Camp Greenway Checklist

Camp Greenway Checklist
Summer Programs Office
Summer Programs Office
The Madeira School – Huffington Library 2nd
floor
The Madeira School – Huffington Library 2nd floor
8328 Georgetown Pike, McLean, VA 22102
Telephone: 703-556-8213 Fax: 703-556-0428
Office Hours: Monday – Friday 8:30 am – 4:30 pm
Downloaded
Completed
By
Parent/
Guardian
Due
Date
N/A
To be Completed For
New Camper
N/A
Form
Returning
Camper*
N/A
Payment Balance Information
Final Payments will be charged to the credit card on file on May 1, 2013. If you would like to
N/A
change the credit card to be used for the final payment or if the expiration date on your card has
changed since you registered, please email: [email protected] with the correct information.
If you want to pay your balance by check, please mail it to the above address to the attention of:
Summer Programs and ensure receipt by May 1, 2013.
Physician
5/1/13
Yes
No
Physical Examination Report and Certification of Immunization (New Campers Only)*
N/A
Required for New Camper’s only –only required for returning Greenway campers if there has been
some change since last year’s physical.) Physical must have been completed after May 1, 2012. The
Commonwealth of Virginia Health Form is acceptable. Please don’t forget we will need a copy of
your child’s immunizations.
Parent
5/1/13 If Needed If Needed
Medical Authorization Form
Or
N/A
Only if child will take medication at camp or has an Epi-Pen or inhaler. The dosage and times to be
Parent &
administered is exactly what appears on the prescription. Every line on this form needs to be
Physician
completed. Provider is The Madeira Health Center. Parent is always required to sign this form.
Parent
5/1/13
Yes
Yes
Authorization Form for Non-prescription Over-the-Counter Skin Products
N/A
If you wish your child to have Sunscreen or Insect repellent applied to them (Only children 8 or
under) there is a new State of Virginia form that needs completed and signed by you. Every line has
to be completed. Children 9 and over apply on their own. Provider name is: Camp Greenway.
Parent and 5/1/13
Yes
No
Department of Social Services Child Registration Form
N/A
Madeira
New Campers Only! An original birth certificate, passport or current Virginia public school report
Employee
card must be presented with this form to the Camp Office. Regrettably we are unable to accept
photocopies of these documents.
N/A
N/A
N/A
N/A
N/A
Camper Group Assignments & Activity Schedule
Activity Schedules by group will be posted on the Summer Forms page of www.madeira.org by the
end of May. Group assignments will be emailed to families in the week prior to the start of the
session.
*In order for us to be in compliance with the State of Virginia, Department of Social Services, any camper who did not attend the previous summer is not
considered a returning camper. Therefore, you must follow the directions as a “new camper”.
Physical Examination and Immunization Report
The Madeira School
8328 Georgetown Pike,
McLean, VA 22102
Telephone: 703.556.8213 Fax: 703.556-0428
This form is only for campers new to Madeira Summer Programs or returning campers with a change in the medical
information or immunizations. Campers who did not attend last year are considered “new campers” by the state and
must fill out this form. This form is due by May 1, 2013. Physical to be completed by the child's physician between
May 1, 2012 – May 1, 2013. Public school forms are acceptable.
Name:_______________________________________________________________________________ Age: _______
Medications and dosage:_____________________________________________________________________________
Allergies: Foods _______________________ Bee Stings_____________Drugs_______________ Other____________
Prescribed Treatment: Benadryl_________ EpiPen __________ Other _________
Significant medical history: __________________________________________________________________________
Illnesses or injuries within past year: __________________________________________________________________
Ht:______ Wt:______ BP:______ P_________
Significant physical and laboratory findings______________________________________________________________:
Recommendations and referrals made: ___________________________________________________________________
Restrictions/ Limitations: ________________________________________________________________________________
Comments: ____________________________________________________________________________________________
To your knowledge has the child had any treatment or counseling for any psychiatric, emotional, behavioral, and /or psychological conditions
including eating disorders or substance abuse: _____Yes _____ No
If yes, a full medical report from the Healthcare Provider including diagnosis, treatment, response to treatment and need for followup is required.
