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Loveland Youth Gardeners 306 North Washington #101 ♥ Loveland, Colorado 80537 ♥ 970-‐669-‐7182 www.LovelandYouthGardeners.org 2015 YOUTH GARDENING PROGRAM APPLICATION: Student Section
DUE: MAY 1th, 2015
**Student, Please Complete and Sign this Section
NAME _______________________________________________________________________ AGE __________ DATE OF BIRTH _________________________ ADDRESS _____________________________________________________________________________________________ ZIPCODE _________________________ PHONE NUMBER _______________________________ EMAIL________________________________ SCHOOL ________________________________________ GRADE _________________ RESOURCE/ESS/OTHER TEACHER __________________________________________________________________________ TEACHER PHONE ______________________________________ TEACHER EMAIL _______________________________________________________________ DO YOU LIVE WITH YOUR PARENTS? yes or no If no, give the name of the person with whom you live and their relationship to you. ______________________________________________________________________________________________________________________ TELL US WHY YOU WANT TO WORK WITH LOVELAND YOUTH GARDENERS THIS SUMMER: __________________________________ _______________________________________________________________________________________________________________________________________________ HAVE YOU EVER WORKED IN A GARDEN BEFORE? yes or no IS THIS YOUR FIRST JOB? yes or no If no, what other jobs have you had _________________________________________________________________________________________________________________________ Do you have any volunteer experience? _________________________________________________________________________________________________ WHAT SKILLS OR PERSONAL STRENGTHS WILL YOU CONTRIBUTE? (Example: hard worker, work well with others, good ideas, physical strength, positive leader) _________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ The Youth Gardening Program of Loveland Youth Gardeners teaches organic gardening and job skills to
teenagers (ages 13-18) who have extra challenges in their lives. A typical week includes: working in the garden,
written assignments, class time learning different aspects of gardening, group discussions, field trips and guest
speakers. Please read and review the following information with your parent or guardian.
You may earn school credit (science, work-study or a combination) if you have an IEP, or community service credit,
and a monetary bonus when you complete the program. Earning credit and money depends on how well you do
with your job tasks and class assignments. In addition, you can keep the produce you grow in your own garden. We
grow “community” vegetables, which we donate to House of Neighborly Service and Food Bank of Larimer County
for Loveland Plant A Row For The Hungry.
Student Name __________________
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EXPECTATIONS
BELOW IS A LIST OF THE EXPECTATIONS OF ALL PARTICIPANTS. PLEASE READ THE
INFORMATION, MAKE A COPY FOR YOURSELF, AND SIGN AT THE BOTTOM OF THE PAGE.
YOUR SIGNATURE SHOWS THAT YOU UNDERSTAND, AND AGREE TO FOLLOW THE RULES
AND EXPECTATIONS OF THE PROGRAM.
ACADEMIC REQUIREMENTS
♦
♦
♦
♦
♦
Daily participation in all work duties
Daily participation in all group activities and discussions
Completion of all journal assignments
Completion of all homework assignments and tests
Completion of final project
IN ORDER TO RECEIVE FULL ACADEMIC CREDIT, YOU MUST COMPLETE ALL ACADEMIC
REQUIREMENTS, AND YOU MAY NOT MISS MORE THAN THREE DAYS OF THE PROGRAM. IF
YOU MISS MORE THAN THREE DAYS, YOU MAY EARN PARTIAL CREDIT.
BEHAVIORAL EXPECTATIONS
♦ On-time daily attendance and compliance with all rules, work requirements, and safety practices
♦ Respectful and cooperative attitude toward staff and co-workers
♦ Appropriate dress/supplies for gardening (this includes: sturdy, closed-toe shoes, water bottle, sunscreen, hats or
other head covering)
3-STRIKES
LOVELAND YOUTH GARDENERS HAS A THREE-STRIKE POLICY. IF YOU EARN THREE
"STRIKES" YOU WILL BE TERMINATED FROM THE PROGRAM. EXAMPLES OF STRIKES
INCLUDE: SWEARING, REPEATED ABSENCES OR TARDIES, AGGRESSIVE BEHAVIOR,
CHEATING, REPEATED INAPPROPRIATE DRESS, BRINGING CIGARETTES, DRUGS, OR
ALCOHOL TO THE GARDEN/PROGRAM, OR OTHER UNSAFE OR INAPPROPRIATE SITUATIONS.
PARENTS WILL BE NOTIFIED IF A STUDENT HAS RECEIVED A STRIKE.
I UNDERSTAND THE REQUIREMENTS AND EXPECTATIONS OF LOVELAND YOUTH GARDENERS,
AND AGREE TO FOLLOW THESE TO THE BEST OF MY ABILITY.
