Camp Guide and Forms

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Ages 6-12
Camps held Mondays - Fridays:
June 13-17, June 20-24
August 8-12, August 15-19
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The Sentara RMH Wellness Center is conveniently located at
2500 Wellness Drive, Harrisonburg.
From 81: Take exit 245/Port Republic Road and head west.
At the intersection of South Main Street (Rt.11), turn left.
Travel approximately 2 miles. At the intersection of
South Main/Stone Spring Road, turn left.
Follow this road, make a right onto Beery Road,
take the second left onto Wellness Drive.
The Sentara RMH Wellness Center will be straight ahead.
The Summer Games will prove the ideal destination for kids ages 6 to 12. Campers
will experience a fun peek inside participating countries’ cultures and customs,
through interactive learning, sports and recreation, crafts, and afternoon swimming.
Day and half-day options available. Ask about FREE childcare before and after camp hours.
2500 Wellness Drive • Harrisonburg, VA 22801 • RMHWellnessCenter.com
3/16
Summer Camp
at the Sentara RMH Wellness Center
Ages 6-12
Camps held Mondays - Fridays.
Each week, we focus on a different theme designed to
spark creativity and curiosity.
Let the Games Begin…
June 13-17 “Olympic Heroes”: This week will focus
on fun activities and games around record breaking
athletes and milestones!
June 20-24 “Amazing Amazon”: Campers will take a
virtual ride down the Amazon as we explore the landscape
and wildlife of Brazil.
Aug 8-12 “Rio Carnival”: In Rio de Janeiro tradition,
we will celebrate a week of bright colors and great music.
Aug 15-19 “Go for the Gold!”: Take your mark, get
set and GO. We will transform camp into an Olympic
Village. Campers will learn about the Olympic nations and
participate in daily activities unique to each country.
FULL WEEK OPTION:
Morning camp (9am-12pm):
Register and pay by May 13: $75; after May 13: $85.
Afternoon camp (1pm-5pm):
Register and pay by May 13: $100; after May 13: $110.
Full day (9am-5pm):
Register and pay by May 13: $135; after May 13: $145.
PER DAY OPTION:
Morning camp (9am-12pm): $25
Afternoon camp (1pm-5pm): $35
Full day (9am-5pm): $40
Please refer to refund and registration policies under
Cancellations, Refunds & Late Registration
FREE Before & After Camp Care
Before and after care is available to camp children at no
additional charge, but pre-registration is required.
Please notify us of your desire to use before and after camp
care at the time of registration. Please pick up your child on
time or additional charges may apply.
Before & After Care Hours:
7:30am–9:00am; Noon–1:00pm; 5:00pm–6:00pm
Registration:
Registration and full payment must be received prior to
your child’s start date of camp. Please register by calling
540-564-7200. If the camp forms are not available in this
packet, please request the forms when you register. Please
review and complete all forms and bring them to your child’s
first day of camp. Important: If you print the forms online,
it is still necessary to call 540-564-7200 to complete your
child’s registration.
Cancellations, Refunds & Late Registration
Cancellations and transfer requests must be received
by us within 5 business days prior to the first day of camp in
order to receive a refund or credit to your member account.
Please notify us of your cancellation, by calling 540-5645684. A $5 fee per child will be charged if payment is not
received 2 business days prior to June 13.
What to Bring Everyday
• Lunch
• Sneakers (closed-toe with rubber soles)
• Water bottle
• Book or magazine
• Sunscreen
• Hat
• Hair brush or comb
• Swim suit & water shoes or flip flops
Afternoon & full day campers: Bring each day.
Morning campers: Fridays only
Please put all items in a book bag with your child’s name on
it. Please do NOT bring any toys from home. Thanks!
Policies & Procedures
Drop-Off:
Each morning, please walk your child to the activity
studio room where you will sign them in. If someone other
than the person bringing the child to camp is picking
them up, you must complete a form stating who will be
picking up your child.
