RETURN COMPLETED FORMS AND FEE TO YOUR CHILD S SCIENCE TEACHER by Wednesday, March 4, Camp Parent Meeting, March 3rd, 6:30 pm, Cafeteria

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1 RETURN COMPLETED FORMS AND FEE TO YOUR CHILD S SCIENCE TEACHER by Wednesday, March 4, 2015 Camp Parent Meeting, March 3rd, 6:30 pm, Cafeteria February, 2015 Dear Parents: After several years of 7 th graders going to Camp Tar Hollow, we are excited about starting a new tradition at the Glen Helen Outdoor Education Center. The purpose of this letter is to answer some of your questions and to get your permission in writing for your student to attend. Please complete the attached forms and return with the camp fee by March 4th. All forms and the fee are to be turned in to your child s science teacher. Location: This outdoor educational program will take place at the Glen Helen Outdoor Education Center located near Yellow Springs, OH. It is about a one hour drive from Bexley. Physical Care: The buildings at Camp Glen Helen include three dorms with two wings each. Each wing can accommodate 16 or 18 students. Bathroom and shower facilities are in each wing. There is a dining and recreation lodge. These buildings are substantial, well-constructed, heated, and safe for our purposes. Supervision: Four BMS staff members will be at the camp the entire period. An additional two will arrive in time each night to be in the dorms overnight. Each dorm wing will have an adult (in a room separate from the students, but nearby). Every effort will be made to provide close supervision for all students at all times. Glen Helen provides naturalists who will take students on hikes, provide other programming and will eat with the students. Cost: The cost is $40.00 per student, which includes meals, programming, lodging, and transportation. Checks should be made payable to Bexley Middle School Camp Program. Dates and Length of Stay: The camp session will begin at 8:40 A.M. on Mon. April 6, or Wed. April 8 when we leave Bexley Middle School. It will end at approximately 2:15 P.M. when the students return to school two days later. Which of the two camp times your child will attend will be determined in early March. Participation in this outdoor educational camp program is part of the seventh grade curriculum. If there are any additional questions, please do not hesitate to call the school. We will be happy to talk with you at any time. The number is You may also Dan Jax at On Tuesday evening, March 3rd, at 6:30 P.M. in the cafeteria, we will present our parent night, which will give you insight into the camp program, and give us a chance to answer any questions you may have. Please plan to attend. You may also visit us at the Bexley City School District Home Page at or reach us by Fax at The Camp Staff Dan Jax, Director Bexley Middle School Camp Program Parent Meeting Tuesday, March 3rd 6:30 P.M. Cafeteria

2 CAMP GLEN HELEN RELEASE AND ASSUMPTION OF RISK FORM ACTIVITY: OUTDOOR EDUCATION CAMP GLEN HELEN 2015 As used herein, Camp Staff shall include, but not be limited to, Dr. Williams, Mr. Caudill, Dr. Jax, Ms. Jax, Mr. Brown, Mr. Maier, Mrs. Bennett, Mrs. Nakasako, Bexley Middle School, the Bexley Board of Education, their teachers, agents, employees, and licensees, or any volunteer assisting the foregoing, and Undersigned shall be the student involved and the father and/or mother, and/or guardian of the student. The Undersigned understands that during the activity in which the student is participating under the direction of the Camp Staff certain risks and dangers may occur, including but not limited to, hazards of accidents or illnesses, the forces of nature, personal injuries, theft and/or destruction of personal property, acts of third persons, and travel by automobile, bus or other conveyance. In partial consideration thereof, and for the right to participate in this activity and related activities, the Undersigned hereby assumes all the risks set forth above and hereby holds the Camp staff harmless from any and all liability, actions, causes of actions, debts, claims, and demands of every kind and nature whatsoever which may arise from or in connection with the above-described activity and related activities. The terms hereof shall serve as a release and assumption of risks for the Undersigned, their heirs, executors, administrators, and family members. Since the student is under the age of majority, the Undersigned agrees to indemnity the Camp Staff for any liabilities imposed on the Camp Staff by reason of any claim, cause of action, or charge of any kind brought about by the student s participation, or by any person on behalf of the student and arising out of the above described activity or incidents related thereto. In consideration for participating in this activity, the Undersigned realize the student is representing Bexley Middle School. The student will abide by all rules, regulations and directions of the Camp Staff. Any inappropriate conduct or behavior, or any violation of school rules will mean the student s immediate removal from Camp Glen Helen and the loss of any fees paid. The Undersigned understand that transportation, if the student is injured and unable to return on the bus, will be the responsibility of the Undersigned. (Parent Signature) (Student Signature) (Date) (Date) Non-Prescription Medication I give permission for the following medications to be administered AS NEEDED if requested by your child and judged helpful by camp staff: acetaminophen, ibuprofen, over-the-counter decongestant, Claritin, Zyrtec, Robitussin, Pepto Bismol, simethicone gas relief, Immodium, Benadryl, Dramamine, Tums, cough drops, or allergy eye drops. I do not give my permission I will be sending our own non-prescription med(s) and will give it (them) to the Nurse by Monday, March 30.

