. Thank you. Central Woodlands Sixth Grade Staff. Permission Slip for Camp Henry.
CENTRAL WOODLANDS 5/6 David Simpson, Principal 400 Alta Dale SE. Ada, MI49301 Phone: 616.493.8790 Fax: 616.493.8795 Dear Sixth Grade Families:
We are excited to offer a trip to start off our year together with three days and two nights of team-building and leaming at Camp Henry. Students will experience different activities that will incorporate team building and
woricing together. These activities include canoeing, survival skills, archery, scavenger hunts, a bog walk, and team challenges. This will be a great time to bond and celebrate our time together building lasting friendships that will extend into middle school. Camp Henry staff, sixth grade staff, and parents will accompany groups of students as they go through each activity. On Monday, October 17, students in Elsholz/Jasperse and May/Hanson will leave Central Woodlands on school buses to Camp Henry, Newaygo, Michigan at 9:00 a.m. and retum to school during the school day on Wednesday, October 19 at 2:00 p.m. Students from Peneycad/Homrich, Tolly/Becker, and Maloney/Koenigsknecht will leave CW on school buses to Camp Henry, Newaygo, Michigan at 9:00 a.m. on October 19 and will retum to school during the school day on Friday, October 21 at 2:00 p.m. Please drop your child off at 8:15 on the moming of departure and pick up your child at 2:00 p.m. on the aftemoon of their arrival back at CW to go home. The total cost for the three days for each child will be $110.00. No student will be excluded based on an inability to pay. Should you need confidential financial assistance, please call Mr. Kessel at 616-493-8790, ext. 3906 for a plan to fit your needs before October 7th, 2016. Please retum the form below with your payment in cash or check payable to Central Woodlands by Friday, October 7,2016.
We are still in search of chaperones for our sixth grade camp experience. Ideally, we would appreciate a chaperone to participate and be available for a complete half week including overnight; however, we will work to pair chaperones with others who are only available for specific days or nights. There will be no cost for chaperones to attend camp. If interested, please email Ted Knudsen at
[email protected]. Thank you. Central Woodlands Sixth Grade Staff
Permission Slip for Camp Henry Homeblock Teacher Name:
My diild, (please print), has permisston to travel by Forest Hills school bus to Camp Henry and participate in the sixth grade team building activities on October 17-19, 2016 or October 19-21, 2016.
I have enclosed $110.00 to cover my child's expense (checks payable to Central Woodlands).. I have enclosed an additional $ to help other students with finandal assistance. 1 am requesting financial assistance for my child. I am willing to chaperone an entire half week! My email is:
I am willing to chaperone but am only available My email Is:
Parent/Guardian Signature
Date
6**^ Grade Camp 2016 CAMP HENRY It is our hope that all sixth grade students will be available to participate in this valuable outdoor educational experience. The camping program promotes social maturity and individual self-reliance as students plan for and experience this two and
half day group experience. They will work hard, play hard, and grow measurably forming memories that will last a lifetime. Team building and school community will be emphasized.
This packet is vital for supplying you with needed information and necessary forms for sixth grade camp.
All five teams will be attending camp on the dates shown below. The camp fee (check made out to Central Woodlands), permission slip, health form and camp rules with
parent/guardian and student signatures are to be turned in to your homeblock teacher.
This must be done by October 7, 2016. The camp fee is $110.00.
Oct. 4: Parent Meeting @ CW (6:30 p.m) with Camp Henry Staff Oct. 17-19: May-Hanson Elsholz-Jasperse Oct. 19-21: Tolly-Becker Homrich-Peneycad
Maloney-Koenigsknecht Camp fees and permission slips are due by 4:00 p.m. on Friday, October 7th, 2016.
The money will cover the expense of food, cabins, transportation, materials and camp activities. While these fees are needed, we do not want to keep any child from enjoying this experience with his/her classmates.
Should you need confidential financial assistance, please call Mr, Kessel at 616-493-8790, ext. 3906 for a plan to fit your needs before October 7th, 2016.