Pick-Up:
Guardians must sign the children out with the camp
counselors. For safety reasons, we will not release
any child to an individual not listed on the child’s
camp registration form. It is our policy to ask
for a valid photo identification card if someone other
than the parent/guardian is picking up your child.
Snacks:
We will provide a morning and afternoon snack for
the children. Please note any food allergies on the sign–in
sheet each day and provide an appropriate snack for your
child.
Lunch:
Lunch may be be ordered at the Trackside Café. Please
complete an order form and payment at the Café each
morning. If you plan on packing a bagged lunch for your
child, please pack perishable items with a cold pack.
Please do not bring food items that require heating.
Please label bagged lunch with the date and your child’s
first and last name. Out of concern for the health of other
campers, please refrain from bringing items containing
nuts.
Swimming:
Afternoon and Full Day campers will be swimming from
3pm - 4pm every afternoon and must have a completed
and signed Acknowledgement of Pool Rules before they
can swim!
Behavior:
We expect participants to respect others,
harmoniously participate in games
and activities, and cooperate with the
counselors. We will report any incidents
of unacceptable behavior to the parents/
guardians of all children involved. We
reserve the right to release a child for
unacceptable behavior. Refunds will
not be issued for children released for
unacceptable behavior.
Illness:
We reserve the right to release a child if he/she
appears too ill to participate in the camp, if they
are considered contagious, or if an emergency
arises. We will notify the child’s parent/guardian or
emergency contact, and request the child be picked
up within the hour. Parents are required to inform
the Center within 24 hours or the next business
day after his/her child or any member of the
immediate household has developed any reportable
communicable disease (see below), as defined
by the State Board of Health:
Diarrhea, difficult or rapid breathing, elevated
temperature, pink eye, severe or whooping cough,
severe itching of body or scalp, head lice, severe
headache with elevated temperature, vomiting,
unusual spots, sores or rashes, yellow skin or eyes,
cranky or unusual behavior, infected skin patches,
swelling, discharge, pus and or sore throat with
elevated temperature.
Medications, Asthma Inhalers and EPI–Pen:
We request that parents administer necessary
medications to their children before or after camp hours.
The Sentara RMH Wellness Center will administer
medication to participants only in situations that
are absolutely necessary for a participant’s health.
Medication must be in the original, labeled container
supplied by pharmacist. The Asthma Inhaler and EPI–Pen
Permission Form is required for EPI–Pens, inhalers and
other long term medications. Include written instructions
concerning the administration times and dosages.
Leftover medication must be picked up by the end of the
summer. All remaining medication will be destroyed after
August 19, 2016. Please speak with your child’s camp
counselor about medication and any special concerns.
Sentara RMH Wellness Center Camp
Acknowledgement Statement
Please read all information included in the registration process. Please complete all forms and bring them to your
child’s first day of camp.
 Sentara RMH Wellness Center Camp Guide / Camp Policies & Procedures
 Child Information Form
 Virginia School Entrance Health Forms
 Certificate of Religious Exemption Form (if applicable)
 Copy of Birth Certificate or Passport
 Medication/Asthma/EPI-Pen Permission Form (if applicable)
 Acknowledgement of Pool Rules Form (required for full day and afternoon campers only)
 Sunscreen Authorization Form
By signing below I acknowledge that I have read, completed and will adhere to the policies and procedures outlined in
the forms listed above.
Parent or Guardian’s Signature
Child’s Name
Date
SENTARA RMH WELLNESS CENTER
CHILD INFORMATION FORM
Nickname:
Child’s Name:
SRMH WC Child Member: YES or NO
Age:
Date of Birth:
Gender:
Parent/Guardian Name(s):
Address:
City:
State:
Telephone Numbers: (
)
Zip Code:
(
)
E-mail address:
EMERGENCY INFORMATION
Please use reverse side of form if necessary
Parent/Guardian Information
Mother/Guardian:
Address:
Work Phone:
Cell Phone:
Father/Guardian:
Address:
Work Phone:
Cell Phone:
In the event of an emergency, we will contact the parents/guardians listed above. Please list local emergency contacts below
who may be reached if we are not able to reach the parents/guardians.
