Time Traveler Day Camp 5B June 11 15, 2018 Kathryn Stagge Marr Community Park 9:00 a.m. 3:45 p.m. Program Aide Registration Packet Registration

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1 Time Traveler Day Camp 5B June 11 15, 2018 Kathryn Stagge Marr Community Park 9:00 a.m. 3:45 p.m. Program Aide Registration Packet Registration Opens: Sunday, April 1, 2018 Registration Deadline: Monday, April 30, 2018 Registration Drop-Off/Questions see page 2 OPEN FOR NEWS ABOUT DAY CAMP! 1

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3 Dear Caregiver: Thank you for your interest in sending your Girl Scout to volunteer day camp. At camp, girls will discover their values and talents through a variety of outdoor activities. Girls will also connect with other girls and adults, learn how to work together as a team, and use that teamwork to take action and make the world a better place. Please complete and return a PA Registration, Health History, Photo Release and PA Code of Conduct Forms found in this packet, for each program aide. Below and on the next page, you will find basic information about day camp. Detailed information and instructions will be sent in a confirmation packet after you have registered. For additional questions or concerns, please contact the day camp directors. Day Camp Director: Bobbie Spaulding PA & Outdoor Program Director: Elizabeth Erb Business Director: Jennifer Horning Registrar: Melissa Rutter Program Director: Alisa Hill Or the committee at DayCamp5Bisfun@gmail.com Looking for additional outdoor activities for your Girl Scout? All of our summer camp and outdoor activities are listed on our website at gswo.org/camp. PA Training Overnight: Mandatory overnight training for all PAs is on June 1 2, 2018, at the Trinity United Methodist Church located at 5767 Woldpen-Pleasant Hill Road, Milford, OH New PAs will need to arrive at 4:00 p.m. Second year and up PAs will need to arrive at 6:00 p.m. The training will end by 2:00 p.m. on Saturday. More details will be included in the confirmation packet. PA Caregiver meeting: We will have a PA caregiver meeting on Friday, June 1, 2018 as well. We will hold one at 4:00 p.m. for caregivers of new PAs and another one at 6:00 p.m. for all other caregivers. Please make every effort for at least one caregiver to attend one of these two meetings. Adult Volunteers Needed: Since the PAs stay at camp all week (Sunday Friday) we need adult volunteers to help chaperone including overnight, transportation as well as delivering items needed. More information will come by once your child has been accepted as a program aide for Day Camp 5B. Adults must be registered scouts and background checked to volunteer. Camp Details: Directions to camp: Kathryn Stagge-Marr Community Park is located at 6662 Goshen Road. Traveling from State Route 28, turn south on Goshen Road. The park is located on the left side of the road, almost immediately after passing Goshen Middle School. Food: Lunch will be provided for the PAs at the school again this year. More information on what meals the PAs need to bring will be covered at the mandatory training. Caregivers: If you feel this camp is unsafe or a hazard to children, you should contact Clermont County Children's Services Department at or Clermont County Combined Health District at /2018 1

