DYS Adventure Awaits Program Registration Form

The DYS Adventure Awaits Program provides an engaging, educational, and fun experience for children entering grades 4 - 8 in Greater Danbury.

All sessions are Full Day and run 9:00 am - 5:00 pm.

$150 per week

FREE Breakfast & Lunch will be provided.

○ STEM Education: Participants will engage in hands-on learning with weekly STEM activities that encourage problem-solving and critical thinking skills.

○ Sports & Recreation: Youth will participate in activities such as soccer and basketball to foster physical fitness and teamwork.

○ Community Service: Participants will understand the importance of giving back to their community through meaningful service projects.

○ Field Trips: Weekly trips to local attractions will broaden the children's learning experience.

○ Bike Refurbishing: Youth will refurbish bicycles, learning practical skills and contributing to the community.

Questions?

Please contact Nina Quqa, Program Coordinator

(c) 203.947.8534

(o) 203.748.2936 ext. 109

nquqa@danburyyouthservices.org

Participant Information

Participant Name*

First NameLast Name

Birth Date*

MonthDayYear

Participant Age*

School attending next year*

Grade as of next school year*

Gender*

Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code

Ethnicity*

Race*

Free/Reduced Meals*

Parent/Guardian Information

Parent/Guardian 1 Name*

First NameLast Name

Cell Number*

Area CodePhone Number

Home Number

Area CodePhone Number

E-mail*

Relationship to Child*

Parent/Guardian 2 Name

First NameLast Name

Cell Number

Area CodePhone Number

Home Number

Area CodePhone Number

E-mail

example@example.com

Relationship to Child

Emergency Contact Information

Emergency Contact Name*

First NameLast Name

Cell Number*

Area CodePhone Number

Relationship to Child*

Are there any drop off/pick up contact names to add on file? If yes, please name.

Does the child have any allergies, asthma or medical conditions? If yes, please describe.

Does the child take any medications? If yes, please list.

If your child has any allergies, asthma or other medical conditions or takes any medications, an Authorization for the Administration of Medication form will be emailed to you. Please complete and return to DYS by the start of the program.

Informed Consent and Acknowledgement

Parent Statement of Understanding - Behavioral Agreement

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature*

Please select the weekly sessions that your child will attend:

WEEK 1: June 29 - July 2 $150.00

Introduction to Teamwork & Fitness (The program will not run on Friday, July 3rd)

WEEK 2: July 6 - July 10 $150.00

STEM Exploration & Problem Solving

WEEK 3: July 13 - July 17 $150.00

Community Engagement & Service

WEEK 4: July 20 - July 24 $150.00

Team Building

WEEK 5: July 27 - July 31 $150.00

Environmental Responsibility & STEM

WEEK 6: August 3 - August 7 $150.00

Field Trip Exploration & Discovery

WEEK 7: August 10 - August 14 $150.00

Celebration & Reflection

Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Cancellation Policy

IF YOU PAY FOR WEEKLY SESSION(S) AND YOUR CHILD IS UNABLE TO ATTEND, YOU MUST NOTIFY DYS ATLEAST 7 BUSINESS DAYS BEFORE THE CHILD'S START DATE FOR REIMBURSEMENT. IF YOUR CHILD IS EXPELLED FROM THE PROGRAM FOR MISBEHAVIOR, THERE WILL NOT BE A REIMBURSEMENT.

DYS Adventure Awaits Registration