Transportation to and from camp will be by Forest Hills school buses. Campers in the first group will meet at Central Woodlands at 8:15 AM, Monday in the parking lot to drop off their camp gear. Then they will go to their classroom. They will be returning on Wednesday at 2:00 PM at CW, where they are expected to be picked up to go home.
The second group will meet at CW on Wednesday at 8:15 AM in the parking lot to drop off their camp gear. Then they will go to their classroom. They will return to the school on Friday at 2:00 PM, when they are expected to be picked up to go home.
NOTE: Parents should plan to meet their children at approximately 2:00 pm on the day of their return in the back of the school. Students will be dismissed for the day at that time.
SPECIFICS FOR 2016
6*^ Grade students in Eisholz/Jasperse and May/Hanson will attend camp on 10/17 -10/19
6"^ Grade students in Peneycad/Homrich, Tolly/Becker, and Maioney/Koenigsknecht will attend camp on 10/19 -10/21
COST: Camp - $110 Permission siips and fees are due no later than 10/07/16. Make checks payable to Central Woodlands. **Students who do not choose to attend camp will have a regular schedule at school.
6th Grade Camp Packing List Camp Henry is thrilled to be welcoming the 6th graders from Central Woodlands in
October. We have had the privilege of serving campers, students, families, and guests at Camp Henry since 1937. We believe that a camping experience at Camp Henry has
the capacity to transform lives in many ways. With such a concentrated amount of time, a beautiful natural environment, intentional camp programs and activities, opportunities
to try something new, and being surrounded by positive and encouraging staff members - the combination is perfect for enhancing and positively changing the lives of the students who come to Camp Henry.
Our expectation is that everyone who comes to Camp Henry - whether a summer camper in July or a student coming in the Fall with their school group - will have the opportunity to have a life changing experience in a loving, caring, authentic, and supportive environment. Our staff members are truly awesome - energetic,
knowledgeable, compassionate, fun-loving, dedicated, hard-working, and full of joy and can hardly wait to welcome you to Camp Henry
Suggested Packing List Bedding
Clothing
Sleeping Bag (preferred)
Sweatshirt or sweater
or sheets/blankets
Shirts
Pillow and case
Jeans or Long Pants
Bathroom Articles
Shorts
To w e l Washcloth
Tennis shoes, boots, or hiking shoes
Soap/Shampoo
Pajamas
Toothbrush/paste
Raincoat/Poncho
Optional Items Flashlight
Warmer coat (depending on weather forecast) Socks & Underwear
Camera
Leave the Following at Home: MoneyA/aluables, Electronics, Cell phone, iPod, Kindle
Safety is always our number one priority - and our staff work hard to ensure that each child will have a safe environment - both physically and emotionally - to learn, grow, and explore.
Camp Henry is licensed by the State of Michigan and accredited by the American Camp Association, meeting or exceeding best practices and policies in the camping industry. www.camphenry.org
CENTRAL WOODLANDS 5/6 David Simpson, Principal 400 Alta Dale SE. Ada. Ml 49301 Phone: 616.493.8790 Fax: 616.493.8795
Sixth Grade Families, Attached is the medical authorization form used at Forest Hills Public Schools. If your child receives medicine at school and you have already completed one of these forms for the year, you may disregard this form unless you administer medication at home that we wili need to give at Camp Henry. If your child receives medication at home that we will need to administer next week at Camp Henry, please compiete this medication authorization form with your healthcare provider. In order for us to administer prescription or over the counter medications, this form must be signed by your physician.
You can then drop the medicine and this form off at school in a ziptoc bag with your chiid's name on it either on October 13 and 14 between 8:00 am and 4:00 pm.
One form does need to be completed for each medication that we administer. In addition, medication must be in its original packaging.
You may fax the completed form to 616-493-8795 or email the completed medication form to
[email protected] Thanks! CW 6th Grade Staff
Forest Hills Public Schools Grand Rapids, Michigan M E D I C AT I O N
A U T H O R I Z AT I O N
FORM
r Central Woodlands 5/6 I 400 Aita Dale SE, Ada. Mi 49301 I PHONE (616)493-8790 FAX (616)493-8795 I ATTN: L.