STUDENT SIGNATURE
DATE
PARENT/GUARDIAN SIGNATURE
DATE
Student Name __________________
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Loveland Youth Gardeners 2015 YOUTH GARDENING PROGRAM APPLICATION: Parent/Guardian Section
-Please read carefully-
Dear Parent/Guardian,
Loveland Youth Gardeners, Inc. is a nonprofit organization focused on youth development. The Youth Gardening
Program is designed to teach organic gardening, job and life skills and to develop a sense of volunteerism to students identified
as at-risk, and/or with special needs. Although there will be strenuous work required, your teen will not be operating any
machinery and will be supervised by 2 or more adults. Please complete this section in order for your teen to participate.
There are 2 Saturdays we ask parents/guardians to attend with their teen. The first is Planting Day May 16 from 9am12pm, and the second is Harvest Day August 15, 9-12pm. Your signature indicates that you understand and will support
the rules and expectations of the program.
TEEN NAME______________________________ PARENT/GUARDIAN NAME__________________________
E-MAIL___________________________________ PHONE NUMBERS (H)_________________________________
(W)____________________ (Cell)__________________ BEST NUMBER TO REACH YOU __________________
ADDRESS________________________________________________________________________________________
EMERGENCY CONTACT (NAME & NUMBER): ___________________________________________________
IS YOUR TEEN PRESENTLY IN GOOD PHYSICAL HEALTH? _______________________________________
DATE OF LAST TETANUS SHOT ______________________
LIST ANY HEALTH PROBLEMS OR ALLERGIES (EG bee stings, seizures, etc.) __________________________
__________________________________________________________________________________________________
LIST ANY MEDICATION YOUR TEEN TAKES _____________________________________________________
FOR WHAT CONDITION______________________ AMOUNT_________________ TIME _________________
In the event a student is required to take medication during program hours, it is his/her responsibility to take the
medication on time and in the correct amount. Loveland Youth Gardeners is not responsible for dispensing medication.
NAME OF PHYSICIAN _____________________________________ PHONE #_____________________________
Is your teen currently in the care of a therapist or other mental health professional? ___________________________
NAME OF THERAPIST/COUNSELOR ____________________________________ PHONE #_______________
HEALTH INSURANCE COMPANY_______________________________ POLICY #__________________
DOES YOUR TEEN HAVE ANY HISTORY OF BEHAVIOR OR EMOTIONAL ISSUES (SUCH AS
AGGRESSION, ASSAULT, ATTEMPTED SUICIDE, FIRESETTING OR RUNNING AWAY?) ___________
IF SO, PLEASE DESCRIBE (attach another page if needed) ______________________________________________
__________________________________________________________________________________________________
In case of emergency, & if we are unable to reach you, can we take your teen for medical treatment? _____________
Will your teen have transportation to and from the program each day? (Either by you, bus, bicycle, or another
adult) yes_____ no_______ How? ___________________________________________________________________
Student Name __________________
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Does your family intend to be gone for more than a week this summer? If so, please explain and give dates:
_________________________________________________________________________________________________________________________________________________ There will be some field trips in June, July & August. Do we have your permission to include your teen on these
trips, whether in public or private transportation? Yes_______ No___________
Are you able to help with field trip transportation?
Yes_______ No___________
If so, how many passengers can your vehicle hold? ___________________________
May your teen be photographed and identified by name for publicity purposes? Yes________ No____________
To help us better assist your teen’s needs, please attach their IEP or give us an idea of services they receive in school:
__________________________________________________________________________________________________
***Please review your teen's application with him/her and the expectations of the program***
PAYMENT INFORMATION:
PLEASE ATTACH THE $100 PROGRAM FEE TO THE APPLICATION unless one of the following applies:
(Check if applicable)
Teen qualifies for free lunch __________________ Teen qualifies for reduced lunch _________________
** NOTE: In order to receive the reduced fee, verification of free or reduced lunch, provided by the student’s
school MUST be attached to the application. When received, sliding scale payment will be determined ($10 min).
Program fee or proof of free/reduced lunch is required upon application; the fee will be returned
if your teen is not accepted into the program.
# of Members in Your
Income
Household
1
2
3
4
5
6
7
8
$42,950
$49,100
$55,250
$61,350
$66,300
$71,200
$76,100
$81,000
For the number of members in your household, including you, please tell
us whether the income is above or below the amount given. (This
information is required for funding; your name and any other identifying details
will not be needed or used.)
Above _________
Below _________
I,______________________________________, give permission for my teen, ______________________, to work with Loveland Youth
Gardeners. I understand that s/he will need to attend every day and comply with the academic and behavioral expectations of the program.
