girls science siesta -...

DeKalb County 1350 W. Prairie Drive Sycamore, IL 60178

Telephone 815-758-8194 FAX 815-758-8199

February 2018

Dear Student:

We are happy to know that you are interested in joining us at our “Girls Science Siesta.” Science Siesta will take place on Friday and Saturday, April 13 & 14 at the Discovery Center

Children’s Museum in Rockford, IL. We are expecting up to 100 fourth, fifth and sixth grade

girls from throughout northern Illinois to attend this program!

At this event, we will be enjoying an action-packed overnight. Together we will: learn about

careers in science, do hands-on experiments, try out neat exhibits at the Discovery Center

Children’s Museum and have lots of fun.

Enclosed is some information to share with your parents. Please note that items 1-5 must be returned to the DeKalb County Extension Office, 1350 W. Prairie Drive, Sycamore, IL 60178 by Friday, March 30th.

1. Registration form: This form, along with a check made payable to University of Illinois Extension should be mailed to the address on the registration form no later than

Friday, March 30. The registration fee is $40.

2. Registration for this event is limited. After we have received 100 completed

registration forms along with payment, registration will be closed.

3. Youth Emergency Medical Information Form & Agreement to Assume Risk Form (Due by Friday, March 30 date of the program, please notify the staff at registration if

medical information changes.)

4. Behavior Guidelines (2 copies): Read through the behavior guideline and consequence

page. This page requires both you and your parent's signature. (Due by Friday, March 30)

5. Consent and Assent Forms: These forms need to be completed and signed so that we

may have permission for participants to complete evaluation instruments on this event.

6. Packing List: This includes suggestions of what to bring with you.

7. Map: Map to the Discovery Center Children’s Museum in Rockford.

8. Schedule: This is a list of what we will be doing during the overnight.

Cancellation policy – Individuals cancelling more than 14 days prior to the event will receive half

of their registration fee. Cancellations made less than 14 days prior to event will not receive

any refunds.

If you or your parents have additional questions regarding this activity, please call Johnna

Jennings at the DeKalb County Extension Office -- 815.758.8194, or email [email protected].

Again, we are really looking forward to Science Siesta and seeing you there!

College of Agricultural, Consumer & Environmental Sciences University of Illinois - U.S. Department of Agriculture • Local Extension Councils Cooperating

University of Illinois Extension provides equal opportunities in programs and employment

mailto:[email protected]

Girls Science Siesta 2018

April 13 & 14 Registration Form (This form must be completed

even if you registered online.)

Name: Address: City/State/Zip: Phone Number: County: Grade Completing in School: Ethnicity: Hispanic or Latino Yes No Race: ______American Indian/Alaskan Native _____Asian ____ Black/African American ______Native Hawaiian/Pacific Islander _____White Some Other Race/Combination E-mail: Parent’s Name: Address: (if different than student’s) City/State/Zip: Phone Number(s) where you can be reached on the days of the event. Phone Number

The registration fee is $40. Payment ($40 check or money order made payable to University of Illinois Extension) and completed registration form must be mailed to: University of Illinois Extension, DeKalb County Office, 1350 W. Prairie Drive, Sycamore, IL 60178. (Registration will be accepted for 160 participants.) Registration includes this form, medical information form and behavior guidelines, assumption of risk, consent and assent forms. Photo and Video Release: I grant the University of Illinois Extension the permission to disclose my (my child’s) identity and to reproduce and distribute videotapes, films, photographs, and transparencies of me (or my child) and sound recordings arising out of Science Siesta. This image (photo or video) may be used in Extension publications or to otherwise promote Extension programs as in posters, audio/video presentations or other displays. The image may also be released to local media to be used in connection with reporting on, promoting, or otherwise publicizing Extension programs.

Participant’s Signature Date Parent/Guardian Signature Date

If you need a reasonable accommodation to participate in this program or have special dietary concerns, please contact Johnna Jennings, University of Illinois Extension Educator at (815) 758-8194.