4 Health: A nurse or first aider will be available at camp. Check with your physician to see if a tetanus booster or any immunizations are necessary. Medications are the responsibility of the caregiver. Campers should give any medications the camper may need to the health supervisor or PA unit leader in the original container on the first day of camp. Be sure to include written instructions. Ensure any allergies or dietary restrictions are recorded on your Girl Scout s Health History form. Clothing: Proper dress for the weather is necessary. No halters or sandals. Wear sturdy shoes, socks, and head cover and bring rain gear. Camp is not cancelled because of rain. Insurance: Every registered Girl Scout and registered adult member is automatically covered under the basic plan by Girl Scouts of the USA. This plan is effective from October to the following October. This insurance provides up to a specified maximum for medical expenses incurred as a result of an accident while a member is participating in an approved Girl Scout activity, after the individual s primary insurance pays out. Activity Costs: Program Aides (going into grades 8-12) and earned their PA pin $50. (T-shirt/patch included) Camp Aides (graduating 2018 girls) $50 (T-shirt/patch included) Membership fee for non-registered girls and adults $ 25. (All school age girls and adults participating in camp must register as Girl Scouts.) Make checks payable to Girl Scouts of Western Ohio. Complete the registration, additional information and release forms and return with payment to: Melissa Rutter 1422 Lela Lane Milford, OH Do not put directly in Melissa s mailbox! Use provided bin on her porch. Do not send registrations to the Girl Scout Center. All registrations received at the Girl Scout Center will be forwarded to the appropriate day camp on a weekly basis and may cause your child to be closed out of camp. In-Person Registration: Thursday, April 5, 2018, 6:00 8:00 p.m. at Panera, 1066 State Route 28, Milford OH Come sign-up, ask questions and get help with registration and/or turn in forms and payment. Financial Assistance: Financial assistance may be available for girls who want to attend but are unable to do so because of limited family income. Applicants must pay at least $20 (40 percent) of the day camp fee. Please include payment for the total amount your family can pay with the registration form. Refund Policy: Money may be refunded for the following reasons only: 1. Moving out of town. 2. Illness or exposure to a communicable disease. 3. Required attendance at summer school. 4. Camp capacity is reached and no other camp is attended; refund will be sent within four weeks of registration date. To request a refund, send a written request within ten business days (by June 29, 2018) from the end of camp to: DayCamp5Bisfun@gmail.com. Please use subject of Day Camp 2018 refund. 2

5 Girl Scout Cadette Program Aide Position Description Purpose of the Program Aide: The Girl Scout Cadette Program Aide is a girl whose responsibilities and role fall somewhere between being a girl and an adult leader. Through the Girl Scout Cadette Program Aide experience, girls will participate in leadership training (Program Aide training) and then implement what they have learned with a group of girls. Girls who are interested in earning their Girl Scout Cadette Program Aide are choosing to take a position of leadership and want to share her Girl Scout knowledge with others. Accountability: Day Camp Staff and Adult leaders General Responsibilities: Working under the guidance of an adult leader, the Girl Scout Cadette Program Aide is responsible for teaching specific skills determined by the needs of the group and her personal strengths. Requirements: A Girl Scout Program Aide must: * Register as a member of Girl Scout of the USA. * Complete the LiA award prior to taking a council approved program aide training. * Take a council approved program aide training prior to assuming their responsibilities. * Work directly with younger girls over six activity sessions. This might be assisting girls on Journey activities (in addition to work she did toward her LiA award), badge activities or general Girl Scout activities. She might work with a group at their meeting, day camps, and service unit events or during a special council event. Qualifications A Girl Scout Program Aide: * Lives by the Girl Scout Promise and Law. * Understands the importance of accepting and understanding kids of all needs, interests, races/ethnicities and religions. * Is able to put the needs of her group before her own personal needs. * Is confident in her abilities. * Is interested in working with younger girls and within the setting for which she applied. Girl Scout Cadette Program Aide Bill of Rights The Girl Scout Program Aide will: * Assist a qualified adult leader to whom she will be accountable to and to whom she can go to if she is in need of assistance. * Work with her adult leader to create an assignment that allows her to teach/share the knowledge and skills she has. * Receive assignments that are challenging, yet appropriate to her knowledge, skills and abilities. * Be consulted regularly regarding her perspective and her level of responsibility. She will be given the opportunity to determine if the scope of her assignment should be broadened or changed to meet her or the adult leader s expectations. * Be kept informed of developments, plans and changes throughout her assignment. * Be given the opportunity to help evaluate the program, both from the perspective of her experiences as a Girl Scout Cadette Program Aide and a participant. * Receive an evaluation of her work during her assignment. This evaluation will include the hours worked and suggestions for improvement. 3