PLEASE ATTACH A COPY OF THE CAMPER'S IMMUNIZATION RECORD TO THIS FORM
I have examined the camper named above and find him/ her physically and emotionally qualified for an active day camp program of
sports, activities, campouts and field trips.
Physician’s signature:____________________________________________________ Date:____________________
Physician’s name printed:_______________________________________________________ Ph:______________________
Physician’s address:___________________________________________________________ Fax:_____________________
Q:\Summer Programs\Camper Forms\contact and authorization.doc
2
Medication Authorization Form
For Prescription and Non-prescription Medications
VDSS Division of Licensing Programs Model Form
INSTRUCTIONS:
• Section A must be completed by the parent/guardian for ALL medication authorizations.
• Section A and Section B must be completed for any long-term medication authorizations (those
lasting longer than 10 working days).
Section A: To be completed by parent/guardian
Medication authorization for: __________________________________________________________
(Child’s name)
_____________________________________has my permission to administer the following medication:
(Name of Child Care Provider)
Medication name: _____________________________________________________________________
Dosage and times to be administered: _____________________________________________________
Special instructions (if any): _____________________________________________________________
____________________________________________________________________________________
This authorization is effective from: __________________________until: ______________________
(Start date)
(End date)
Parent’s or Guardian’s Signature: ______________________________________ Date: _____________
Section B: to be completed by child’s physician
I, ________________________________________ certify that it is medically necessary for the medication(s) listed
(Name of Physician)
below to be administered to:____________________________________ for a duration that exceeds 10 work days.
(Child’s name)
Medication(s): _________________________________________________________________________________
Dosage and Times to be administered: ______________________________________________________________
Special instructions (if any): _______________________________________________________________
______________________________________________________________________________________
This authorization is effective from: __________________________until: _______________________
(Start date)
(End date)
Physician’s Signature: ________________________________________________ Date: ___________________
032-05-0570-05-eng (06/12)
Physicians Phone: _______________________________
Authorization Form for
Non-prescription Over-the-Counter Skin 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
• Diaper ointment or cream
• Insect repellent
________________________________________________ has my permission to apply the non-prescription
(Name of Provider)
over-the-counter (OTC) skin product listed below to my child, ______________________________________.
(Child’s name)
Product Name: __________________________________________________________________________
Known Adverse Reactions (if any): __________________________________________________________
_______________________________________________________________________________________
•
All OTC products must:
o Be in the original container and, if provided by the parent, labeled with the child's name
o Be used according to manufacturer's recommendation and instructions for application
o Not be used beyond the expiration date of the product
•
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
•
Diaper ointment/cream and Insect repellents:
o Shall be kept inaccessible to children
o Record of use shall be kept that includes child’s name, date, frequency of application, and any adverse
reactions
This authorization is effective from: _______________________until: ______________________
(Start date)
Parent’s Signature: ____________________________________
032-05-0430-00-eng (06/12)
(End date)
Date: _____________
DEPARTMENT OF SOCIAL SERVICES
CHILD REGISTRATION FORM
ALL NEW CAMPERS MUST COMPLETE THIS FORM CAREFULLY (PLEASE PRINT)
INSTRUCTIONS: PLEASE COMPLETE THIS FORM COMPLETELY. "PROOF OF YOUR CHILD'S
IDENTITY WILL NEED TO BE SHOWN TO ANY CAMP EMPLOYEE. ONLY ORIGINAL
DOCUMENTATION WILL BE ACCEPTED; NO PHOTOCOPIES, PLEASE.
Acceptable proof of age and identification:
•
•
•
•
•
Certified copy of the child's birth certificate
Birth registration card
Notification of birth (hospital, physician or midwife record
Passport
Copy of the placement agreement or other proof of the child's identity from a child placing
agency (foster care and adoption agencies0
• Record from a public school in Virginia
• Copy of the entrustment agreement conferring temporary
For additional information regarding identification please visit:
http://www.dss.virginia.gov/files/division/licensing/licensed_child_care/child_day_centers/forms/0
32-05-0252-00-eng.pdf
Nickname
Child's Name
Sex
Father/Guardian's Name
Mother/Guardian's Name
OFFICE USE ONLY
IDENTITY VERIFICATION
Place of birth
Birth Date
Birth Certificate No.