The program is being conducted by:

College of Agricultural, Consumer & Environmental Sciences United States Department of Agriculture• Local Extension Councils Cooperating


Return this form by Friday, March 30 CONFIDENTIAL

UNIVERSITY OF ILLINOIS EXTENSION YOUTH EMERGENCY MEDICAL INFORMATION

EVENT:___________Girls Science Siesta – April 13 & 14, 2018

PARTICIPANT'S NAME: ______________________________________________________________

Address: ______________________________________________________________________________

Street City State/Zip Code

Age: ____________ Sex: ________________ Date of Birth: __________/________/_________

PARENT/GUARDIAN/OTHIS EMERGENCY CONTACTS:

Name: __________________________________________________________________________________

Relationship

Home Phone: _(______)_________-______________ Work Phone: _(______)_________-______________

Address: ________________________________________________________________________________


Name: __________________________________________________________________________________

Relationship

Home Phone: _(______)_________-______________ Work Phone: _(______)_________-______________

Address: ________________________________________________________________________________


HEALTH INFORMATION STATEMENT

Check below any information you feel staff and/or volunteers may need, to maximize the safety and the well-

being of the participant. To the right of the condition statement is space for more information relating to the

condition checked. Please be specific. In case of emergency, this health information may be the only source

of accurate, important information.

[ ] Nervous or Mental (epilepsy, emotional stress, convulsions) _________________________________

_________________________________________________________________________________

[ ] Lung Disease (asthma, persistent cough, tuberculosis) ______________________________________

_________________________________________________________________________________

[ ] Disease of Heart or Blood Vessels, Increased or Abnormal Blood Pressure______________________

_________________________________________________________________________________

[ ] Pain in Chest or Shortness of Breath (heart murmur, rheumatic fever) _________________________

_________________________________________________________________________________

[ ] Stomach or Intestinal Trouble (ulcers, gall bladder or liver disorder, jaundice, hisnia, colitis)

_________________________________________________________________________________

[ ] Arthritis, Diabetes, Kidney or Bladder Disease ___________________________________________

_________________________________________________________________________________

[ ] Hay Fever or Allergies ______________________________________________________________

_________________________________________________________________________________

[ ] Allergy to Medicines (including penicillin, tetanus) ________________________________________

_________________________________________________________________________________

Return this form by Friday, March 30 CONFIDENTIAL

[ ] Impaired Sight or Hearing, Chronic Ear Infections_________________________________________

_________________________________________________________________________________

[ ] Recent Surgical Operation, Accidents or Injuries__________________________________________

_________________________________________________________________________________

[ ] Any Infectious Disease______________________________________________________________

_________________________________________________________________________________

[ ] Skin Disease_______________________________________________________________________

_________________________________________________________________________________

[ ] Allergy to Foods___________________________________________________________________

_________________________________________________________________________________

[ ] Currently taking Medicines (list names & doses) __________________________________________

_________________________________________________________________________________

Prescription medicines are to be handed in at registration with the exception of rescue inhalers.

[ ] Medication that needs refrigeration ____________________________________________________

_________________________________________________________________________________

[ ] Under on-going care of a Physician (NAME & PHONE #) for chronic or recurring problem

_________________________________________________________________________________

[ ] Do you wear glasses? YES [ ] NO [ ] SOMETIMES [ ]

[ ] Do you wear contact lenses? YES [ ] NO [ ] SOMETIMES [ ]

[ ] Date of last TETANUS BOOSTER____________________________________________________________

[ ] Date of last FLU SHOT _____________________________________________________________________

[ ] Significant Orthopedic and/or Neuromuscular Impairment (e.g. loss of limb, spinal cord injury)

_________________________________________________________________________________________

Primary Care Physician: __________________________________________________________________________

Clinic/Hospital Affiliation: __________________________________________________________________________

City: _________________________________State: ______________Phone: _(____)_____-______________________

Health Insurance Provider: ________________________________________________________________________

Owner's Name: ____________________________________ ID/Policy Number: ______________________________

Medical Privacy Statement: It is the policy of University of Illinois Extension 4-H Youth Development Programs to keep any medical information it

may have regarding 4-H Youth Development program participants confidential. However, there may be time in which such medical information will be needed and may need to be shared with others. Examples of sharing might include: providing information to medical perdaughternel in the event of an

emergency so that a youth may be treated; providing information to Extension staff or volunteers who are coordinating specific events in the case of a

request for reasonable accommodation; and providing information to chaperones or host families who are responsible for the health and safety of program participants at a specific event. Except in the case of emergency, prior to sharing any medical information, it may have with those external to

the University, Extension, or 4-H, every effort will be made to get the permission of the program participant or parent or guardian.

