All Forms and Money Must Be Returned By

Camp Classen

Student forms to return

ALL FORMS AND MONEY MUST BE RETURNED BY:

Friday, October 7, 2016

PLEASE DO NOT REMOVE STAPLE

Page 1 – Student/Parent Agreement – signatures are required

Page 2 – General medication information – signature required

Page 3 – Medical/Insurance information – signature required, copy of insurance card required

Page 4 – Medication Consent Form*

Page 5 – Form to allow student to self-administer medication (example: inhaler, diabetes medication…)

*yellow form must be completed by a physician if any type of medicine will be sent with the student (Tylenol, allergy medicine, cough drops, etc.)

2

Student Agreement

As a student of Moore Public School Outdoor School Program, you must agree to the following statements. Your signature is required to show that you accept these responsibilities.

I understand that failure to assume these responsibilities may result in loss of privileges or in being sent home.

I will:

·  conduct myself in a mature, responsible manner

·  be respectful to adults and peers at all times

·  be friendly to all other campers

·  exhibit a positive attitude at all times

·  willingly follow the rules of my cabin counselors, teachers, and camp staff

·  be willing to help with all duties (clean up, etc.) at all times

·  be a good role model to my cabin mates

·  participate in all activities as directed by the camp director and teachers

I will NOT:

·  participate in pranks or horseplay of any kind

I have read and agree to all of the above.

Student Signature ______Date______

______

Parent Agreement

My child has permission to attend outdoor school during the week of November 7-November 11, 2016. I understand that students will be in the woods and other rugged terrain for nature and environmental study part of each day. An adult will supervise all students. Information about my child’s medical condition and/or medications may be shared with the adults on an as needed basis (Heritage Trails employees and cabin parents) who will be caring for him/her. In case of medical emergency, I understand I will be contacted as soon as possible. I give permission for Moore Public Schools/Heritage Trails Staff to transport my child to a hospital or medical office if necessary to secure emergency medical care. I give my consent for any Heritage Trails Camp Staff to make any necessary medical decisions on my child's behalf.

Photo Release: I hereby give representatives of Heritage Trails Elementary and Moore Public Schools the unqualified right to take pictures of my child while he/she is attending the Heritage Trails Elementary Outdoor Education Program at Camp Classen and to place the finished pictures on the Heritage Trails Elementary/Moore Schools website and on the camp video. I understand that these pictures will be accessible to anyone with Internet access and may be used in instructional settings. NO children’s names will be published.

Signature of Parent/Guardian: ______Date ______

Important Medications Information: Please read carefully

Feeling ill or having headaches, etc. is hard enough as a child when you ARE in the comfort of your own home. Having these problems when you are AWAY from home can be a little tougher to deal with. It is important for us to offer the suggestion of considering what COULD flare up during the child’s stay and consider sending some medication, etc. By no means are we suggesting you HAVE to send anything, but after going to camp for several years we have experienced instances where some Tylenol or over the counter allergy meds could have made a difference for the child.

As per Moore Public Schools policy we must have a prescription EVEN for over the counter medications. Please don’t let that deter you from sending them. The bottle will not suffice for this requirement. The Moore Public Schools Parent Medication Consent Form is attached to this packet. Please make copies of this form for EACH medication sent with your child. The physician will complete the form as the prescription. The nurse can even fax the form to us! Without this form we can’t even give them a cough drop! The label on the bottle alone, or the computer printout from the pharmacy will not be acceptable for us to dispense medication to the students.

Per District Guidelines:

ALL MEDICINES MUST BE IN PRESCRIPTION VIAL WITH THE PHARMACY LABEL THAT STATES: PHYSICIAN’S NAME, NAME OF MEDICATION, AND DIRECTIONS FOR THE ADMINISTRATION OF THE MEDICATION TO THE STUDENT. OVER THE COUNTER MEDS MUST BE IN THE ORIGINAL CONTAINER AND ACCOMPANIED BY THE PHYSICIANS WRITTEN REQUEST AND INSTRUCTIONS FOR THE ADMINISTRATION AT SCHOOL OR CAMP CLASSEN…NO EXCEPTIONS!

