Microsoft word - cm 21 - parent letter to counselor.doc

Camp Menzies Parent Letter to Counselor
Girl Scouts Heart of Central California I 6601 Elvas Avenue Sacramento, CA 95819 I
RETURN ALL PAPERWORK - No later than four weeks prior to camp session Please complete the information requested below. This will help camp staff “get acquainted” with each camper and know what both girls and parents/guardians expect from this camp experience. Detailed information and honesty are greatly appreciated. Please attach additional sheets if necessary. Camper’s Name _____________________ Prefers to be called ______________________ Birthdate ___________________ Girl Scout Grade Level in the fall. (circle one) Brownie Junior Cadette Senior Ambassador Why have you and your camper chosen a Girl Scout Heart of Central California resident camp program? _______ Returning camper from ______ (year) ______ Friend attending _______ Heard about it from previous camper ______ Other (list) _______________________________________________ What other Girl Scout or non-Girl Scout camps has she attended? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Did you (the adult) ever go to camp?  Yes  No Have older brothers or sisters gone to camp?  Yes  No Has your camper ever been away from home for a week or more without members of the family?  Yes  No After talking with your camper, list two to three things she wants to do at camp. ___________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ What are your expectations? ________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Does your camper have any special physical needs of which the camp staff should be aware? (such as diet, sleepwalking, bedwetting,, mobility problems, retainer instructions, contact lens instructions, etc.) ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Does your camper have any special behavior needs of which the camp staff should be aware? (such as learning problems, hyperactivity, attention problems, etc.) ___________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ How does your camper react to new situations? _________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Is there anything else you would like the camp staff to know? ________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Are there questions you would like camp staff to answer about your camper’s experience at camp in their letter home to you? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Is your camper attending camp with a friend?  Yes  No Did you request she be in your daughter’s living unit?  Yes  No If yes, please list her/their name(s) ____________________________________________________________________________ _______________________________________________________________ _____________________________________ Camp Menzies Letter to My Counselors
Girl Scouts Heart of Central California I 6601 Elvas Avenue Sacramento, CA 95819 I
Session #:_________ Program Name: ______________________________________ RETURN ALL PAPERWORK - No later than four weeks prior to camp session Hi! My name is ______________________________ _____________________________________ (first) I am _______ years old and will be in the _______ grade in the fall. I decided to go to Camp Menzies because ________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ I want to learn how to ________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ One thing you need to know about me is . . . . . ________________________________________________________________________________ ________________________________________________________________________________ I have/haven’t been to camp before. My favorite part was _____________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Some things I don’t like doing as much are . . . . . ________________________________________________________________________________ ________________________________________________________________________________ I’m really looking forward to seeing you at Camp Menzies! I can hardly wait!!! Camper’s signature: ___________________________________ Date _________________________ Camp Menzies Horseback Riding Release
Girl Scouts Heart of Central California I 6601 Elvas Avenue Sacramento, CA 95819 I
Forms are due four weeks prior to camp session If you are attending the Two of Us Camp. Please complete the Two of Us Riding Release form. Camp Menzies will be offering beginning and intermediate horseback rides as well as special horse camp programs. Campers can participate regardless of age or riding experience (we do not have the staff and equipment available to accommodate riders with significant balance or mobility impairments). All Campers including those attending a riding program need to complete this form. For non-horse programs, two levels of riding are available. The one hour program includes safety orientation, arena instruction and trail ride. Girl Scout Brownies will have arena instruction only, and will play games in the arena rather than go on the trail ride. Cost: Included in camp fees. (If you do not wish for you daughter to ride, please indicate below AND on the health form!) Intermediate: Two hour program includes: extended arena lesson, basic horsemanship, and horse handling techniques, safety refresher and 1 1/2 hour trail ride, intermediate rides are not available on four and five day sessions. Prerequisite – Campers MUST be 10 years or older and have 10 or more hours previous solo riding experience off a lead line. Camp Menzies reserves the right to move a rider to the beginning level if prerequisite is not met. Cost: $20  For safety reasons, riders need to be able to mount, dismount, and balance on their horse and control the reigns with both hands in order to ride.  Additional riding sessions are not necessary for campers attending a riding program  Only one riding session per camper per camp session is available.  For planning purposes, intermediate rides must be requested and paid for at least four weeks prior to the camp session. NO exceptions. Please enclose payment with this form.  All riders must wear long pants and closed toe shoes  Due to time constraints, intermediate rides are NOT available for any four and five day sessions, which include: Sessions 1, 2, 4, 5, 7, 9, 10, 12 All necessary information can be found on the billing statement. Camp Program _______________ Session # _____ Camper’s Name ______________________________ Mailing Address ________________________________________________________________________ City/Zip ______________________________________________________________________________ Day Phone ___________________________________ Evening Phone ______ ______________________ Level of Instruction Requested: Beginning (No fee) ___ Intermediate ($20) ____ Payment must be enclosed for intermediate instruction. If no payment is enclosed, camper will ride beginning. Make check payable and return to: Girl Scouts Heart of Central California 6601 Elvas Ave Sacramento, CA 95819 I do not wish for my daughter to ride a horse while at camp.__________ (initial)
I understand that horseback riding is classified as a RUGGED ADVENTURE ACTIVITY, and that there are numerous risks always present in such an activity despite safety precautions. I assume full responsibility for the above minor in the event of bodily injury, death, and loss of personal property and expenses thereof as a result of my minor’s negligence in said activity. I give the above named minor permission to participate in Girl Scouts Heart of Central California sponsored horseback riding activity. Signature of Parent or Guardian ___________________________________ Date ____________________ Acknowledgment of Receipt of Parent Handbook/
Contact Information/T-Shirt Size Request
Girl Scouts Heart of Central California I 6601 Elvas Avenue Sacramento, CA 95819 I
Campers Name: _________________________________________________ Session Number: ______________
ACKNOWLEDGE OF RECEIPT OF PARENT HANDBOOK My Camper’s name is (please print) __________________________________________________ , I acknowledge that I have received a copy of the Camp Menzies Parent Handbook for Girl Scouts. I have read the handbook, and agree to comply with the guidelines and obligations contained in the handbook. I also understand and agree that Girl Scouts Heart of Central California reserves the right to revise, modify, delete or add to any and all guidelines and procedures stated in this handbook or in any other document. However, any such changes must be in writing and must be authorized by the Camp Director. We recognize that campers and counselors develop close, trusting relationships with one another at camp and that these relationships are healthy, wholesome and beneficial to campers and staff alike. We also recognize that it is natural for campers to want to keep in touch with their favorite counselors after camp. As a camp we do not encourage or sanction the exchange of contact information between campers and our staff, nor do we take responsibility for what may occur as the result of such contact. Therefore, our guideline is to forbid the exchange of contact information of any kind between campers and our staff, whether paid or volunteer. If a parent or legal guardian wishes their child to exchange such information with a camp staff member, the parent or legal guardian must sign a written form expressly granting this permission and accepting full responsibility for whatever may occur as a result. As the parent or legal guardian of _______________________________________, (camper’s name) □ I hereby grant permission for my child to exchange contact information with her counselor(s). I understand that by granting this permission I, as the parent or legal guardian, take full responsibility for any action, behavior or situation that may arise from any contact—online, in person or otherwise—that may occur between my child and a camp staff member. I recognize fully that the camp discourages their staff from having contact with campers after camp; that the camp does not recommend their staff as baby-sitters, Nannies or child companions outside of camp; and that the camp does not take responsibility for the behavior of their staff off-season. I also understand that this permission must be renewed for each camp season. □ I do not grant permission for my child to exchange contact information with her counselor(s). I recognize that the camp discourages their staff from having contact with campers after camp; that the camp does not recommend their staff as baby-sitters, Nannies or child companions outside of camp; and that the camp does not take responsibility for the behavior of their staff off-season. All campers receive a Camp Menzies t-shirt as part of the camp fee. In an effort to provide the correct t-shirt size, please complete the following information. Every effort will be made in filling the requested size. T-Shirt Size Camp Menzies Transportation Information &
Release Authorization
Girl Scouts Heart of Central California I 6601 Elvas Avenue Sacramento, CA 95819 I
Camper Name __________________________________
Departing Bus Location _________________________
Returning Bus Location _________________________
Dates of Program _______________________

Buses depart and return to Sacramento, Stockton, Salida and Angels Camp. More details are available in your
Camp Menzies Parent Handbook.
Release Information:
Please help us to provide a safe and enjoyable camp experience for your camper. We are asking you to designate those adults, INCLUDING parents, who are authorized to pick up the camper either from camp or at the bus return location. A delay will occur if the camper is being picked up by an adult not on the authorized list. The camper will not be released until proper authorization can be obtained. Finally, identification will be checked at the time of pick up, so please make sure to have a valid driver’s license (or similar photo identification) available. Please include additional adults who may pick camper up in case of an emergency. All campers MUST be signed out prior to leaving the return location. Are there any custody situations that we need to be aware of? If yes, please explain . . . (additional room on back of form) ___________________________________________________________________________________________ Authorized adults camper may be released to, parents included: To add additional people to whom campers may be released to, please use the back of this form: __________________________________ _______________ Signature at pick up Driver’s License at pick up Camp Menzies Camper Health History Form
Girl Scouts Heart of Central California I 6601 Elvas Avenue Sacramento, CA 95819 I
Camper Name: ___________________________________________ Bus Stop Location: ________________________________________________ Program: ________________________________________________ Session#: ________________________________________________________ Address __________________________________________________________________________ Phone ______ __________________________________ ____________________________________________________________________________ Birthdate _____________________________________ (1) Name _________________________________________________________________________ Phone 1 _______ ________________________________ Place of work _____________________________________ Title ______________________ Phone 2 _______ ________________________________ (2) Name _________________________________________________________________________ Phone 1 ______ _________________________________ Place of work _____________________________________ Title ______________________ Phone 2 ______ _________________________________ If parents can’t be reached, call (Name) _____________________________________________ Phone _____ ___________________________________ Address _________________________________________________________________________ Relationship ___________________________________ Name of Family Physician __________________________________________________________ Phone ______ __________________________________ Name of Dentist/Orthodontist _____________________________________________________ Phone I understand that my personal insurance will be primary coverage for camper accidents and illnesses and Girl Scouts Heart of Central California’s insurance is secondary up to a maximum of $15,000 for accident, $10,000 for illness and $4,000 for dental claims. Exception: if the total claim is less than $130, GSHCC will pay the full amount. On claims above $130, GSHCC will coordinate payments for deductibles and co-pays. If you have questions, please contact GSHCC at 916-452-9181. My insurance company: ____________________________________________________________ Policy #: _____________________________________ Insurance Company address: _______________________________________________________________________________________________________ Not currently insured – GSHCC reserves the right to subrogation if it is later determined that personal medical insurance was in place. Does the camper have any allergies or dietary restrictions we should be aware of? ____Yes ____No If yes, please explain (if you need more room please attach additional pages): ___________________________________________________________________________________________________________________________________ Does camper have any other medical conditions we should be aware of? ____Yes ____No Campers with medical conditions and/or injuries should complete a separate medical information form (form CM 34) in consultation with their medical care provider and submit it no later than four weeks prior to camp.
Recent operations or serious injuries ________________________________________________ Date __________________________________________ Hospitalizations __________________________________________________________________ Date __________________________________________ Any known recent illness or exposure to contagious disease (within the last six weeks)? _____ Yes _____ No Details _________________________ ___________________________________________________________________________________________________________________________________ Is the child currently under the care of a physician or psychologist? _____ Yes _____ No Details ____________________________________________ ___________________________________________________________________________________________________________________________________ Please list any limitations or restrictions to activities while at camp? _____________________________________________________________________ ___________________________________________________________________________________________________________________________________ Has child menstruated? _______ Has she received information on menstruation? _______ Menstrual problems? ________________________ Camper Name: ___________________________________________ Bus Stop Location: ________________________________________________ Program: ________________________________________________ Session#: ________________________________________________________ MEDICATIONS: The following non-prescription medications are commonly stocked in camp health centers and are used on an as needed basis to manage illness and injury. Cross out those items the camper should not be given. Lice shampoo or scabies cream (Nix® or Elimite®) Diphenhydramine (Benadryl®) Clotrimazole ATTACH A COPY OF THE CAMPER’S IMMUNIZATION HISTORY OR PROVIDE IMMUNIZATION DATES List any medications being brought to camp with dosage and their purpose. Medication, both prescription and over-the-counter, MUST be in the original container; camp CANNOT administer medication otherwise. Prescription medication must be labeled with the camper’s name and address and instructions. Add additional sheets as needed. Activities vary from program to program, and may include hiking, stewardship activities (for example, plant removal and trail maintenance), horseback riding, archery, canoeing, swimming, outdoor cooking (including the use of knives and propane stoves), fire building, backpacking, kayaking, surfing and sports. Some programs involve travel in camp vehicles driven by Girl Scouts Heart of Central California employees. I understand that by attending camp, my camper can be exposed to a variety of risks and hazards, foreseen and unforeseen, some of which are inherent and cannot be eliminated without fundamentally altering the unique characteristics of the camp program, These inherent risks include, but are not limited to, environmental risks and hazards, including rapidly moving, deep, or cold water; plants, insects, snakes, and predators, including large animals; falling and rolling rock; lightning; and unpredictable forces of nature, including weather that many change to extreme conditions without notice. Possible injuries and illnesses include allergic reactions, anaphylaxis, hypothermia, frostbite, sunburn, heatstroke, dehydration, infectious diseases, musculoskeletal injuries, and other mild or serious conditions or injuries including death. Emergency evacuation and medical care may be delayed thirty minutes or more due to the remote location of some camp activities. The above named camper has my permission to engage in all camp activities, except as noted by me. The medical information I have provided above is correct and complete to the best of my knowledge. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. I hereby authorize Girl Scouts, through the appointed camp medical personnel, to provide routine medical health care; to administer medications; and to order X-rays, routine tests as deemed advisable by a licensed physician. It is understood that every effort will be made to contact me or the person noted above before taking this action. I understand that this permission is given in advanced of need to any diagnosis, treatment, or hospitalization. I give permission for this form to be photocopied for trips outside of camp.


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