6 The Girl Scout Cadette Program Aide will not be: * The only person asked to perform errands; she will be willing to take her turn. * Solely responsible for supervising a group of girls at any type of activity. * Act as a first aider, troop camp certified adult, lifeguard or other solely adult activities. * Responsible for discipline, but, will serve as a role model of appropriate Girl Scout behavior, modeling the Girl Scout Promise and Law. * Be counted toward girl/adult ratio. I m a Role Model! Yes you are! As a Girl Scout Cadette Program Aide, you have the opportunity to be a role model to younger girls. A role model is someone who serves as an example and whose behavior is emulated (copied) by others. This means that you must be aware of how you act at all times, because you never know who is watching. Things to keep in mind Behavior * The way you work with others, handle problems and solve differences of opinions is very important. The things you say and the way you speak will be listened to, copied and quoted at home. If you wouldn t say it in front of your parents or teachers, then don t say it around the girls you were working with. * Girl Scouts always make sure that everyone feels welcome. This means that you shouldn t make racial, ethnic or sexual jokes that may make someone feel uncomfortable. You may think that they are harmless, but you never know whose feeling you might hurt. This also includes any songs you may sing. * Have you ever noticed that girls seem to be everywhere all the time? This means that even when you think you are alone with friends, girls may be around. Remember that subjects of boyfriends/girlfriends or parties are not for girls to hear. * It s okay to get involved, get excited and be enthusiastic, but make sure you are still in control of yourself and the group. If you get too crazy, so will the girls, and then someone might get hurt. * Never argue or criticize anyone in front of the girls. If you are feeling emotional, angry or upset, ask someone to fill in for you while you go to calm down. Dress * At Girl Scout events, you should dress appropriately for the occasion. This means appropriate length shorts. Short shorts or tight dress, halter or crop tops, bikini bathing suits, low cut pants, under garments showing or anything that is see through or too revealing should not be worn. Consider wearing our Girl Scout uniform sash or vest or any Girl Scout t-shirt. * Remember basic safety rules. Always wear closed-toe shoes and the appropriate clothing for the event. * If the girls are required to wear clothing for the event such as long pants, boots or helmets, then you are expected to wear it too. * Look at what your clothes might say or look like. You may find some slogans humorous or funny, but the parents of the girls may not. Never wear anything that promotes alcohol, tobacco or illegal substances. * Be careful about symbols or attire that promotes a certain lifestyle or anything personal in nature like politics or religion. Small religious symbols like a cross or Star of David are acceptable. The Leader in You: One of the greatest gifts you have as a leader is your ability to inspire others, your family, your friends, your community, the media, or even the world. To inspire others is to influence them in positive ways. Your strengths and talents are the boxes which wrap those gifts. They re what give character to your voice. They are directly tied to your passion and your passion is what propels you to create change. What is inside you that makes you a good leader? What strengths and talents do you have that allow you to inspire others? 4