3 February 2015 Dear parents, The food service at Glen Helen can accommodate special dietary needs of students who go to the Glen Helen Outdoor Education Center. If your child has a special dietary consideration (Celiac s (gluten-free), vegetarian, food allergy, or religious consideration) we need to know by March 4, This is the date that forms and payment are due. The camp food is good and plentiful. Adequate meals and snacks are provided throughout the day. Please DO NOT SEND SNACKS to camp with campers. Any special circumstances related to diet should be discussed with me by the time this form is due (March 4). It is best to reach me via You will have an opportunity to discuss dietary concerns (if you need to) with the Glen Helen Outdoor Education Center Director at the parent meeting in the Cassingham cafeteria on March 3, 2015 at 6:30 PM. Thank You, Dan Jax - Director Bexley Middle School Camp Glen Helen OPTIONAL FORM -- Please complete and return this form only if your child needs a special diet. My child (NAME) needs a special diet while at Camp Glen Helen. Please describe the need:

4 Building: BEXLEY MIDDLE SCHOOL BEXLEY CITY SCHOOLS FIELD TRIP PERMIT has my permission to go with the class to GLEN HELEN OUTDOOR (student) EDUCATION CENTER scheduled for April 6 to April 8, 2015, or April 8 to April 10, We will be: walking bicycling transported by private automobile* X_ transported by school bus X_ for expenses, entrance fees, etc. $40.00 plus money in an envelope for the camp store (if desired) and $5 to $10 to stop at Young s Dairy on the way home. bring a sack lunch Signed (parent or guardian) I request permission to attend the field trip and agree to abide by the established safety rules and behavior guidelines. Signed (student) OPTIONAL: My student must go to Glen Helen in the group checked below: April 6 to 8 April 8 to 10 REQUIRED (if checked): Reason for needing to go the time that is checked *Only Board of Education approved adult transportation volunteers are being used. These volunteers are covered through the district s excess liability coverage only as secondary coverage. Revised 11/95

5 GLEN HELEN OUTDOOR EDUCATION CENTER OUTDOOR SCHOOL HEALTH FORM School Grade PERSONAL INFORMATION Child s Name Birthdate Age Sex Street Address City State Zip Code Parent/Guardian 1 Does this parent reside at the address listed above? Y / N Phone (h) Phone (c) Phone (w) Parent/Guardian 2 Does this parent reside at the address listed above? Y / N Phone (h) Phone (c) Phone (w) Emergency contact other than Parent/Guardian Relationship to Child Phone(s) HEALTH HISTORY Child s Physician Phone Date of last visit Date of last Tetanus shot Is your child up to date on all immunizations required for Ohio public school attendance? Please Check All Past and Present Health Concerns ADD Bedwetting Hemophilia Nightmares ADHD Diabetes High Blood Pressure Psychiatric Allergies Eating Disorder Hypoglycemia Sleepwalking Asthma Hearing Loss Insomnia Seizures Athletes Foot Heart Disease/Defect Muscular Disorder Ulcers Please explain the above or and other pertinent health concerns: Please list allergies (food, drug, other) and reactions: Please explain any recent infectious diseases: Please explain any dietary restrictions or special needs: Please explain any reason why your child should follow a limited schedule of physical activity: Please explain any other behavioral or medical concerns we should be aware of: (OVER)

