __
Relationship ________________
Contact# _________________
Name ______________________________________ __
Relationship ________________
Contact# _________________