As a parent or guardian, I understand that if a serious illness/injury develops, medical or hospital care will be given.

I further understand that in case of serious illness/injury, I will be notified. However, if it is impossible to contact me,

I give my permission for emergency treatment, x-ray or surgery, as recommended by an attending physician.

I also understand that any accident insurance in effect (IF PROVIDED) for the event, does not cover pre-existing

conditions or self-inflicted injuries.

SIGNED:____________________________________________________ DATE:__________________________

Parent or Guardian

College of Agricultural, Consumer & Environmental Sciences

University of Illinois | U.S. Department of Agriculture | Local Extension Councils Cooperating University of Illinois Extension provides equal opportunities in programs and employment

ASSUMPTION OF RISK AND RELEASE FROM LIABILITY

Youth’s name: ______________________________________(printed)

Agreement to Follow Behavior Guidelines and Safety Polices: I agree that my child and I will fully discuss, and my

child will adhere to, the Youth Behavior Guidelines, Code of Conduct for 4-H Events and any other safety policies

provided to me by 4-H. I understand and agree that 4-H staff have the authority to remove my child from an activity if

the staff determines that my child’s behavior or actions pose a threat to other participants.

Acknowledgement and Assumption of Risks: I understand that 4-H provides for children a wide array of high-risk,

medium-risk and low-risk activities, including, but not limited to: horse- and pony-riding practices and competitions,

shooting sports practices and competitions, 4-H fairs and competitions, day and overnight camps, field trips (some of

which include overnight stays), project workshops and 4-H club meetings. I understand and acknowledge that

participation in 4-H activities carry certain inherent risks and hazards, including, but not limited to, accidents from

shooting sports and equine activities, transportation accidents, the unavailability of immediate or adequate emergency

care, weather-related other environmental hazards, slips and falls, pinches, scrapes, sun burns, twists and jolts. I

understand that these inherent risks and hazards might result in the physical injury (such as scratches, bruises, sprains,

lacerations, fractures, concussions), disability (such as paralysis or other severely debilitating injuries) or death of my

child and the loss of or damage to my child’s personal property. I acknowledge many of these risks cannot fully be

eliminated regardless of the care taken to avoid them. I acknowledge that the University of Illinois neither guarantees the

personal health or safety of my child nor of his/her personal property.

I hereby assert I fully and knowingly assume such risks, hazards and dangers, known or unknown, of my child’s

participation in the 4-H Program and accept all responsibility for losses, costs, injuries and damage my child, my

property, or my child’s property incurs as a result of such participation.

Consent to Treatment: In the event that my child requires medical care while participating in a 4-H activity and no

designated emergency contact (including myself) can be reached, I grant to 4-H the authority to consent to all medical

and/or dental care deemed necessary and to provide to medical personnel the UI Extension 4-H Program Youth

Emergency Medical Information form with all pertinent medical and health information about my child. This consent

expires when my designated emergency contact can be reached. I understand I, and not the University of Illinois, will be

solely responsible for paying any bills, co-payments and deductibles associated with such care and treatment.

Waiver, Indemnification and Hold Harmless: In consideration of my child’s participation in this 4-H activity, I do

hereby release, waive, discharge, and covenant not to sue the Board of Trustees of the University of Illinois and its

respective officers, employees, and agents for any and all claims including those which result in personal injury,

accidents or illnesses (including death), and property loss arising from, but not limited to, participation in the 4-H

activities on behalf of myself and my child, heirs, personal representatives or assigns. I agree to INDEMNIFY AND

HOLD the Board of Trustees of the University of Illinois HARMLESS from any and all claims, actions, suits,

procedures, costs, expenses, damages and liabilities, including attorney’s fees, brought as a result of my child’s

involvement in the 4-H activity and to reimburse it for any such expenses incurred.

Acknowledgment of Understanding: I have read this entire document, fully understand its terms, and understand

that, by signing it, I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the

agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all

liability to the greatest extent allowed by law.