6 MEDICAL INSURANCE Name of Medical Insurance Company Phone Number Name of Policy Holder Policy Number Address Group Number All students are required to have coverage by accident and illness insurance during their stay. This insurance can be provided through the policy that Glen Helen has with the Special Markets Insurance Consultants, Inc. Will this child be insured by the Accident/Illness policy offered through Glen Helen? Please circle Y / N If yes, please make arrangements for coverage and payment with the coordinating teacher at your child s school. PARENT/GUARDIAN AUTHORIZATION (signature required for attendance) The information contained in this form is correct, to the best of my knowledge, and the child described herein has permission to engage in all Glen Helen Outdoor Education Center activities, except as noted. I hereby consent to the following: authorization for consent for treatment may be given by any teacher or administrator of my child s school or school district or by the Outdoor Education Director or Assistant Director, any of whom may sign all documents necessary to obtain such treatment; the administration of any and all necessary medical treatment by a licensed physician or dentist either at his/her office or at a hospital; and the transfer of the minor, if necessary, to a specialty hospital, such as children s hospital. I understand that the parent/guardian is fully responsible for the child s transportation if he/she is dismissed for disciplinary, behavior, or medical reasons. I absolve Glen Helen Outdoor Education Center and all of its employees of any and all liability, financial and/or otherwise arising from participation in the Outdoor Education Center program and/or the administration of medication to the child named herein under the terms of this release. I understand that Glen Helen Outdoor Education Center is not responsible for payment for any medical expenses incurred during participation in the program. Signature of Parent or Legal Guardian Date

7 BMS Glen Helen Health/Medication Form 2015 How to fill out attached form: Section A: If your child has a prescription medication that needs to be given during the trip, Section A must be filled out by Physician and signed by parent/guardian. There is room to list multiple meds. *Prescription medication must be in the original container, clearly labeled with the student s name, name of medication and dosage. If you need an extra labeled container, your pharmacist can provide you with one. DO NOT send medication in a baggie or envelope. * Non prescription meds see the Release and Assumption of Risk form. Section B: If your child has an Epi Pen or an inhaler, please indicate in the appropriate section. We will use forms already at school if we have them. If we do not have forms at school, we will need those filled out. They are available from the nurse. If student needs medication, the exact amounts of prescription medications and/or non prescription medication in their original containers with Dr. Name, medication, dose and times, must be into the clinic by: March 30, 2015 MEDICATION CANNOT BE ACCEPTED AS YOUR CHILD IS GETTING ON THE BUS We will keep all medications with us in a central location. The exception to this would be medication such as inhalers or Epi Pens that students need to carry or be given to the chaperone to carry. Please call if you have any questions or last minute medication changes or additions. Thank you. Joann Spain R.N. Office: , ext Katie Talbott R.N. Office: , ext. 3146

8 BMS GLEN HELEN 2015 MEDICATION FORM Student Name Group # This form and any medications need to be in the clinic ON or BEFORE Monday, March 30, 2015 Section A: Physician Request for the Administration of Prescription Medication #1 (medication) (dosage) (am, pm, as needed, other) Reason for giving med (i.e. diagnosis, health concern): Possible side effects: Special administration or storage instructions: #2 (medication) (dosage) (am, pm, as needed, other) Reason for giving med (i.e. diagnosis, health concern): Possible side effects: Special administration or storage instructions: #3 (medication) (dosage) (am, pm, as needed, other) Reason for giving med (i.e. diagnosis, health concern): Possible side effects: Special administration or storage instructions: #4 (medication) (dosage) (am, pm, as needed, other) Reason for giving med (i.e. diagnosis, health concern): Possible side effects: Special administration or storage instructions: Physician Name (print) Phone ( ) Physician Signature: Date: Parent Signature: Date:

9 This form and any medications need to be in the clinic ON or BEFORE Monday, March 30, 2015 Section B: Epi Pen and/or Inhaler Epi Pen: Allergy Self carry Chaperone carry Both Auth. form on file Inhaler: Type Self carry Chaperone carry Both Auth. form on file OPTIONAL: I would like a nurse to contact me before the trip about health concerns. Yes No Name (print) Phone ( )

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