While no one expects an accident to occur I nevertheless acknowledge that injury accidents do occur from time to time even when the
greatest of care is taken. While I understand that my teen will be carefully and thoroughly instructed before s/he engages in any activity,
s/he will be directly responsible for his/her own safety. The following describe the physical activities in which my teen will engage and
the implements s/he will use: lifting buckets filled with soil, rock, compost and mulch, pushing a wheelbarrow filled with
rock/compost/soil/mulch, digging weeds, digging holes for plants, using hand trowels, weeding tools and pruning/ sharp cutting tools,
shovels, hoes, rakes, spade forks, and hammers. My teen will also be working with scissors, pencils, markers and paper in written work
during the program. I understand my teen could be immediately dismissed from the program if they exhibit behaviors deemed unsafe or
dangerous to themselves or others. I expect my teen to wholeheartedly participate in these activities and give my permission for her/him
to participate.
In permitting my teen to participate in these activities I forever waive and release and agree to indemnify and hold harmless Loveland
Youth Gardeners (their staff, volunteers, sponsors and administrators), First United Methodist Church and Thompson School District,
from any and all claims I or my teen may have against them, arising out of any and all injuries and or losses sustained by me or my teen
during his/her participation in Loveland Youth Gardeners.
PARENT/GUARDIAN SIGNATURE
Student Name __________________
DATE
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YGP APPLICATION CHECKLIST & DATES (please read & sign)
APPLICATION DATES:
·
PLEASE COMPLETE AND RETURN THE ENTIRE APPLICATION BY MAY 1, 2015 TO:
LOVELAND YOUTH GARDENERS (YGP), 306 North Washington Avenue, # 101, Loveland, CO 80537
•
THE FIRST SESSION WILL BE MONDAY, MAY 11, 4-6pm. THIS IS AN INTERVIEW AND ALL
APPLICANTS MUST ATTEND IN ORDER TO BE CONSIDERED FOR THE PROGRAM.
•
You will be called by May 12th regarding acceptance into the program.
PLEASE MARK YOUR CALENARS WITH THE FOLLOWING 2015 REQUIRED PROGRAM DATES & TIMES:
•
Monday May 11, 4:00-6:00pm; (Student Interview/Orientation)
•
Saturday May 16, 9:00-12:00pm; (Orientation & Planting) --Students & Parents/Guardians
•
After-school workdays in May:
o Wednesday May 13th, 3:30-5:30pm
o Tuesday May 19th, 3:30-5:30pm
o Thursday May 21st, 3:30-5:30pm
•
Main Program: Monday June 1 through Thursday August 13: Mondays, Tuesdays, Wednesdays, &
Thursdays 9am-12pm
•
Saturday June 6, 9:00-11:00am at Benson Sculpture Park (Clean Up Day)
•
Saturday, June 20, 8:00am –2:30pm; (Loveland Garden Tour-- We will have several shifts)
•
Thursday, July 30, 8:00am-12:30pm; (Larimer County Fair)
•
Saturday, August 15, 9:00am-12:00pm; (Harvest Day!) --Students & Parents/Guardians
•
Help with the gardens (including watering & harvesting) will also be required
YOUR SIGNATURES INDICATE THAT YOU HAVE READ AND UNDERSTAND THE YGP DATES
___________________________________________________
__________________________________________________________
STUDENT SIGNATURE
PARENT/GUARDIAN SIGNATURE
DATE
DATE
APPLICATION CHECKLIST: Please make sure all of the following are completed & attached
Student Application (read, filled out, signed)
Program Fee or Free OR Reduced Lunch Voucher
Parent Form (read, filled out & signed)
Student & Parent Signed Required Dates
Release of Information Form (read & signed)
Send or Deliver Completed Form BY MAY 1, 2015
Loveland Youth Gardeners, 306 North Washington Avenue, # 101, Loveland, CO 80537
Student Name __________________
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Loveland Youth Gardeners
306 North Washington Street #101 ♥ Loveland, Colorado 80537
www.LovelandYouthGardeners.org ♥ 970-669-7182
RELEASE OF INFORMATION FORM
In order to help my child be successful while participating with Loveland Youth Gardeners,
I, ___________________________________, give permission
(your name)
for Loveland Youth Gardeners to obtain relevant information about my child __________________ from
(name of child or teen)
his/her teacher_____________________ and/or mental health professional ______________________.
(name of teacher)
(name of mental health professional)
This information may include:
•
•
•
•
Individualized Education Plan (IEP) goals, areas of need, & transition skills
Pertinent medical history and current information
Criminal background information
Behavioral patterns and effective methods for working with these behaviors
I also give my permission to share this information with Loveland Youth Gardeners staff and volunteers
when needed, to help my child/teen be successful while participating in one or more of the Youth Education
Programs.
Signature
Date
Student Name __________________
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