__________________________________________ ____________________________________

Signature of Parent of Minor (under 18) Date Signature of Participant Date

Approved as to Legal Form by the Office of University Counsel – LTI – 8/2016

College of Agricultural, Consumer & Environmental Sciences University of Illinois | U.S. Department of Agriculture | Local Extension Councils Cooperating


University of Illinois Extension Code of Conduct for 4-H Events & Activities

ALL participants in events and/or activities planned, conducted, and supervised by the University of Illinois Extension and 4-H, are responsible for their conduct to U of I Extension personnel and/or volunteers supervising the events. This responsibility is necessary for the health, safety, and welfare of the participants, and will be rigidly adhered to and uniformly enforced. The following conduct is not allowed while participating in any 4-H event or activity and is subject to disciplinary action:

Category 1

a) Possession, use or distribution of alcohol and other drugs, including tobacco products*

b) Theft or destruction of public or private property c) Involvement in sexual misconduct or harassment d) Possession or use of dangerous weapons or materials (including fireworks) e) Fighting or other acts of violence that endanger the safety of the participant or

others Category 2

a) Willfully breaking curfew b) Unauthorized use of vehicles c) Leaving the site of the event d) Participation in gambling e) Absence from the planned program f) Intentionally interfering with or disrupting the event g) Use of profane or abusive language h) Disregard for public or personal property i) Public displays of affection or inappropriate actions j) Failure to comply with direction of Extension personnel, including designated

adults acting within their duties and guidelines * Prescription drugs must be listed on an Emergency Medical Information form. Consequences: The University of Illinois Extension reserves the right to restrict participation in future activities for those individuals who have been removed from an activity for behavior, as outlined in Category 1 or Category 2. In all cases, the participant will be responsible for restitution of any damages incurred by his/his actions.

Event/Coordinator Copy Return this form by Friday, March 30

Category 1: 1. When notified of any of the actions listed under Category 1, the adult in charge, will

ascertain the relevant facts, and with concurrence from the U of I Extension staff, will notify the affected participant of the action and any supporting evidence. The participant will be allowed an opportunity to answer the allegations and, if necessary, law enforcement officials will be notified. While facts are being verified, the participant will be removed from the 4-H activity/event and be under direct supervision of an adult chaperon.

2. The parent of guardian will be notified of the actions of the participant, and upon finding

the allegations to be true, must immediately remove the participant from the activity at the parent’s or guardian’s expense.

3. Documentation must be completed on an “Incident Report Form.” Category 2: 1. When notified of any of the actions listed under Category 2, the adult in charge, will

ascertain the relevant facts, and, with concurrence from the U of I Extension staff, will notify the participant of the action and any supporting evidence. The participant will be allowed an opportunity to answer the allegations and, if necessary, law enforcement officials will be notified. While facts are being verified, the participant will be removed from the 4-H activity/event and be under direct supervision of an adult chaperon.

2. The parent or guardian of the participants who violate curfew, use vehicles without

authorization or leave the site of the event (as outlined in Category 2, letters a, b, c) will be notified of the actions by the participant. The parent or guardian must immediately remove the participant from the activity, at the parent’s or guardian’s expense. Participants who willfully disobey conduct as described Category 2, letters d-j, will receive a verbal and written warning (initialed by the adult and the participant). Upon receiving a second warning, the parent or guardian will be notified of the behavior and must make arrangements for removal of the participant from the activity, at the parent’s or guardian’s expense.

“We understand and accept the responsibility for following the “Code of Conduct” for this 4-H event or activity. We further understand that failure to do so will result in disciplinary action as outlined above and forfeiture of any participant’s fees.” Signature of Participant Date Signature of Parent/Guardian Date

Note: Failure to have two bonafide signatures above shall be sufficient reason to

disqualify the participant from this activity or event.

Two copies of this form must be signed. One copy shall be returned to the Event Coordinator and one copy shall be kept by the parent/guardian.