Emergency Contacts/Persons Authorized to Pick Up Child
1.) Name:
Address:
Home Phone:
Work Phone:
2.) Name:
Address:
Home Phone:
Work Phone:
Parent/Guardian Consent and Agreement
I am requesting that the above child be admitted to the program, and I understand the nature and the scope of the program
listed above and will adhere to all policies and procedures of the program. I understand that there are risks and dangers
associated with the program. I understand that it is not the function of the Sentara RMH Wellness Center, its employees, agents,
operators, or instructors to guarantee the safety of participants with respect to this program. I also understand that each
participant has the responsibility to exercise due care in the performance of the program for the safety of himself/herself and
other participants. In the event that I cannot be reached in an emergency involving the above named participant, I hereby give
permission to the personnel to provide medical treatment deemed necessary.
In the consideration of the participant being permitted to enroll in the program, I hereby release, indemnify, and hold
harmless Sentara RMH Wellness Center, its employees, operators, counselors, and instructors from any and all claims and
demands, costs, charges, and expenses for harm, injury, damage, or loss which may be sustained by the participant as a result of
or relating to participation in the program.
I hereby consent, permit and authorize Sentara RMH Wellness Center and its affiliates to use my child’s image in
photographs, videotapes, or other media materials which may be used for promotional purposes and distributed by means of
various media including advertisements, television, brochures, Sentara RMH Healthcare web sites or Sentara RMH Healthcare
social media sites.
I HAVE READ AND UNDERSTAND THE CONDITIONS OF THIS CONSENT AND AGREEMENT.
Parent/Guardian Signature
Date
Administrator of Center Signature
Date
COMMONWEALTH OF VIRGINIA
SCHOOL ENTRANCE HEALTH FORM
Health Information Form/Comprehensive Physical Examination Report/Certification of Immunization
Part I – HEALTH INFORMATION FORM
State law (Ref. Code of Virginia § 22.1-270) requires that your child is immunized and receives a comprehensive physical examination before entering public
kindergarten or elementary school. The parent or guardian completes this page (Part I) of the form. The Medical Provider completes Part II and Part III of the
form. This form must be completed no longer than one year before your child’s entry into school.
Name of School: ____________________________________________________________________________________ Current Grade: _______________________
Student’s Name: _________________________________________________________________________________________________________________________
Last
First
Middle
Student’s Date of Birth: _____/_____/_______ Sex: _______ State or Country of Birth: ________________________ Main Language Spoken: ______________
Student’s Address: ______________________________________________________ City: ____________________ State: _______________ Zip: _______________
Name of Parent or Legal Guardian 1: ____________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______
Name of Parent or Legal Guardian 2: ____________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______
Emergency Contact: __________________________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______
Condition
Allergies (food, insects, drugs, latex)
Allergies (seasonal)
Asthma or breathing problems
Attention-Deficit/Hyperactivity Disorder
Behavioral problems
Developmental problems
Bladder problem
Bleeding problem
Bowel problem
Cerebral Palsy
Cystic fibrosis
Dental problems
Yes
Comments
Condition
Diabetes
Head injury, concussions
Hearing problems or deafness
Heart problems
Lead poisoning
Muscle problems
Seizures
Sickle Cell Disease (not trait)
Speech problems
Spinal injury
Surgery
Vision problems
Yes
Comments
Describe any other important health-related information about your child (for example; feeding tube, hospitalizations, oxygen support, hearing aid, dental appliance,
etc.):__________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
List all prescription, over-the-counter, and herbal medications your child takes regularly:
_______________________________________________________________________________________________________________________________________
Check here if you want to discuss confidential information with the school nurse or other school authority.