7 Day Camp 5B Time Traveler Program Aide Application Program Aide s Name: Phone: Address: City: State: Zip: School: County: DOB: Age: Grade in Fall 2018: Caregiver s Name: Home Phone: Work Phone: Caregiver s Troop Leader s Name or Troop #: Service Unit Name or #: Check box if not currently registered as a Girl Scout. (Please submit your $25 registration fee to be a Girl Scout with your camp fee.) Custodial Care: Mother only Father only Both Other Re-registering Girl Scout New Girl Scout Program Aide - Girl Scout Cadettes/Seniors/Ambassadors (Going into Grade 8 12 in fall 2018) I have earned my PA pin Yes No Date: Location: Camp Aide - Girl Scout Ambassadors (Graduating Spring 2018) New this year, limited appointments available. T-Shirt Size: Adult SM MED LRG XL XXL XXXL Financial Assistance (if needed): Please complete the section below. To be answered by caregiver: How would this girl benefit from day camp? $ Amount family can pay (applicants must pay $20 (40 percent) of the fee) + $ Financial assistance requested = $ TOTAL I give full permission for my daughter/son to attend day camp and participate in all phases of activities, except those noted. I have read the Day Camp flier and agree to cooperate with the guidelines listed. I understand that my camper must have written permission to leave camp early or with someone other than a caregiver. If I cannot be reached in an emergency, I give permission to give emergency treatment to my child. Caregiver Signature: Date: TOTAL FEES Day Camp Fee $ Registration Fee for non-girl Scouts (if applicable) $25 $ Cookie Dough* $ Late Fee ($10) after 4/30/2018 $ TOTAL $ Cell: Mail completed application form, additional information and release form, health form, photo release, camp code of conduct and Bus form with fee to: Melissa Rutter 1422 Lela Lane Milford, OH Deadline: Registrations will be accepted from April 1-30, Girls will be accepted on a first come, first served basis based on the number of volunteers available and according to postmark. Priority will be given to girls with caregivers who are volunteering. After April 30, 2018, registrations will only be accepted based on unit availability. A $10 Late Fee will be charged. Camp fee must be received to confirm spot /2018 5

8 Program Aide Additional Information and Release Form Program Aide s Name: Date of birth Age Address: Caregiver s Name: Home Phone: Work Phone: Caregiver s Transportation Information Cell: I understand that my daughter will only be released to the people listed below with proper ID: Name: Relationship to girl: Phone # Name: Relationship to girl: Phone # Name: Relationship to girl: Phone # Emergency Contact Information Emergency contact in case we can t reach caregiver: Name Relationship to girl Home phone: Work phone: Cell: Caregiver Permission and Consent to Treatment (Name of participant) is in good physical health and has had a physical examination in the past 12 months. Participant has my permission to attend Girl Scout day camp and to participate in all activities except those noted. I have read the day camp flier and understand and agree to cooperate with all regulations. I further understand that the deposit is refundable only for the reasons noted on the flier. Emergency Medical Authorization: This health history is correct to the best of my knowledge, and the person herein described has permission to engage in all prescribed Girl Scout activities except as specifically noted. Authorization for Treatment: In the event reasonable attempts to contact me at the provided phone numbers have been unsuccessful, I hereby give my consent to the administration of emergency medical treatment by any licensed physician or dentist and to transfer the child to any reasonably accessible hospital facility. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery. My daughter may be registered as a Girl Scout member through September 30, Caregiver Signature: Date: 6

9 Program Aide Application For Girls Entering Grades 8 12 only A Program Aide (PA) is a Girl Scout who is interested in sharing her interests and experiences with younger girls in a troop, group or camp setting. Being a PA at Day Camp VB is a leadership opportunity for girls to develop skills while giving service to others. Duties could range from leading games and songs, assisting in crafts or activities to helping set-up or clean-up. Please complete the following information for consideration. Criteria to apply: Has completed the grade 7 Has attended a Girl Scout Camp previously Is interested in giving time and service to enhance this camp experience for younger girls Name: PA Name (if known): Have you attended Day Camp 5B previously? Yes No If yes, please list the years Do you have any PA experience? Yes No, 2018 will be my 1 st 2 nd 3 rd 4 th 5 th (circle one) year as a PA at this camp As a PA at Day Camp VB, please list the assignments that you have had in the past: If elsewhere, please detail the experience(s): What qualities do you have that would make you a great PA: What contributions would you give to make camp a success for the younger campers, other PAs and adults? Please make sure you complete all of the forms and send them and payment in on time, note below if using Cookie Dough. We do give priority to girls who bring an adult volunteer with them. We must do that to have enough adults to staff the camp. If you are not accepted for our day camp, we will mail your check back to you. Please contact the Girl Scout Center at for other program aide opportunities or to find out about the new requirements for Girl Scout Cadette Program Aide Awards and Counselor-In-Training Awards. *Cookie Dough Must fill out the form at: gswo.org/cookiedough. Enter your Cookie Dough redemption code in the Cookie Dough Code box and your camp code in the Event/Camp Details box. Camp ID: 5bcamp 7