Return this form by Friday, March 30 Event/Coordinator Copy

University of Illinois Extension Code of Conduct for 4-H Events & Activities

ALL participants in events and/or activities planned, conducted, and supervised by the University of Illinois Extension and 4-H, are responsible for their conduct to U of I Extension personnel and/or volunteers supervising the events. This responsibility is necessary for the health, safety, and welfare of the participants, and will be rigidly adhered to and uniformly enforced. The following conduct is not allowed while participating in any 4-H event or activity and is subject to disciplinary action:

Category 1

a) Possession, use or distribution of alcohol and other drugs, including tobacco products*

b) Theft or destruction of public or private property c) Involvement in sexual misconduct or harassment d) Possession or use of dangerous weapons or materials (including fireworks) e) Fighting or other acts of violence that endanger the safety of the participant or others

Category 2

a) Willfully breaking curfew b) Unauthorized use of vehicles c) Leaving the site of the event d) Participation in gambling e) Absence from the planned program f) Intentionally interfering with or disrupting the event g) Use of profane or abusive language h) Disregard for public or personal property i) Public displays of affection or inappropriate actions j) Failure to comply with direction of Extension personnel, including designated adults

acting within their duties and guidelines * Prescription drugs must be listed on an Emergency Medical Information form. Consequences: The University of Illinois Extension reserves the right to restrict participation in future activities for those individuals who have been removed from an activity for behavior, as outlined in Category 1 or Category 2. In all cases, the participant will be responsible for restitution of any damages incurred by his/his actions.

Parent/Guardian Copy Keep this copy for your files.

Category 1: 1. When notified of any of the actions listed under Category 1, the adult in charge, will ascertain

the relevant facts, and with concurrence from the U of I Extension staff, will notify the affected participant of the action and any supporting evidence. The participant will be allowed an opportunity to answer the allegations and, if necessary, law enforcement officials will be notified. While facts are being verified, the participant will be removed from the 4-H activity/event and be under direct supervision of an adult chaperon.

2. The parent of guardian will be notified of the actions of the participant, and upon finding the

allegations to be true, must immediately remove the participant from the activity at the parent’s or guardian’s expense.

3. Documentation must be completed on an “Incident Report Form.” Category 2: 1. When notified of any of the actions listed under Category 2, the adult in charge, will ascertain

the relevant facts, and, with concurrence from the U of I Extension staff, will notify the participant of the action and any supporting evidence. The participant will be allowed an opportunity to answer the allegations and, if necessary, law enforcement officials will be notified. While facts are being verified, the participant will be removed from the 4-H activity/event and be under direct supervision of an adult chaperon.

2. The parent or guardian of the participants who violate curfew, use vehicles without authorization

or leave the site of the event (as outlined in Category 2, letters a, b, c) will be notified of the actions by the participant. The parent or guardian must immediately remove the participant from the activity, at the parent’s or guardian’s expense. Participants who willfully disobey conduct as described Category 2, letters d-j, will receive a verbal and written warning (initialed by the adult and the participant). Upon receiving a second warning, the parent or guardian will be notified of the behavior and must make arrangements for removal of the participant from the activity, at the parent’s or guardian’s expense.

“We understand and accept the responsibility for following the “Code of Conduct” for this 4-H event or activity. We further understand that failure to do so will result in disciplinary action as outlined above and forfeiture of any participant’s fees.” Signature of Participant Date Signature of Parent/Guardian Date

Note: Failure to have two bonafide signatures above shall be sufficient reason to disqualify the

participant from this activity or event. Two copies of this form must be signed. One copy shall be returned to the Event Coordinator and one copy shall be kept by the parent/guardian.

Parent/Guardian Copy Keep this copy for your files.

DeKalb County University of Illinois Extension

1350 W. Prairie Drive Sycamore, IL 60178

Telephone 815-758-8194 FAX 815-758-8199

Science Siesta Parent Consent Form

Dear Parent/Guardian:

In order to determine the effectiveness of this program, we invite your daughter to participate in a research project comprised of a short pre-test, post-test, and program evaluation. We estimate that each research instrument will take 5 minutes or less to complete, requiring a total of 15 minutes of your daughter’s time overall. Time to complete the instruments has been built right into the event schedule, so participation in program research will not require your daughter to arrive early or stay past the regular start and stop times, nor will it mean that she will miss out on any of the fun. This research will assist us in improving our offerings to youth like your daughter.