Yes
No
Please provide the following information:
Pediatrician/primary care provider
Name
Phone
Date of Last Appointment
Specialist
Dentist
Case Worker (if applicable)
Child’s Health Insurance: ____ None
____ FAMIS Plus (Medicaid)
_____ FAMIS
_____ Private/Commercial/Employer sponsored
I, ______________________________________ (do___) (do not___) authorize my child’s health care provider and designated provider of health care in the
school setting to discuss my child’s health concerns and/or exchange information pertaining to this form. This authorization will be in place until or unless you
withdraw it. You may withdraw your authorization at any time by contacting your child’s school. When information is released from your child’s record,
documentation of the disclosure is maintained in your child’s health or scholastic record.
Signature of Parent or Legal Guardian: ______________________________________________________________________Date: _______/________/ __________
Signature of person completing this form: ____________________________________________________________________Date:_______/________/___________
Signature of Interpreter: __________________________________________________________________________________Date: ______/_____/_______
MCH 213G reviewed 03/2014
1
COMMONWEALTH OF VIRGINIA
SCHOOL ENTRANCE HEALTH FORM
Part II - Certification of Immunization
Section I
To be completed by a physician or his designee, registered nurse, or health department official.
See Section II for conditional enrollment and exemptions.
A copy of the immunization record signed or stamped by a physician or designee, registered nurse, or health department
official indicating the dates of administration including month, day, and year of the required vaccines shall be acceptable
in lieu of recording these dates on this form as long as the record is attached to this form.
Only vaccines marked with an asterisk are currently required for school entry. Form must be signed and dated by the
Medical Provider or Health Department Official in the appropriate box.
Student’s Name:
Last
First
IMMUNIZATION
Date of Birth: |____|____|____|
Mo. Day Yr.
Middle
RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN
*Diphtheria, Tetanus, Pertussis (DTP, DTaP)
1
2
3
4
5
*Diphtheria, Tetanus (DT) or Td (given after 7
years of age)
1
2
3
4
5
*Tdap booster (6th grade entry)
1
*Poliomyelitis (IPV, OPV)
1
2
3
4
*Haemophilus influenzae Type b
(Hib conjugate)
*only for children <60 months of age
*Pneumococcal (PCV conjugate)
*only for children <60 months of age
1
2
3
4
1
2
3
4
Measles, Mumps, Rubella (MMR vaccine)
1
2
*Measles (Rubeola)
1
2
*Rubella
1
*Mumps
1
2
*Hepatitis B Vaccine (HBV)
 Merck adult formulation used
1
2
3
*Varicella Vaccine
1
2
Date of Varicella Disease OR Serological Confirmation of Varicella
Immunity:
Hepatitis A Vaccine
1
2
Meningococcal Vaccine
1
Human Papillomavirus Vaccine
1
2
3
Other
1
2
3
4
5
Other
1
2
3
4
5
Other
1
2
3
4
5
Serological Confirmation of Measles Immunity:
Serological Confirmation of Rubella Immunity:
I certify that this child is ADEQUATELY OR AGE APPROPRIATELY IMMUNIZED in accordance with the MINIMUM requirements for attending school, child
*care
Required
vaccine
or preschool
prescribed by the State Board of Health’s Regulations for the Immunization of School Children (Reference Section III).
Signature of Medical Provider or Health Department Official:
Date (Mo., Day, Yr.):___/___/____
Certification of Immunization 11/06
MCH 213G reviewed 03/2014
2
Student’s Name:
Date of Birth: |____ |_ ___|___ _|
Section II
Conditional Enrollment and Exemptions
Complete the medical exemption or conditional enrollment section as appropriate to include signature and date.
MEDICAL EXEMPTION: As specified in the Code of Virginia § 22.1-271.2, C (ii), I certify that administration of the vaccine(s) designated below would be
detrimental to this student’s health. The vaccine(s) is (are) specifically contraindicated because (please specify):
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________.