10 Please write a brief paragraph explaining why you want to serve as a program aide this year at day camp. This is your personal evaluation of your own skills in the indicated areas. Please honestly evaluate what you believe your skill level is in each area. We will be using what you mark as a guide to help us. Check the appropriate box on the right in each skill level. #1 Very skilled, I can teach this skill to younger campers on my own #2 Somewhat skilled, I can help someone else to teach this skill to younger campers. #3 Limited experience, I can assist in this area. #4 No experience, I have never performed this skill, but I am happy to learn. SKILL Skill Level SKILL Skill Level #1 #2 #3 #4 #1 #2 #3 #4 Outdoor cooking Box Oven Buddy Burner Charcoal Chimney Dutch Oven Stick Cooking Foil Dinners Homemade ice cream Dishwashing Skills Compass Knife Safety Knots Letterboxing Flag Ceremonies Cleaning Latrines Other (please specify) Nature Plant/Animal identification Creeking Hiking Trail Signs Games/Activities Crafts Inventure Games Parachute Games Lemme Sticks Tininkling Poles Songs Games Fire Building Cleanup Safety 8

11 HEALTH INFORMATION AND RELEASE FORM To be completed and reviewed annually by parent/guardian or adult. This form should be kept with the troop/group records and accompany the troop/group leader on all troop/group activities. It is designed to provide the troop/group leader with the information needed to access medical care for your daughter. It should be reviewed and updated (as needed) when information changes. Name: Date of Birth: Phone: Address: City: Zip: Troop/Group#: Part I: Parent Information and Release She is under the custodial care of: Both Parents Mother/Caregiver only Father/Caregiver only Other (specify) Mother/Caregiver Name: Address (if different than girl): Employer: Occupation: Phone (day): Phone (evening): Cell Phone: Father/Caregiver Name: Address (if different than girl): Employer: Occupation: Phone (day): Phone (evening): Cell Phone: PART II: EMERGENCY CONTACT AND RELEASE INFORMATION In the event that I cannot be reached in an emergency, the following are authorized to act in my behalf: Name: Relationship to Participant: Address: City: State: Zip: Phone (day): Phone (evening): Cell Phone: Name: Relationship to Participant: Address: City: State: Zip: Phone (day): Phone (evening): Cell Phone: ADDITIONAL RELEASE INFORMATION: In addition to the above parent(s)/guardian(s) and emergency contacts, this participant may also be released to the following persons: Name: Relationship to Participant: Name: Relationship to Participant: PART III: HEALTH CARE INFORMATION: Physician s Name: Phone: Address: City: Zip: Dentist s Name: Phone: Address: City: Zip: 9