Your daughter’s participation in this research project is completely voluntary. In addition to your permission, your daughter will also be asked if she would like to take part in this evaluation. Only those youth who have parental permission and who want to participate will do so. Any youth may stop taking part at any time. You are free to withdraw your permission for your daughter’s participation at any time and for any reason without penalty. If your daughter decides that she does not wish to participate, it will not affect her participation in this or future University of Illinois Extension programs. If your daughter does not want to answer some or the questions on the research instruments, it is okay. In order to match your daughter’s responses from the pre-test and post-test, she will be assigned a code number that will discreetly appear on her name tag. She will enter that code number on her tests. Once the post-test has been completed, the list connecting your daughter’s name with the code number will be destroyed. Therefore, your daughter’s responses will be anonymous.

We believe that this research project presents no greater risks than those we all face in everyday life. The information that is obtained during this evaluation will be kept strictly confidential and will not become part of your daughter’s record. Any sharing or publication of the research results will not identify any of the participants by name. On the enclosd forms, please indicate whether you do or do not want your daughter to participate in the research project and return this letter with her Science Siesta registration packet by March 30. Please keep a second copy of this letter for your records.

If you have any questions about this program, please contact me. If you have any questions about your rights as a participant in research involving human subjects, please feel free to contact the University of Illinois Institutional Review Board (IRB) Office at 217.333.2670 or [email protected]. You are welcome to call these numbers collect if you identify yourself as a research participant.

Sincerely,

Johnna Jennings Extension Unit Educator, 4-H Youth Development 1350 W. Prairie Drive, Sycamore, IL 60178 Phone 815-758-8194; Email: [email protected]



PARENT CONSENT FOR PARTICIPATION ON APRIL 13 & 14, 2018

Youth’s Name (print):

I do / I do not (circle one) give permission for my child to participate in this study.

I understand what participation means and that my child is free to stop at any time.

A signed copy of this form is mine to keep.

Parent or Guardian’s Name (print):

____________________________________________________

Parent or Guardian’s Signature: ______________________________________

Date____________

Please keep a copy of this letter for your records.

Return a copy of this letter with your child’s Science Siesta Registration forms by

March 30th.




Telephone 815-758-8194 FAX 815-758-8199

Science Siesta Parent Consent Form

Dear Parent/Guardian:

In order to determine the effectiveness of this program, we invite your daughter to participate in a research project comprised of a short pre-test, post-test, and program evaluation. We estimate that each research instrument will take 5 minutes or less to complete, requiring a total of 15 minutes of your daughter’s time overall. Time to complete the instruments has been built right into the event schedule, so participation in program research will not require your daughter to arrive early or stay past the regular start and stop times, nor will it mean that she will miss out on any of the fun. This research will assist us in improving our offerings to youth like your daughter.

Your daughter’s participation in this research project is completely voluntary. In addition to your permission, your daughter will also be asked if she would like to take part in this evaluation. Only those youth who have parental permission and who want to participate will do so. Any youth may stop taking part at any time. You are free to withdraw your permission for your daughter’s participation at any time and for any reason without penalty. If your daughter decides that she does not wish to participate, it will not affect her participation in this or future University of Illinois Extension programs. If your daughter does not want to answer some or the questions on the research instruments, it is okay. In order to match your daughter’s responses from the pre-test and post-test, she will be assigned a code number that will discreetly appear on her name tag. She will enter that code number on her tests. Once the post-test has been completed, the list connecting your daughter’s name with the code number will be destroyed. Therefore, your daughter’s responses will be anonymous.

We believe that this research project presents no greater risks than those we all face in everyday life. The information that is obtained during this evaluation will be kept strictly confidential and will not become part of your daughter’s record. Any sharing or publication of the research results will not identify any of the participants by name. On the enclosed forms, please indicate whether you do or do not want your daughter to participate in the research project and return this letter with her Science Siesta registration packet by March 30. Please keep a second copy of this letter for your records.

If you have any questions about this program, please contact me. If you have any questions about your rights as a participant in research involving human subjects, please feel free to contact the University of Illinois Institutional Review Board (IRB) Office at 217.333.2670 or [email protected]. You are welcome to call these numbers collect if you identify yourself as a research participant.

Sincerely,

Johnna Jennings Extension Unit Educator, 4-H Youth Development 1350 W. Prairie Drive, Sycamore, IL 60178 Phone 815-758-8194; Email: [email protected]

Keep this copy for your file



PARENT CONSENT FOR PARTICIPATION ON APRIL 13 & 14, 2018


I do / I do not (circle one) give permission for my child to participate in this study.