DTP/DTaP/Tdap:[
]; DT/Td:[
This contraindication is permanent: [
]; OPV/IPV:[
]; Hib:[
], or temporary [
]; Pneum:[
]; Measles:[
]; Rubella:[
]; Mumps:[
]; HBV:[
]; Varicella:[
]
] and expected to preclude immunizations until: Date (Mo., Day, Yr.): |___|___|___|.
Date (Mo., Day, Yr.):|___|___|___|
Signature of Medical Provider or Health Department Official:
RELIGIOUS EXEMPTION: The Code of Virginia allows a child an exemption from receiving immunizations required for school attendance if the student or the
student’s parent/guardian submits an affidavit to the school’s admitting official stating that the administration of immunizing agents conflicts with the student’s religious
tenets or practices. Any student entering school must submit this affidavit on a CERTIFICATE OF RELIGIOUS EXEMPTION (Form CRE-1), which may be obtained at
any local health department, school division superintendent’s office or local department of social services. Ref. Code of Virginia § 22.1-271.2, C (i).
CONDITIONAL ENROLLMENT: As specified in the Code of Virginia § 22.1-271.2, B, I certify that this child has received at least one dose of each of the vaccines
required by the State Board of Health for attending school and that this child has a plan for the completion of his/her requirements within the next 90 calendar days. Next
immunization due on __________________.
Date (Mo., Day, Yr.):|___|___|___|
Signature of Medical Provider or Health Department Official:
Section III
Requirements
For Minimum Immunization Requirements for Entry into School and
Day Care, consult the Division of Immunization web site at
http://www.vdh.virginia.gov/epidemiology/immunization
Children shall be immunized in accordance with the Immunization Schedule developed and published by
the Centers for Disease Control (CDC), Advisory Committee on Immunization Practices (ACIP), the
American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP),
otherwise known as ACIP recommendations (Ref. Code of Virginia § 32.1-46(a)).
(Requirements are subject to change.)
Certification of Immunization 03/2014
MCH 213G reviewed 03/2014
3
Part III -- COMPREHENSIVE PHYSICAL EXAMINATION REPORT
A qualified licensed physician, nurse practitioner, or physician assistant must complete Part III. The exam must be done no longer than one year before entry
into kindergarten or elementary school (Ref. Code of Virginia § 22.1-270). Instructions for completing this form can be found at www.vahealth.org/schoolhealth.
Developmental
Screen
Health Assessment
Student’s Name: _______________________________________________ Date of Birth: _____/_____/__________
Sex: □ M □ F
Physical Examination
Date of Assessment: _____/_____/_______
1 = Within normal
2 = Abnormal finding 3 = Referred for evaluation or treatment
Weight: ________lbs. Height: _______ ft. ______ in.
1
2
3
1
2
3
1
2
3
Body Mass Index (BMI): ___________ BP____________
HEENT
□ □ □ Neurological □ □ □ Skin
□ □ □
 Age / gender appropriate history completed
Lungs
Abdomen
Genital
□ □ □
□ □ □
□ □ □
 Anticipatory guidance provided
Heart
□ □ □ Extremities
□ □ □ Urinary □ □ □
TB Screening: □ No risk for TB infection identified □ No symptoms compatible with active TB disease
□ Risk for TB infection or symptoms identified
Test for TB Infection: TST IGRA Date:_______
TST Reading _____mm
TST/IGRA Result: □ Positive □ Negative
CXR required if positive test for TB infection or TB symptoms.