—.
Student
Date of birth
Grade
Te a c h e r / C l a s s r o o m
T O B E C O M P L E T E D B Y T H E H E A LT H C A R E P R O V I D E R O R A U T H O R I Z E D P R E S C R I B E R
Name of medication: Reason for medication (optional): Method of administration:
□ Tablet/Capsule □ Liquid □ Inhaler □ Injection □ Nebulizer □ Other Instructions (schedule and dose to be given at school): Time(s): Dose:
Start date of medication: □ Date form received Other dates Stop date of medication: □ End of school year Other date/duration □ For episodic/emergency events only Restrictions and/or important side effects: □ None anticipated □ Yes If yes, please describe:
Special storage requirements: □ None □ Refrigerate □ Other This student bothQcapable responsible for this medication: ■ □ isNo Yes -and supervised Q self-administering Yes - unsupervised
This student may carry this medication on him/her: □ Yes □ No Phone:
Signature of Health Care Provider
Fax:
Printed name of Health Care Provider
T O B E C O M P L E T E D B Y PA R E N T / G U A R D I A N
I request that receive the above medication at school according to standard school policy. I request that be allowed to self-administer the above medication at school according to the school policy.
Signature
Relationship
Date
Forest Hills Public Schools Grand Rapids, Michigan
ADMINISTERING
M E D I C AT I O N
TO
STUDENTS
The guidelines for administering student medication have been developed to promote a safe and drug-free educational environment while providing for the medical needs of students. A D M I N I S T R AT I O N O F M E D I C AT I O N :
• A Medication Authorization Form must be completed by the student's health care
provider and parent/guardian before anv medication Is administered by school personnel or, when permitted, self-admlnlstered by the student. • A student's parent/guardian may administer medication to his/her child at school
provided arrangements have been made with the principal or designee. • Administration of medication by Injection or ultrasonic Nebulizer will be Individually planned with the student's parent/guardian, school nurse, health care provider and principal.
• School personnel are not permitted to honor Independent requests from a parent/legal guardian to administer medication other than as specified on the medication authorization.
• All medications administered by school personnel must be delivered to school by the parent/guardian or other authorized adult. In the current original container with an unaltered prescription label attached.
• Any change In medication, dosage, or directions will require the completion of a new Medication Authorization Form.
• All signatures. Including health care provider, parent/guardian, must be original and handwritten.
• Faxed Medication Authorization Forms requiring a health care provider's signature must be sent directly to the school from the health care provider's office. SELF-ADMINISTRATION OF MEDICATION BY STUDENTS:
• Elementary Students - Grades K-6
The only medications that can be carried and self-admlnlstered by elementary students are metered-dose Inhalers and emergency Injectable medications. If authorized In writing by both the student's health care provider and parent/legal guardian. • Middle School Students - Grades 7-8
Prescription medication may not be self-admlnlstered by middle school students with the exception of metered-dose Inhalers, and emergency Injectable medication. If authorized In writing by both the student's health care provider and parent/guardian.
Over-the-counter medication may be carried and self-admlnlstered by middle school students If authorized In writing by the student's parent/guardian. All medication must be
In the original container that contains no more than one day's dosage. • High School Students - Grades 9-12
Prescription medication may be carried and self-admlnlstered by high school students If authorized In writing by both the student's health care provider and parent/guardian. Over-the-counter medication may be carried and self-admlnlstered by high school students If authorized In writing by the student's parent/guardian. All medication must be
In the original container that contains no more than one day's dosage. Any questions or concerns regarding the administration of medication should be directed to the school nurse, at 493-8870, who will determine appropriate action.
4
CAMPHENRY General Release Form under 18
School/Group Name
J Date(s) attending Camp Henry
Participant Name
J Male or Female (circle one) Birthdate.
Address
J P h o n e N u m b e r. J E-mail
City, St. Zip
J Emergency Phone.
Parent/Legal Guardian. Health Insurance
J Policy Number.