Date Issued
Other Form of Proof
________________________________
Camp Administrator/Employee
________________________
Date
Proof of the child's identity and age may include a certified copy of the child's birth certificate, birth
registration card, notification of birth (hospital, physician or midwife record), passport, copy of the
placement agreeme4nt or other proof of the child's identity from a child placing agency (foster care
and adoption agencies), record from a public school in Virginia, certification by a principal or his
designee of a public school in the U.S. that a certified copy of the child's birth record was previously
presented or copy of the entrustment agreement conferring temporary legal custody of a child to an
independent foster parent. Viewing the child's proof of identity is not necessary when the child
attends a public school in Virginia and the center assumes responsibility for the child directly from the
school (i.e., after school program) or the center transfers responsibility of the child directly to the
school (i.e., before school program). While programs are not required to keep the proof of the child's
identity, documentation of viewing this information must be maintained for each child.
Q:\Summer Programs\2009 Forms\DEPARTMENT OF SOCIAL SERV ICES.doc
Camp Greenway COOKOUTS 2013
Session 1:
Cookout Grades K-1st - 7/1/13
Cookout Grades 2nd-3rd - 6/27/13
Cookout Grades 4th-6th – 7/2//13
Cookout Grades 7th-9th– 6/28/13
Session 2: Cookout Grades K-1st - 7/15/13
Cookout Grades 2nd-3rd - 7/11/13
Cookout Grades 4th–6th - 7/16/13
Cookout Grades 7th–9th- 7/12/13
Session 3: Cookout Grades K-1st - 7/29/13
Cookout Grades 2nd-3rd - 7/25/13
Cookout Grades 4th-6th – 7/26/13
Cookout Grades 7th–9th– 7/30/13
Campers in the younger groups K-3rd grades (Little Snails are not eligible to
attend cookouts) are welcome to attend the cookout offered once per session. To
assure a quality experience, enrollment is limited to 55 campers per cookout, and
spaces are reserved on a first come first served basis. If at registration you did
not choose the cookout option and would like to now register your child, email us
at [email protected]. We will let you know if there is still space available.
The fee for cookouts is $45.00, which we will charge to the credit card we have
on file. The cookout for this age groups ends at 8:00 at which point their parents
pick them up from the Hurd Sports Center.
Rising 4th through 9th graders may attend cookouts as well. During the evening,
campers canoe, and swim at Black Pond, gather firewood for the campfire and
take a nature hike and of course make and eat dinner and s’mores! After dinner
the campers will gather together to watch a movie under the stars. The cookout
ends at 10:00 at which point their parents pick them up from the Hurd Sports
Center.
Attendance is limited to 40 campers per event on a first come first serve basis.
To ensure that we can have adequate staffing levels, we close enrollment when
the event reaches capacity or three days prior to the event, whichever comes
first. We are unable to add campers the day of the event. Many of you
registered for these events at point of registration. If you did not, and would like
to enroll your child please email us at [email protected] and indicate the
name of the child and the cookout date(s). Refunds of 50% of the cost will be
given for campers withdrawn from cookouts/campouts no later than one week
prior to the event date.
* Cookouts for Rising 7th-9th graders are held on Friday evenings. Pick-up is
from the Hurd Sports Center at 10:00 pm.
Cookouts begin directly after camp. Please note if your child is enrolled in
extended day you need only pay an additional $20.00 to enroll your child for the
cookout.
Children attending the cookout should be picked-up at 8:00 or 10 pm (depending
on grade) at the games field (directly across from the Hurd Sports Center).
For those of you who are returning campers, we no longer have the permission
slip attached; it has been integrated into your application.
Please circle the dates you’ve chosen and retain this page for your records.
Thank you for doing this, it will save us a great deal of phone calls.
Release of Liability for Cookout at Camp Greenway
I give my permission for my child, to participate in Camp Greenway's evening
cookout. I release The Madeira School, Camp Greenway and their employees from
any and all claims, demands, and liabilities arising out of or in any way connected
with my child's participation in this event.
I give my permission for my rising ______ grade child ________________________,
to participate in the Session 1 2 3 (circle all that apply) cookout(s) on
_____________________ (date).
Parent’s Signature ____________________________
Print Parent's Name_____________________________
Telephones: Home ___________________________
Work/Cell_______________________________
Please return this permission slip to the camp office.