I understand what participation means and that my child is free to stop at any time.

A signed copy of this form is mine to keep.

Parent or Guardian’s Name (print):

____________________________________________________

Parent or Guardian’s Signature: ______________________________________

Date____________



March 30th.

Keep this for your file.



Telephone 815-758-8194 FAX 815-758-8199

Science Siesta Youth Assent Form

Dear Science Siesta Participant: Hi! I am from the University of Illinois Extension, and as a Science Siesta committee member, I wanted to let you know how pleased we are to have the opportunity to provide you with this educational experience. During this program, you will have the opportunity to learn more about science and science related careers. You will meet a variety of scientists from the northwestern Illinois area, and you will learn about the work of some specific scientists during hands-on workshops based on the “Wonderwise” science curriculum. So that we may determine the effectiveness of this program, we invite you to participate in a research project by completing a short pre-test, a short post-test, and a simple program evaluation. Time has been built into the Science Siesta schedule for you to complete them, so you will not have to come early or stay after the event to participate, nor will you miss out on any of the fun. Each research instrument is expected to take you five minutes or less to complete, which means that no more than 15 total minutes of your time will be required. Even if your parent or guardian has given permission for you to participate in this research project, your participation is voluntary. This means that you are free to decide whether or not you want to participate. If you want to stop completing the tests or program evaluation at any time, you can stop. There aren’t any risks from participating, other than those you’d find in everyday life. If you choose not to participate in this research project or decide to stop partway through, there is no penalty to you. Your participation in future U of I Extension programs will not be affected in any way. All pre-tests, post-tests, and program evaluations will be kept private and confidential. Only members of our research team will see them, and they will be destroyed after the study finished. Any publications we make from this project will not identify you, but will only report general results. If you have any questions about this program, please contact me. If you have any questions about your rights as a participant in research involving human subjects, please contact the University of Illinois Institutional Review Board (IRB) Office at 217.333.2670 or [email protected]. You are welcome to call this number collect as long as you identify yourself as a research participant. On the enclosed forms, please indicate whether you do or do not want to participate in the research and return a copy of this letter with your registration packet by March 30. Please keep a second copy of this form for your records. Sincerely, Johnna Jennings Extension Unit Educator, 4-H Youth Development 1350 W. Prairie Drive, Sycamore, IL 60178 Phone 815-758-8194; Email: [email protected]




YOUTH ASSENT FOR PARTICIPATION ON APRIL 13 & 14, 2018


I do / I do not (circle one) voluntarily agree to participate in this study. I

understand what participation means and that I am free to stop at any time. A

signed copy of this form is mine to keep.

Participant’s Name (print): ____________________________________________________

Participant’s Signature: ______________________________________ Date____________



March 30th.




Telephone 815-758-8194 FAX 815-758-8199

Science Siesta Youth Assent Form

Dear Science Siesta Participant: Hi! I am from the University of Illinois Extension, and as a Science Siesta committee member, I wanted to let you know how pleased we are to have the opportunity to provide you with this educational experience. During this program, you will have the opportunity to learn more about science and science related careers. You will meet a variety of scientists from the northwestern Illinois area, and you will learn about the work of some specific scientists during hands-on workshops based on the “Wonderwise” science curriculum. So that we may determine the effectiveness of this program, we invite you to participate in a research project by completing a short pre-test, a short post-test, and a simple program evaluation. Time has been built into the Science Siesta schedule for you to complete them, so you will not have to come early or stay after the event to participate, nor will you miss out on any of the fun. Each research instrument is expected to take you five minutes or less to complete, which means that no more than 15 total minutes of your time will be required. Even if your parent or guardian has given permission for you to participate in this research project, your participation is voluntary. This means that you are free to decide whether or not you want to participate. If you want to stop completing the tests or program evaluation at any time, you can stop. There aren’t any risks from participating, other than those you’d find in everyday life. If you choose not to participate in this research project or decide to stop partway through, there is no penalty to you. Your participation in future U of I Extension programs will not be affected in any way. All pre-tests, post-tests, and program evaluations will be kept private and confidential. Only members of our research team will see them, and they will be destroyed after the study finished. Any publications we make from this project will not identify you, but will only report general results. If you have any questions about this program, please contact me. If you have any questions about your rights as a participant in research involving human subjects, please contact the University of Illinois Institutional Review Board (IRB) Office at 217.333.2670 or [email protected]. You are welcome to call this number collect as long as you identify yourself as a research participant. On the enclosed forms, please indicate whether you do or do not want to participate in the research and return a copy of this letter with your registration packet by March 30. Please keep a second copy of this form for your records. Sincerely, Johnna Jennings Extension Unit Educator, 4-H Youth Development 1350 W. Prairie Drive, Sycamore, IL 60178 Phone 815-758-8194; Email: [email protected]




