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After School Permission Slip

Town of Rochester
Community Center/Youth Department
PO Box 65, Accord, NY 12404
Office Phone: (845) 626-2115  Fax (845) 626-0141  Youth Center Phone (845) 626-3053
Carol Dennin, Director
Valerie Weaver, Assistant Director  
Funded by New York State Office of Children & Family Services
This program does not deny services to participants regardless of race, creed, color, national origin, sex, or disability.

2008 Community Center Program & Activities

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Dear Parents,

Snack is offered every day at 4:00 pm. We encourage parents to send their children with a snack or snack money to the Center. We will gladly store your child’s labeled snacks, (i.e., cup of soup, yogurt, easy macaroni and cheese, etc.). Donating snacks occasionally for everyone to share would very much appreciated.

Every day the staff has a mandatory homework time from 5:30 pm - 6:00 pm. This allows your child to receive tutoring from the coordinators, and the opportunity to research information on the web if needed.

Every Friday, until the weather changes we will be walking to the Town Park. We will also be going outside daily at the Center and all children must participate. We ask that all parents/caregivers send in a bag with hats, gloves, sweatshirts, etc., labeled with your child’s name to be kept here for when weather demands it.

We follow the School Calendar, and when School is closed, we’re closed. Remember, when children have early dismissal, or when after-school activities are cancelled, so is the Youth Center AFTER SCHOOL PROGRAM!! Please make alternate arrangements for those occasions.

Attending the after school program at the Youth Center is a privilege, not a right. We have a set of rules that children must adhere to in order to be a part of the program. A 3-strike rule is in effect after receiving a third strike the child’s right to attend the Center will be revoked until further notice.

Parents must be on time when picking up their childrenno later than 6 pm! Parents must come in to sign out their child when they leave the Center daily.
Town of Rochester
Community Center/Youth Commission
PO Box 65, Accord, NY 12404
(845) 626-2115  Fax (845) 626-0141  Youth Center Phone (845) 626-3053
Carol Dennin, Director
Valerie Weaver, Assistant To Director
Funded by New York State Office of Children & Family
This program does not deny services to participants regardless of race, creed, color, national origin, sex, or disability.


2008 Activities Registration and permission slip
Name: _________________________________________________________________

Address: _______________________________________________________________

City/ Town/ State/ Zip:_____________________________________________________

Date Of Birth: _________________        Gender: ____    Age ______      School: ___________

Ethnicity: White ___ Black___ Hispanic___ Native American__ Asian __Other___

Name Of Parents/ Guardians:  _______________________________________________

Telephone # (Home): ________________________            Work:     ________________

Does your Child have any allergies? __________________________________________

Is he/she currently taking any medication? _____________________________________

Does your child have any disabilities and/or health conditions that the staff should know about?

_______________________________________________________________________

In Case of Emergency notify:

Name: ___________________________________________ Phone: ________________


Name: ___________________________________________ Phone: ________________


Physician’s Name _________________________________ Phone: _________________


Hospital Preference in case of an emergency: ___________________________________

Do you have any restrictions and/or limitations on snack? _________________________



Below is a set of rules that must be followed. Participation in the programs at the Community Center is a privilege that can and will be revoked if your child refuses to adhere them.

1.      Child must be signed in and out (first and last name) with time   of arrival and departure next to their name.
2.      Foul and abusive language will NOT be tolerated.
3.      Absolutely NO smoking or drinking in or around the Community Center building or grounds
4.      Fighting, vandalism, abuse, or misuse of the centers facilities and equipment will revoke your privilege to re-enter the center and you may face possible consequences.
5.      All supplies and use of equipment will require signing a responsibility and use form.
6.      All participants will clean up after themselves. General Room Cleanup will be shared.
7.      We require parents to BE ON TIME picking up children from programs & activities.

We have read the following set of rules:


_______________________________                 ____________________________
Child’s Signature                                                       Parents Signature


______________________________                  ___________________________
Date                                                                Date









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Rochester Town Hall - 50 Scenic Road, PO Box 65, Accord, NY 12404
Phone: (845) 626-7384    Fax: (845) 626-3702    Hours: 8:30am - Noon, 1:00pm - 4:00pm
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