CXR Date: __________ □ Normal □ Abnormal
EPSDT Screens Required for Head Start – include specific results and date:
Blood Lead:___________________________________________
Hct/Hgb ____________________________________________
Assessed for:
Emotional/Social
Within normal
Assessment Method:
Concern identified:
Referred for Evaluation
Problem Solving
Language/Communication
Fine Motor Skills
Gross Motor Skills
1000
2000
□ Referred to Audiologist/ENT
4000
R
Vision
Screen
 Screened by OAE (Otoacoustic Emissions): □ Pass
 With Corrective Lenses (check if yes)
Stereopsis
 Pass
 Fail
Distance
Both
R
20/
20/
Care, or Early Intervention Personnel
Recommendations to (Pre) School , Child
 Pass
□ Unable to test – needs rescreen
□ Permanent Hearing Loss Previously identified:
L
L
20/
 Referred to eye doctor
___Left
___Right
□ Hearing aid or other assistive device
□ Refer
 Not tested
Test used:
Dental
Screen
Hearing
Screen
 Screened at 20dB: Indicate Pass (P) or Refer (R) in each box.
 Unable to test – needs rescreen
 Problem Identified: Referred for treatment
 No Problem: Referred for prevention
 No Referral: Already receiving dental care
Summary of Findings (check one):
□ Well child; no conditions identified of concern to school program activities
□ Conditions identified that are important to schooling or physical activity (complete sections below and/or explain here): _______________________
_____________________________________________________________________________________________________________________________
___ Allergy □ food: _____________________ □ insect: _____________________ □ medicine: _____________________ □ other: _________________
Type of allergic reaction: □ anaphylaxis □ local reaction Response required: □ none □ epinephrine auto-injector □ other: ________________
___Individualized Health Care Plan needed (e.g., asthma, diabetes, seizure disorder, severe allergy, etc)
___ Restricted Activity Specify: _________________________________________________________________________________________________
___ Developmental Evaluation
□ Has IEP □ Further evaluation needed for: ___________________________________________________________
___ Medication. Child takes medicine for specific health condition(s).
□ Medication must be given and/or available at school.
___ Special Diet Specify: ______________________________________________________________________________________________________
___ Special Needs Specify: ______________________________________________________________________________________________________
Other Comments: _____________________________________________________________________________________________________________
Health Care Professional’s Certification (Write legibly or stamp)
□ By checking this box, I certify with an electronic signature that all of
the information entered above is accurate (enter name and date on signature and date lines below).
Name: _____________________________________
Signature: ________________________________________ Date: ____/_____/______
Practice/Clinic Name: __________________________________________
Address: ____________________________________________________________
Phone: _______-_______-____________________
MCH 213G reviewed 03/2014
Fax: _______-_______-______________ Email: ______________________________________________
4
COMMONWEALTH OF VIRGINIA
CERTIFICATE OF RELIGIOUS EXEMPTION
Name ____________________________________
Birth Date _______________________
Student I.D. Number __________________________________
The administration of immunizing agents conflicts with the above named
student's/my religious tenets or practices. I understand, that in the occurrence of an
outbreak, potential epidemic or epidemic of a vaccine-preventable disease in my/my
child's school, the State Health Commissioner may order my/my child's exclusion
from school, for my/my child's own protection, until the danger has passed.
_______________________________________________
Signature of parent/guardian/student
___________________________
Date
I hereby affirm that this affidavit was signed in my presence on
This ____________________________________________ Day of _____________________
Notary Public Seal
Form CRE-1; Rev. 00/92
MEDICATION, ASTHMA INHALER & EPI-PEN
PERMISSION FORM
Child’s Name
Date of Birth
The Sentara RMH Wellness Center requires that all participants in camp who possess and/or self-administer,
Medication, Asthma Inhaler or EPI-Pen must have a signed permission form from the child’s parent and health care
professional.
Parent Section
Permission is granted to the Sentara RMH Wellness Center to allow my child to possess and use:
Medication Name:
Dosage and times to be administered:
Special Instructions:
Parent/Legal Guardian Signature
Date
All medication must be presented to the staff in original packaging and accompanied by a note from
parent/guardian.
Licensed Medical Personnel Must Complete This Section
Medication
Name of Medication
Date
Route and Dosage of Medication
Specific Recommendations for administration (list symptoms that would indicate need for medication)
I hereby verify that (Child listed above) has a valid prescription for the following at the Sentara RMH Wellness
Center.