12 PART IV: ALLERGIES (Check those that apply and specify nature of allergic reaction.) Animals Hay Fever Pollen Food Insect Stings Plants Penicillin Other Medicines/Drugs: Other (specify): Girl Scout Leaders do not administer over-the-counter medications for complaints such as headaches, fever, stomachaches, sunburn, etc. If those medications are needed, parents must supply them with written instructions. Please explain any items that are checked. Indicate any information useful to the adult in charge in relation to any of these health conditions. Also, indicate any activities to be encouraged or restricted: PART V: OTHER HEALTH CONDITIONS (Check those that apply.) Please explain any items that are checked. Indicate any information useful to the adult in charge in relation to any of these health conditions. Also, indicate any activities to be encouraged or restricted: Asthma Bed Wetting Bleeding/Clotting Disorders Constipation Convulsions/Seizures Diabetes Emotional/Behavior Disturbances Ear Infections Fainting Hearing Impairment Heart Defect/Disease High Blood Pressure Hypertension Menstrual Cramps Musculoskeletal Disorders Motion Sickness Sickle Cell Trait or Disease Nosebleeds Rheumatic Fever Special Dietary Regimen Sleep Disturbances Urinary Infections Visual Impairment Wears Glasses or Contact Lenses Other (specify): Please explain any items that are checked. Indicate any information that would be useful to the adult in charge in relation to any of these health conditions. Also, indicate any activities to be encouraged or restricted. PART VI: IMMUNIZATION HISTORY Immunization Year Primary Series Completed Year of Last Booster Which of the following has the participant had? DTP (Diphtheria; Tetanus; Whooping Cough) Chicken Pox Hepatitis B German Measles MMR (Measles/Mumps/Rubella) Hepatitis Oral Polio Measles TD (Tetanus/Diphtheria) Tuberculin Test (most recent) Result Others: Mumps PART VII: MEDICATION (For day outings or overnights only.) Current Medication(s): Being Taken For: (condition) Dosage and Frequency: EMERGENCY MEDICAL AUTHORIZATION: This health history is correct to the best of my knowledge, and the person herein described has permission to engage in all prescribed troop/group activities except as specifically noted. AUTHORIZATION FOR TREATMENT: In the event reasonable attempts to contact me at the above listed phone numbers have been unsuccessful, I hereby give my consent to the administration of emergency medical treatment by any licensed physician or dentist and to transfer the child to any reasonably accessible hospital facility. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery. Signature of Parent/Caregiver: Date: Is the participant covered by family medical/hospital insurance? Yes No If so, indicate carrier or plan name: Policy or Group #: Name of insured: Relationship to participant: Is the participant covered by family medical/hospital insurance? Insurance ID #: 10

13 Date(s): June 10 15, 2018 Photo Release Photographer/Producer: Girl Scouts of Western Ohio Assignment: Day Camp 5B June 2018 Location: Kathryn Stagge Marr Community Park Activity: Through day camp, you will have the opportunity to try new things and meet new people in a fun, safe and nurturing environment. Come learn new skills and create new memories that will stay with them long after day camp is over. RELEASE FOR MINORS For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I hereby consent and agree to the following: 1. I hereby grant to Girl Scouts of Western Ohio, and others working for Girl Scouts of Western Ohio or on its behalf, and each of its respective licensees, successors and assigns (each a Releasee ), the irrevocable, royalty-free, perpetual, unlimited right and permission to use, distribute, publish, exhibit, digitize, broadcast, display, modify, create derivative works of, reproduce or otherwise exploit my name, picture, likeness and voice (including any video footage of the same) (collectively, Media ), or to refrain from so doing, anywhere in the world, by any persons or entities deemed appropriate by Girl Scouts of Western Ohio, for any purpose (except defamatory) including, without limitation, any use for educational, advertising, non-commercial or commercial purposes in any manner or media whatsoever (whether known or hereafter devised) including, without limitation, on the internet, in print campaigns, in-store and via television. I agree that I have no interest or ownership in any of the Media. 2. I shall have no right of approval, no claim to compensation and no claim (including, without limitation, claims based upon invasion of privacy, defamation or right of publicity) arising out of any use, alteration, blurring, illusionary effect or use in any composite form of my name, picture, likeness and voice. I agree that nothing in this Release will create any obligation on Girl Scouts of Western Ohio to make any use of the Media or the rights granted in this Release. I hereby release and hold harmless Releasees from any claim for injury, compensation or negligence resulting or arising from any activities authorized by this Release and any use of the Media by Girl Scouts of Western Ohio. Name of Minor (please print): Address: City: State: Zip: Daytime Phone Number: ( ) Additional Phone (optional): ( ) Release for minors (those under the age of eighteen): I, the undersigned, being a caregiver of the minor, hereby consent to the foregoing conditions and warrant that I have the authority to give such consent. Name of Caregiver (please print): Signature of Caregiver (Required): Caregiver Address*: (*will not be used for any other purposes or distributed to third parties) Region: Troop#: Service Unit: Date:

14 PA CAMP CODE OF CONDUCT I, (Camper s name), understand that my attitude and behavior are critical to my success and the success of others during camp. Therefore, for the good of all, I agree to abide by the following: 1. I will try to be sensitive to the needs of each of my fellow campers by performing my assigned duties, including but not limited to unit kapers, all-camp kapers, mealtime cleanup, participating in all camp activities, etc. 2. I will respect the places and the people with whom I come in contact. This includes leaving my unit without permission. 3. I understand that the use of profane language and gestures is prohibited. 4. I will be responsible for my personal belongings and equipment and will not hold Girl Scouts of Western Ohio or any other outsider responsible for the loss or damage due to my negligence or neglect. 5. I will treat equipment provided by Girl Scouts of Western Ohio, or any other person, with care. 6. I will use any safety equipment furnished by Girl Scouts of Western Ohio for my own protection. 7. I understand I will be sent home for any and all acts of physical aggression, threats or intimidation of physical injury. I understand this can affect my eligibility for 5B camp next year. 8. I understand that the use of alcohol, tobacco or drugs is prohibited. I understand that if I do not abide by this rule, I will be sent home. 9. I understand that it is my responsibility to make sure my areas and common areas are clean at all times. 10. I understand that if I do not abide by the guidelines listed above, the camp director will notify my caregivers, and I will be sent home. I also understand that if I am sent home early due to misconduct, I will not receive a refund. This form must be signed by both the camper and the caregiver. Program Aide s Signature Date Caregiver s Signature Date I have read and understand and agree with the above responsibilities of my camper. 12

15 Permission Slip Must be completed anytime your troop goes anywhere away from their usual meeting place. Return the bottom portion of this form by (date): With Registration Application for Day Camp5B DC5B is planning is for: All Day Camp 5B Attendees: Bus ride to Spaulding Elementary School for lunch then back to the park. Date(s): June 11 15, 2018 Time: Approximately between 11:00 am and 12:30 pm, Monday Thursday 2:00 pm. On Friday, transport is only to the school. After the ceremonies at the school, they will walk to the Middle School for departure. Location: Day Camp at Community Park and Spaulding Elementary School Phone: Mode of Transportation: Goshen School Transportation Department Place of Departure: Kathryn Stagge Marr Community Park Time:approximately leaving around/after 11:00 a.m. Place of Return: Kathryn Stagge Marr Community Park Time:approximately returning around/by 12:30 p.m. Adults Accompanying the Unit: Name: Day Camp Unit leader the camper is assigned to Phone: Name: Day Camp Unit leader the camper is assigned to Phone: Each Girl Will Need: Expenses $: N/A Equipment: N/A Contact In Case Of Emergency: Name: Bobbie Spaulding Phone: My daughter, (name): Has my permission: To ride Goshen Transportation School bus to have lunch and then return to camp at the park. She is in good physical health and does not have any serious illness or has not recently had an operation. Her updated health form is in the leader s possession or is being returned with this form with information updated (as needed) and signed on the back. During the activity, I may be reached at: Address: Data submitted on page 5 City: Data submitted on page 5 State: Data submitted page 5 Zip: submitted pg 5 Work Phone: Data submitted page 5 Home Phone: Data submitted page 5 Cell Phone:Data submitted page 5 If I cannot be reached in the event of an emergency, the following person is authorized to act on my behalf: Name: Data submitted on page 9 Address: Data submitted on page 9 City: Data submitted on page 9 State: Data submitted on page 9 Zip: submitted pg 9 Work Phone: submitted on page 9 Home Phone: submitted on page 9 Cell Phone: submitted on page 9 I understand that my child will not be released to any person other than the above named or myself. I understand that, for my daughter s protection, all persons will be asked for identification. Persons named above should be prepared to provide identification to the satisfaction of the leaders in charge (i.e. current driver s license with photo identification). Parent/Caregiver Signature: Date: