BACKGROUND INFO. Child's Likes and Dislikes: ( Please let us know what you feel is important to the program)

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1 BACKGROUND INFO Childs Name: School: Grade: Areas of Concern or Safety Behavioral Concern of Parents: (For Example, please let us know if your child tends to run away, or if your child frightens easily etc..) Areas Of Positive Intervention Effective Interventions ( to be used in a behavioral situation): _ Child's Likes and Dislikes: ( Please let us know what you feel is important to the program) Child's Strengths & Weaknesses ( Please let us know what you feel is important to the program) Areas of Improvement Childs means of Communication ( verbal etc..) Child's Ability to Describe/ Recognize Emotions: _ Child's Level of Independence ( Please specify the child's level of needed supervision) Additional Comments:

2 Physical Activity Release Dear Parent/ Caregiver, All participants of our Special Needs Services programs will have the opportunity to engage in physical activity such as playing basketball, yoga, and other physical related activities. Participants will be closely supervised during all physical activity and will be given breaks as needed. Not only will the participants enjoy instructional activities, they will gain social skills and life skills. Please complete the following permission slip below. I give permission for to participate in the physical activities while in session at the JCC of Staten Island. -Or- I do not give permission for to participate in the physical activities while in session at the JCC of Staten Island. Parent/ Caregiver Signature: Date:

3 Photo Release I hereby grant the JCC full and comprehensive release to use pictures and / or video of the individual below in any advertising or promotional material including the JCC website and/or JCC social media. NAME OF PARTICIPANT SIGNATURE OF PARENT/GUARDIAN: DATE

4 Release of Information Form I,, hereby authorize Marvin s Camp staff of the Jewish Community Center of Staten Island to act on my behalf in either obtaining information verbally or written from outside providers( such as teachers, support staff etc.) that provide support to my child at home and /or at school. I understand that this information will be shared for the purpose of enhancing the efficacy my child s camp experience as well as ensuring that it meets the larger needs and goals of each individual. Parent/Guardian Signature Date Staff Signature Date

5 Swim Release Form Dear Parent/ Caregiver, All Participants of our Special Needs Services programs have the opportunity to utilize the JCC swimming pool. Participants will change for the pool in the Family Changing Room with staff assistance. Participants will not only enjoy instructional activities, they will gain social skills and life skills. Please make sure to send a bathing suit, towel and pool shoes. Staff will assist as necessary. Please complete the following permission slip below. I give permission for to participate in the swim program while in session at the JCC of Staten Island. -Or- I do not give permission for to participate in the swim program while in session at the JCC of Staten Island. Parent Signature Date

6 JCC of Staten Island Special Needs Registration Application Date: Child s Name *Allergy Alerts* Sex: Male Female Date of Birth: / / *Sezures* Yes No Address: City: Zip: Parent/ Caregiver Information Name: Relationship to child: Home Phone: Work Phone: Cell Phone: Address: City: Zip: Address: Emergency Contact Information -1- Name: Relationship to child: Home Phone: Work Phone: Cell Phone: Address: City: Zip: Address: Emergency Contact Information -2- Name: Relationship to child: Home Phone: Work Phone: Cell Phone: Address: City: Zip: Address: Pick-up Drop-off Information Please include their name/address/phone number and relationship to child *Please Note* We will ask for identification and will NOT release your child to anyone who you do not specify in writing is approved to pick-up your child. Please inform individuals to bring their I.D. when picking up your child. Individuals permitted to pick up your child -1- Name: Relationship to child: Home Phone: Work Phone: Cell Phone: Address: City: Zip: -2- Name: Relationship to child: Home Phone: Work Phone: Cell Phone: Address: City: Zip: -3- Name: Relationship to child: Home Phone: Work Phone: Cell Phone: Address: City: Zip: REVISED

7 Education Child s Name: School: Grade: Class Setting: Areas of Concern and Safety Behavioral Concerns of Parents. For Example, please let us know if your child tends to run away, or if your child frightens easily, etc. Areas of Positive Intervention Effective Interventions With Your Child: Childs Like and Dislikes (Please let us know what you feel is important for us to know) Childs Strength and Weakness Please specify child's level of language: Childs ability to describe emotions: Childs level of independence needed (Please specify the Childs level of needed supervision) Additional Comments: OFFICE USE ONLY Update Intake Informtion Updated Medical Swim Waiver Photo Waiver REVISED

8 DATE HEALTH RECORD FOR CAMP PARTICIPANTS AT THE JEWISH COMMUNITY CENTER OF STATEN ISLAND (This side to be filled in by parent before presentation to physician) NAME OF PROGRAM K Ton ton, Shalom, Chalutz, Maccabiah, Nesiyah/Teen Travel, Tikvah/Marvin s Camp, CIT I, CIT II / / M F CHILD'S LAST NAME FIRST NAME BIRTHDATE SEX Home Address: Phone: Parent or Guardian Phone: Place of Employment: Father (Guardian) Phone: Mother (Guardian) Phone: In case of emergency, notify: Phone: If Parent, Guardian is not available in an emergency, notify: 1. Phone: Or 2 Phone: Important: Has this participant been exposed to any communicable disease during the three weeks prior to camp attendance: Yes No (If yes, state type of exposure and please provide physician letter for program clearance): HEALTH HISTORY: (Check box if child has had afflictions, give appropriate dates) Allergies Rheumatic Fever Hay Fever Food Seizures Poison Ivy, etc. REACTION TO ALLERGEN Diabetes Insect Stings Asthma Penicillin Chicken Pox Other Drugs Other Past Illnesses Operations or Serious Injuries (Dates) Hospitalization (Dates) Chronic or Recurring Illness Any specific activities to be encouraged?

9 First Name Last Name Conditions that require activity to be restricted? Permission for all program activities unless otherwise noted by Dr. Appliance worn (glasses, contacts, etc.) Medication taken(include frequency and dosage)- Suggestion from Parent/Guardian CONSENT FOR EMERGENCY MEDICAL TREATMENT I do hereby give authority to the Jewish Community Center of Staten Island to obtain necessary emergency medical treatment for my child in the event that no one can be reached for serious injuries and with the understanding that the family will be notified as soon as possible. Relationship Signature Date Tel. #

10 First Name Last Name PHYSICAL EXAMINATION (To be filled out by Physician please note information on reverse side) The purpose of this health record is to provide the staff with pertinent information which will help to serve the needs of this child. All Immunization Records can be attached to this form. IMMUNIZATION HISTORY This is a record of dates of basic immunization and most recent booster doses. DTaP, DTP, DT, Td Polio MMR Hemophilus Influenzae type b (Hib) Hepatitis B Varicella Pneumococcal Conjugate (PCV) Other Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Other Date Other Date Blood work showing immunity will be accepted if dates are not available TB mandatory if not completed within 12 months. Please attach results. MEDICAL EXAMINATION To be filled out by licensed physician. Examination is acceptable when performed no more than 12 months prior to arrival at camp. Code: S = Satisfactory X = Not Satisfactory (Explain) 0 = Not Examined General Appearance Genitalia Height Weight Blood Pressure Posture & Spine Throat - Tonsils Nose Teeth Abdomen Hernia Feet Lungs Skin Hgb. Test (Date) Urinalysis (Date) Eyes Vision w/glasses Extremities Heart Ears Hearing Neurological Findings Describe Abnormal Findings and/or Handicapping Conditions Recommendations and restrictions while in camp: Special Diet Special Medicine (If being administered onsite, we need an MD prescription and medication in a blister pack if possible) Is parent/guardian sending special medicine? Activity Restrictions Swimming Diving General Appraisal: Physician Stamp required by the Board of Health General Appraisal: Physician Stamp required by the Board of Health for Camp I have examined the person herein described, reviewed his/her health history and it is my opinion that he/she is physically able to engage in Day Camp/Year Round Afterschool and Youth Center activities, except as noted above. M.D. EXAMINING PHYSICIAN (SIGNATURE) PHYSICIAN'S NAME (PLEASE PRINT) Telephone Address Date of Examination ZIP CODE

11 PARENT PERMISSION TO GIVE P.R.N (as needed) OVER-THE-COUNTER MEDICATION Name Date of Birth Today s Date Over-the-counter (OTC) medications are drugs that do not require a prescription and are purchased over-the-counter. This form is required before over-the-counter medications can be administered at the JCC. Please contact the Special Needs Nurse for any additional information. PLEASE INITIAL EACH MEDICATION FOR WHICH YOU ARE GIVING PERMISSION I approve all medications listed below OR Please check off what you allow to be provided if necessary. Antibiotic Cream ( Bacitracin, Polysporin, Neyomycin) Hydrocortisone Cream Benadryl Cream ( Caladryl, Diphenhydramine) Sunscreen First Aid and Burn Cream ( Benzalkonium Chloride & Lidocaine) Burn Gels Ibuprofen (Advil, motrin) Acetaminophen Antacid Cold Medication Oral Products containing Benocaine (Oragel, Chloraseptic) Antihistamine (Benadryl, chlorpheniramine, loratadine) Please note the above medications may not always be readily available, please provide the participant with their own supply to ensure its availability. OTC medications will be given at the manufacturer s recommended dosage, for no longer than two days in a row without a Dr. s order. The JCC is not able to supply OTC medication for frequent or daily use. THE MEDICATIONS INDICATED ABOVE MAY BE ADMINISTERED (Signature of Parent or Guardian) (Date) MD Signature (Signature of Doctor or Primary Care Physician) (Date)

12 JEWISH COMMUNITY CENTER OF STATEN ISLAND PPD TEST VERIFICATION FORM Name: Address: Date PPD Administered: Site of PPD: Lot #: Expiration Date: Date Results Read: Indurations: Results: Follow Up: MD Signature: *QuantiFERON Gold blood-work is also accepted. After two negative PPD s and/or QuantiFERON Gold testing within 12 months no further testing is necessary for JCC programs unless the individual is showing signs or symptoms of Tuberculosis. If choosing to do QuantiFERON Gold please attach results. Please contact the Special Needs Nurse Delia Levy-Bianchino with any questions: (718) dlevybianchino@sijcc.com *If there are any contraindications for TB testing, Dr. may write a note stating the reason and when testing may be available.

13 Camp Committee Co-Chairs Susan Perel Ayelet Schwartz Camp Co-Directors Glenn Wechsler, MSW Stephanie Feldman, M.S., Ed., School Psychology Camp Staff Team Heather Ascher Carrie Bernstein Leah Commer Samantha Goodman Laura Gotlin Lucy Kamil Dale Oks Lisa Quinn Randy Topper JCC President Gail Castellano Executive Director David Sorkin Ass t. Executive Directors Rebecca Gallanter Orit Lender Dear Parents, Summer 2017 We are pleased to announce that, once again, we will be offering catered lunch at camp this summer, in partnership with B & Y caterers. The daily cost for lunch is $7.00. Each kosher meal includes an entrée, side and drink. The weekly menu is as follows: Mondays: Tuesdays: Wednesday: Thursday: Friday: Square Pizza, Fruit & Cookie Hamburger, Tater-tots & Veggie Turkey Sandwich, Potato Chips & Fruit Chicken Nuggets, French Fries & Veggie Square Pizza, Fruit & Cookie Please note the following: All meals are served with a bottled water Lunch program is not available on trip days Lunches are served in individual packages Substitutions are not available We are unable to distribute refunds/credits to absent campers Lunch orders for the first week of camp are due no later than Friday, June 16th. Lunch orders must be placed one week in advance of the date you wish for your child to start receiving lunch, please refer to the cut off dates listed below to order or change lunch: Week 1: June 16 th Week 5: July 26 th Week 2: July 5 th Week 6: August 2 nd Week 3: July 12 th Week 7: August 9 th Week 4: July 19 th Week 8: August 16 th If you have any questions, feel free to contact us. FUN IS OUR TRADITION! Samantha Goodman Sgoodman@sijcc.com through June 28 th Joan after & June Alan 29 Bernikow th Jewish Community Center Joan & Alan Bernikow Jewish Community Center 1466 Manor Road Staten Island, New York July/August Sept/June