We will be sending a baggie with a medication log inside for you to complete IF you are sending any medications. This will come home right before we leave. These will be checked in to us as you arrive the morning of departure. Please DO NOT put medications in your child’s bags for camp. However, feel free to send the prescription note in ahead of time. If the form is not included WE ARE PROHIBITED FROM DISPENSING ANY MEDICATION TO THEM. It is very hard to turn someone away because they have not taken the necessary steps.

------

By signing this form, the parent with legal custody or guardianship understands that under state law, the Board of Education, the Moore School District, or employees of the District shall not be liable to the student or the student’s parents or guardian for civil damages for any personal injuries to the student which result from acts or omissions of school employees in administering the medication. I hereby give my consent and authorize the school nurse, principal, or designated employee at Heritage Trails Elementary to give medication(s) to my child, ______as (student’s name)

recommended by Dr.______for the purpose of treating the following condition(s)______. I give school personnel permission to contact the prescribing physician if necessary.

Signature of Legal Parent/Guardian______date______

Camp Classen Outdoor School Program

Emergency/Health/Medications Information

Student’s name______Male_____ Female_____

Birthdate:___/____/______Age:______Home Phone:______

Home Address: ______

Parents / Guardians: ______

Work Phone: (mom) ______(dad) ______

Cell phone: (mom) ______(dad) ______

Emergency contact (Other than Parent) :______

Phone: ______Relationship: ______

Family doctor: ______Phone: ______

Date of last tetanus shot (REQUIRED) ______

Does your child have any history of:

_____Diabetes _____ Seizures _____Hives

_____Stomach Problems _____Frequent Headaches

_____Bed Wetting _____Migraines _____Asthma

_____Allergies (Type:______)

Other Health Concerns or Physical Limitations that we need to be aware of:

______

Insurance:

Insured Carrier's Name:______Carrier's DOB:______

Insurance Company:______Subscriber Policy #______

_____ I am attaching a copy of BOTH sides of my child's insurance card. I will assume responsibility for any medical charges not covered by the insurance company.

_____ My child has no insurance coverage, but I will assume responsibility for medical charges incurred by my child.

Parent Signature:______Date:______

Circle T-shirt size: YS YM YL AS AM AL AXL

Boating Parental Permission: Please check one:

My child MAY _____ MAY NOT_____

Life jackets are required and provided by the camp.

Horseback Riding Parental Permission: Please check one:

My child MAY _____ MAY NOT_____

______

Parent Signature Date

CONTRACT FOR EXCEPTION:

TO SELF-ADMINISTER AND RETAIN MEDICATION ON PERSON

*Provisions under 70 O.S. 1984, Section 1-116.3 and the Moore Public Schools Policy #7150 allow a student to self administer a prescribed asthma, anaphylactic medication or diabetic medication. Approval to self administer medications must be authorized by the prescribing physician. The parent/ guardian of the student is to provide the school an emergency supply of the student’s medication.

___I have instructed ______in the proper use of his/her medication and it is my professional opinion that this student is capable of self-administration of the medication and should be allowed to carry and use that medication by himself/herself.

______/______/______

Physician signature Date

I understand this request is governed by Moore Public Schools regulations on self-administration of medication and there are conditions and exceptions to self-administration. I have instructed my child to inform school personnel if symptoms persist so additional emergency care can be obtained, if needed. I also understand that this permission may be revoked if my child misuses the medication. I understand that Moore Public Schools, its agents and employees shall incur no liability for any adverse reaction or injury suffered by this student as a result of self-administration.

We, the undersigned, absolve the school of any responsibility in safeguarding our child’s medication.

______/_____/______

Signature of Legal Parent/Guardian Date

3