YOUTH ASSENT FOR PARTICIPATION ON APRIL 13 & 14, 2018


I do / I do not (circle one) voluntarily agree to participate in this study. I

understand what participation means and that I am free to stop at any time. A

signed copy of this form is mine to keep.

Participant’s Name (print): ____________________________________________________

Participant’s Signature: ______________________________________ Date____________



March 30th.


Things to Pack —

Pillow

Sleeping bag or sheets + blanket

Soap, Wash Cloth and/or Towel - if you want to wash up (no showers are available)

Comfortable clothes (pajamas for sleeping and casual clothes for event, etc.)

Comfortable shoes

Contact lenses + supplies

Glasses

Hair brush/comb

Prescription medicines (to be handed in at registration with the exception of

rescue inhalers)

Sleeping mat (optional but floors are very hard)

Things Not to Pack —

Non-prescription medicines/drugs

Snacks

Alcohol

Tobacco

Money

Electronic devices (i.e. iPads, cell phones, computers, etc.)

Matches, lighters or candles

Weapons

Flashlight

Discovery Center Children’s Museum 711 N. Main Street

Rockford, IL 61103

Assuming no construction or detours:

From East:

Exit I-90 at the Rockford-Business 20 (State Street) exit going west. Follow Business 20/State

Street approximately 7 miles until you reach Rockford’s downtown area. Watch for the

intersection of State Street and Jefferson Street, an Amoco/McDonalds gas station will mark

the intersection. Turn right on Jefferson Street, a one-way street, and follow it across the Rock

River. One block beyond the river is the intersection of Jefferson and Wyman. Turn right onto

Wyman, Left at Park, then Right on North Main, staying in the right lane, to Discovery Center

Museum, located in Riverfront Museum Park at 711 North Main Street.

From North:

Once in Rockford, head south on Highway 251, take the Whitman Street Bridge exit. After the

bridge, turn left on Church, a few blocks south make a left on Locust, make the next left on to

North Main St. move to the right lane, to Discovery Center Museum, located in Riverfront

Museum Park, 711 North Main Street.

From West:

Follow Bypass 20 around Rockford to the South Main/Illinois 2 exit. Exit north onto South Main

and follow this road through the downtown area. The road will flow right and around a plaza and

direct you along Wyman Street. Wyman jogs left around Beattie Park and becomes Park Street.

Turn right at the light onto North Main Street. Discovery Center is two blocks north on the

right side of the road in Riverfront Museum Park, 711 North Main Street.

From South:

Take I-39 to Bypass 20 West exit. Follow Bypass 20 West around Rockford to South

Main/Illinois 2. Exit north onto South Main and follow it through the downtown area of Rockford.

It will flow around a plaza and direct you along Wyman Street. Wyman jogs left around Beattie

Park and becomes Park Street. Turn right at the light onto North Main Street. Discovery Center

is two blocks north on the right side of the road in Riverfront Museum Park, 711 North Main

Street.

Tentative Schedule

Time Activity

5-5:30 p.m.

5:15-5:30 p.m.

Arrival-Registration at Discovery Center

Pizza

6:10-7:50 p.m. Welcome-Meet REAL Scientists

8:00-9:00 p.m. Hands-on workshop sessions based upon choice

9:00-9:15 p.m. Snack

9:15-9:30 p.m. Select Sleeping Assignment

9:30-11:00 p.m. Fun activities at the museum

11:00-11:30 p.m. Quiet time & go to bed

7-7:30 a.m. Awake, Packing time

7:30 a.m. Breakfast/Wrap-Up

8:30 a.m. Homeward Bound (Depart from Discovery Center)

girls science siesta -...

Documents