Medication
Asthma Inhaler
Epinephrine Auto-Injector
Licensed Medical Personnel Signature
Print Name
Date
Business Phone
Emergency Phone
If you or your child’s health care professional has any questions, please contact the Children’s Programming
Coordinator at 564-5684.
SENTARA RMH WELLNESS CENTER
ACKNOWLEDGMENT OF POOL RULES
The Sentara RMH Wellness Center wants to provide a safe environment for your child while attending camp. Please take time
to review our Pool Rules with your child before he/she attends camp. We also ask that you let us know if your child is unable
to swim independently or if he/she has any medical condition(s) and/or are taking any medication(s). After you review the
rules with your child and complete the remainder of this form, please be sure to sign and date it. Your child will not be
allowed to swim with camp unless this from has been completed. If you have any questions, please call the children’s
programming coordinator at 540-564-5684.
RULES TO REVIEW WITH YOUR CHILD PRIOR TO CAMP:
 Listen to the staff and the lifeguard(s) on duty.
 No running on the pool deck, and no pushing other children into the pool.
 No diving into the pool, and no dunking other swimmers.
 If jumping from the side, look out for others in the pool. Jump in feet first.
 Stay with your group and counselor at all times. If you need to leave the pool area for any reason, tell the counselor or a
lifeguard. Do not go anywhere else without an adult.
 You are not allowed in the whirlpool or locker rooms without an adult.
 Have fun!
If your child is unable to swim independently, your child MUST wear a personal flotation device. For the safety of your child,
an age-appropriate swim test will be given to determine if a flotation device will be required. Also, if you know that your child
cannot swim independently, we ask that you inform us. Your child may bring his/her own flotation device or we can provide
them with one. Please understand that the Sentara RMH Wellness Center may or may not provide lifeguard services while
your child is in the pool area. Regardless of the presence or absence of a lifeguard, you and your child will be permitted to
swim with the understanding that you are swimming at your own risk.
Check here if your child cannot swim independently and needs a flotation device.
If your child has any medical conditions or takes any medications that may affect his/her ability to swim, please be sure to tell
the counselor.
ACKNOWLEDGMENT:
I,
_, the parent/legal guardian for
, acknowledge that I
have reviewed the Pool Rules with my child. I have also informed the staff if my child is unable to swim independently or if
there is a physical or medical condition that may affect my child’s ability to swim. I acknowledge that swimming can be a
strenuous or even hazardous activity, and may involve potential health risks to my child such as leg cramps, bodily injury,
drowning, and even death. Understanding these risks, I accept and assume all such risks on behalf of me and my child,
whether the risks are known or unknown. I also release and waive on behalf of me and my child any claims, losses, costs, or
damages arising from or related to my child’s participation in the pool, whether caused by the negligence of the Sentara RMH
Wellness Center or otherwise.
Signature of parent/legal guardian
Date
Authorization Form for
Sunscreen Products
Licensed Child Day Centers
VDSS Division of Licensing Programs Model Form
INSTRUCTIONS:
This form must be completed by the parent/guardian to authorize the use of:
Sunscreen
________________________________________________ has my permission to apply non-prescription
(Name of Provider)
sunscreen product listed below to my child, ______________________________________.
(Child’s name)
Product Name: _________________________________________________________________________
Known Adverse Reactions (if any): __________________________________________________________
_______________________________________________________________________________________
Sunscreen:
o Must have a minimum sunburn protection factor (SPF) of 15
o Shall be inaccessible to children under 5 yrs. & children in therapeutic or special needs programs
o Children nine yrs. and older may self administer sunscreen if supervised
o
If in the event the child does not bring sunscreen, we will provide sunscreen for application.
This authorization is effective from: _______________________until: ______________________
(Start date)
Parent’s Signature: ____________________________________
032-05-0430-00-eng (06/12)
(End date)
Date: _____________