I recognize that adventure courses/climbing can be a strenuous endeavor requiring my child/ward to be in good physical condition. I here by certify that my child/ward does not suffer from any physical infirmities or illnesses which would affect the ability to engage in adventure
activities and that if my child/ward is now under treatment for any of the follovring, I will circle the proper headingfs) and discuss them with the Camp Henry instructor prior to my child/ ward engaging in the activities;
Circle Appropriate Headings Cardiac or Pulmonary Condition/Disease
Migraines
Fainting Spells Hearing Loss or Impairment Back or Neck Injury
Diabetes Shortness of Breath
Any Orthopedic Problems Recent Injuries
Asthma
High Blood Pressure Kidney Related Diseases beaming Disabled Anxiety/Depression Insect Allergies
A D H D
I n s o m n i a
Emotionally Impaired
Other
• I understand that during my child's participation in this adventure course or activity my child may be exposed to psychologically and physically stressful and challenging situatiorrs. I recognize that certain hazards and dangers are inherent in camp events and
Food Allergies of safety against risk and unforeseen injury, as detailed above, and consent to the participation of the above named participant in the adventure program. I also authorize the treatment of my child/ward
by licensed medical personnel in the event of any emergency. This
programs and particularly, but not limited to: swimming, boating, low ropes, high ropes courses, team courses, tower climbing, traversing
reach
wall climbing, canoeing, fishing, hiking, night hiking and campfires.
. CAMP HENRY EQUINE UABIUTY RELEASE: Please read the
• I understand, too, that although the program has taken precautions to provide proper organization, supervision, irxstruction, and equipment for each activity it is impossible for the program to guarantee absolute safety. Also, I understand that my child shares responsibility for his/her safety and I have instructed my child in the importance of knowing and abiding by the camp rules, regulations and procedures for the safety of the camp participants. Further, I waive any claim that may arise against Camp Henry and/or its employees as a result of participation in the program, except for those which are the direct result of the gross negligence of Camp Henry or its employees, staff or volunteers. • I have accepted responsibility for verifying my child's personal health and medical history on top of this sheet and my child has no physical or psychological problems that would prohibit or limit my child's participation in this program. Any medicines, prescription or non-prescription, will be dispersed by authorized school/group personnel. • In sicfning this form, I give permission to Camp Henry to use
authority is granted only after a reasonable effort has been made to me.
following agreement and liability release for horseback riding and or horse related activity at Camp Henry before signing: WARNING; Under the Michigan equine activity liability act, an equine professional is not liable for an injury to or the death of a participant in an equine activity resulting from an inherent risk of the equine activity. As a guest at Camp Henry, 1, the undersigned, recognize that Camp Henry is located in a rustic setting with natural and artificial hazards
(including surface and subsurface conditions). The undersigned also understands that it is the propensity of an equine to behave in ways that may result in injury, loss, or death. Equines can act unpredictably to sounds, sudden movements, unfamiliar objects, persons, or other animals. It is also understood by the undersigned that there could be a collision with another equine, animal, person, or an object while riding on Camp Henry premises. The undersigned will be given basic riding instruction prior to riding, yet there is a potential for the participant to act or fail to act in a manner that could contribute to injury, loss, or death. I understand that by mounting a horse and by taking the reins that the rider is in
photographs, videotapes, and any other media, including my child/ ward to be used in camp publicity; for my child/ward to be
primary control of the horse. The rider's safety largely depends on
transported for approved out-of-camp activities; for the release of medical information in case of illness; and I agree to assume all financial responsibility for any medical attention needed by my child/ ward and otherwise not covered by my insurance or Medicaid
remain balanced aboard the moving equine.
coverage.
liability, if any, of Camp Henry/Westminster Presbyterian Church of Grand Rapids, MI and its staff and volunteers.
• And I/we acknowledge that there can be no absolute guarantee
his/her ability to carry out simple instructions and hisAier ability to I/We, the undersigned, have read and do understand and agree to the foregoing agreement, warnings, waiver, and the assumption of risk. We assume the risk of injury from the above danger, and waive
Parent/Legal Guardian Signature (REQUIRED) Participant Signature