14 Shalom Trip - DO NOT ORDER * Maccabiah Trip - DO NOT ORDER* Marvin s Trip s - DO NOT ORDER* Chalutz Trip DO NOT ORDER* Maccabiah Trip - DO NOT ORDER* Maccabiah Trip - DO NOT ORDER* JCC OF S.I. LILLIAN SCHWARTZ DAY CAMP LUNCH FORM 2017 Child s Name: Home Phone: Parent Cell Phone: CIRCLE ONE: K Ton Ton Shalom Chalutz Maccabiah Marvin s Camp DIRECTIONS: Please circle the individual dates that you wish to purchase lunch (INCLUDES: ENTRÉE, BEVERAGE & DESSERT) for your child. Then, tally the number of circled days and multiply that number by $7.00. Send the completed form, along with a check made out to the JCC of Staten Island, to JCC, ATTN: Samantha Goodman, 1466 Manor Road, Staten Island, NY REMEMBER DO NOT ORDER LUNCH ON TRIP DAYS! LUNCH ORDERS ARE DUE NO LATER THAN THURSDAY, JUNE 16th. MONDAYS Square Pizza, Fruit & Cookie TUESDAYS Hamburger, Tater Tots & Veggie WEDNESDAYS Turkey Sandwich, Chips & Fruit THURSDAYS Chicken Nuggets, French Fries & Veggie FRIDAYS Square Pizza, Fruit & Cookie July 3 NO CAMP July 5 July 6 July 7 July 10 July 11 July 12 July 13 July 14 July 17 July 18 July 19 July 20 July 21 July 24 July 25 July 26 July 27 July 28 July 31 August 1 August 2 August 3 August 4 August 7 August 8 August 9 August 10 August 11 August 14 August 15 August 16 August 17 August 18 August 21 August 22 August 23 August 24 August 25 PARENT S WORKSHEET: # of Lunch Days X $7.00 (Daily Lunch Fee) = (Total Amount Due)18CF102 PLEASE NOTE: *On Trip days please send a brown bagged lunch. Maccabiah Overnight August 18th Lunch Provided Lunches orders must be placed at least one week in advance. We are unable to distribute refunds/credits to absent campers. Substitutions are NOT available If ordering additional lunches, a new form must be submitted with payment Please adhere to the following due dates: Week Lunch Wanted : Form Due By Week 1: June 16th Week 2: July 5th Week 3: July 12th Week 4: July 19th Week 5: July 26th Week 6: August 2nd Week 7: August 9th Week 8: August 16th

15 JCC/Lillian Schwartz Day Camp at Henry Kaufmann Campgrounds 1131 Manor Road, Staten Island, NY MEDICAL ALERT CARD NAME OF CAMPER: Camp: K Ton Ton, Shalom, Chalutz, Maccabiah, Marvin s Camp, Nesiyah/Teen Travel, CIT I or CIT II (please circle camp division) Parent 1 Name Cell # Wk# Parent 2 Name Cell # Wk# Dear Parents, In order for camp to successfully meet the safety needs of your child, please provide us with the following information: Insurance/Medical Policy # Other Medical +/or Accident Insurance Family Physician Name Physician Phone # ALLERGIES, MEDICATIONS EMERGENCY CONTACT PHONE # S & RELATIONSHIP TO CAMPER AUTHORIZATION FOR PEDIATRIC EMERGENCY-MEDICAL AND/OR SURGICAL TREATMENT EXPLANATION It is the firm hope that the authorization granted on this card will never have to be used. For the safety of the children, however, sound medical practice calls for such authorization. In emergency situations, where for some reason the parent of the child cannot be contacted immediately, this card may be extremely important. The authorization granted by this card will be used only where absolutely necessary and only after every attempt has been made to contact the parent. AUTHORIZATION IN CASE OF EMERGENCY, I HEREBY AUTHORIZE THAT THE DOCTOR OR THE HOSPITAL TO WHICH MY CHILD OR CHILDREN MAY BE BROUGHT (AND WHOMEVER THEY MAY DESIGNATE AS THEIR ASSISTANTS) TO PERFORM ANY EMERGENCY PROCEDURE OR OPERATION, TO GIVE TREATMENT AND THE ADMINISTRA- TION OF ANESTHETIC TO MY CHILD. I ALSO AUTHORIZE THE USE OF MY HOSPITALIZATION OR MEDI- CAL INSURANCE COVERAGE AS INDICATED ON THE REVERSE SIDE. SIGNATURE RELATIONSHIP TO CHILD DATED: / / /

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