SCI-Girls WSKG Science Week

Partnership with Broome County Promise Zone – Summer Zone

Student Information (Camper Application Page 1 of 3)

1. Student Name: ______2. Date of Birth (MM/DD/YYYY): ______

3. Gender: M______F______Other______4. Grade Completed: ______5. Adult T-Shirt Size: ______

6.Parent/Guardian Name: ______

7.Permanent Address: (Street) ______(City/State/Zip)______

8.Parent/Guardian Phone: (Home) ______(Work)______(Cell)______9. Parent/Guardian Email Address: ______

10.With whom does the child reside (if different than parent/guardian):

______

11.​Emergency Contact ​ If parent/guardian is not available in an emergency, please contact:

a. Name: ______/ Relation to child: ______
Address: ______/ Home Phone: ______
______/ Cell Phone: ______
Work Phone: ______
b. Name: ______/ Relation to child: ______
Address: ______/ Home Phone: ______
______/ Cell Phone: ______
Work Phone: ______

Acknowledgement of Summer Zone Policies (Camper Application Page 2 of 3)

Student Name: ______Date of Birth (MM/DD/YYYY): ______

Parent/Guardian: Please initial by each statement to confirm understanding and compliance of said statements. Your signature and the date will be requested at the end of all of the statements.

_____ 12​ . I understand that I am responsible for any medication needs for my child and will make necessary arrangements to meet these needs.

_____ 13. I understand that my child must sign in and sign out each day of the summer program.

_____ 14. I understand that if my child arrives after everyone has left to go on a field trip, then I will need to transport my child to the field trip location, or the child will not be permitted to attend the field trip.

_____ 15. I acknowledge that it is my responsibility to keep my child’s records current to reflect any significant changes as they occur, ex. telephone numbers, home address, work location, emergency contacts, child’s physician, child’s health status, etc.

_____ 16. I understand that I will be informed by the Promise Zone staff of any incidents, including illnesses, injuries, etc, that include my child. In the event that parents, physicians, or other authorized persons cannot be contacted, the staff is hereby authorized to take whatever action is deemed necessary, in their judgement, for the health and safety of my child. I will not hold Promise Zone financially responsible for the emergency care and/or transportation for my child if such actions are necessary.

_____ 17. I understand that at field trips, snacks and meals will be provided. The only food necessary to be brought from home will be what is necessary for a special diet. If your child cannot eat what the Program is serving for lunch or snack for the day, please plan on sending a lunch from home with your child.

_____ 18. I understand that my child will attend the Program from ​ 9:00​ AM until 2:00 PM.. ​ M​ y child will not be​ permitted to leave earlier unless s/he makes special arrangements with myself and the Program Staff.

_____ 19. I understand that while no tuition is charged, students are required to attend daily program sessions.

_____20. I understand that there will be several family events as part of this program.

_____ 21. I understand that the Summer Zone staff retain the right to dismiss any student whose general attitude, behavior, or habitual actions are contrary to the policy and/or the interest of the Summer Zones. I further understand that this will be a last resort only after reasonable intervention has failed.

22. By signing this agreement, I acknowledge my acceptance of the Summer Zone policies of attendance and procedures as referenced above. I agree to ensure that my child will attend this program regularly if s/he is accepted.

a. Parent/Guardian Signature ______b. Date ______

Photo Release and Field Trip Consent (Camper Application Page 3 of 3)

Student Name: ______Date of Birth (MM/DD/YYYY): ______

23. Photo Release​

By signing here, I give my consent to Broome County Promise Zone to photograph, videotape, or document pictures of my child and to use such pictures and/or stories in connection with any of their work without consideration of compensation of any kind, and I do release Promise Zone from any claims whatsoever which may arise in said regards.

a. Parent/Guardian Signature: ______b. Date: ______

24. Field Trip Consent:​

I give permission for my child to attend field trips associated with Summer Zones. I understand that if my child does not have permission to attend, he/she will not attend the camp the day a field trip is scheduled. If inclement weather or unforeseen circumstances change a planned outing, parents and guardians will be notified accordingly.

I assume all responsibility for the risks and hazards incidental to participation in the Summer Program. I assume all responsibility for the behavior of my child and grant the staff and volunteers of the Summer Program to discipline my child based on the agreement for behavior. I do not hold the Summer Program or any of their personnel responsible for injuries or accidents of any kind, or loss of personal property.

I grant Summer Zones to obtain medical care in case of an emergency when a parent or guardian cannot be contacted to grant authorization for emergency treatment.

a. Parent/Guardian Signature: ______b. Date: ______

Medical/Allergy Information (Medical Information Page 1 of 3)

Student Name: ______Date of Birth (MM/DD/YYYY): ______

1.My child has the following health conditions that staff should be aware of:______

______

2.If any of these could affect participation in the program, please provide details:

______

3.Please list your child’s allergies (food, medication, and other): ______

______

4.Every program is required to have first responders trained in CPR and First Aid. In the event of an emergency, the school staff will contact 911 and follow their instructions. Every attempt will be made to contact a parent, guardian, or a designated emergency contact.

a.Hospital Choice: ______

b.Doctor’s Name: ______c. Phone: ______

d. Parent/Guardian Signature: ______f. Date: ______

5. Family Health Insurance Information (Please be aware that few doctors will directly bill out of state patients)

a. Carrier: ______b. Group #: ______c. Policy #: ______

d.Carrier Address: ______

e.Name of Insured: ______

f.Relationship to Insured: ______I.D. #: ______

6. To be signed by parent/guardian (Must be signed for your child to participate on the field trips)​

I hereby give permission to my child’s school/chaperones to provide routine health care, administer prescribed medications, and seek emergency medical treatment including ordering x-rays and routine tests. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. I give permission to my child’s school/chaperones to arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by my child’s school/chaperones to secure and administer treatment, including hospitalization, for the person named above.

a.Signature of Parent/Guardian: ______

b.Printed Name of Parent/Guardian: ______c. Date: ______

Medication/Prescription Information (Medical Information Page 2 of 3)

Student Name: ______Date of Birth (MM/DD/YYYY): ______

***Please complete the remainder of this form ONLY IF your child is on medication, prescription OR non-prescription

(ex: Inhaler, Epi-Pen, Insulin) that may need to be administered during Summer Camp.***

IMPORTANT: PLEASE READ

New York State Guidelines state any medication (prescription & non-prescription) must be accompanied by a written release from both the physician/licensed prescriber and the parent/guardian. The guidelines are the same as the requirements in the school setting.

All medication needs to be brought in the original container. For your convenience, we have single dose packages of the following over the counter medications in our office (Extra Strength Tylenol, Motrin, Benadryl, Pepto Bismol, and Dramamine) but can’t dispense any medication unless the licensed prescriber​ initials/dates it on the attached form. This​ form needs to be filled out in detail to prevent any confusion or the person assisting with medication.​

Please be sure the licensed prescriber checks the self-directed box which will allow trained, unlicensed personnel to​ assist your child with their medications in the nurse’s ​ absence.​

Please return the signed, attached form along with the medications on opening day. If you prefer to mail or email the form back to us, the information is below.

Our goal is to always provide your child with a safe and healthy experience here at Broome County Promise Zone. Thank you for your cooperation in assisting us with this goal!

Broome County Promise Zone

Binghamton University

PO BOX 6000

Binghamton, NY 13902-6000 Phone: 607-240-8964

Email: ​

Facebook: Union Endicott Promise Zone

**Prescription medication must be in the original pharmacy labeled container with specific orders and name of medication. Non-prescription medication must be in original packaging.

**Medication/Refills must be brought to the program by parent/guardian/responsible adult.​

A. TO BE COMPLETED BY PARENT OR GUARDIAN

1. I request that my child receive the medication as prescribed below by our physician.

a. Parent/Guardian Signature:______b. Date: ______

2. Date of your child’s last Tetanus immunization: ______

PHYSICIAN/LICENSED PRESCRIBER Medication/Prescription Information (page 3 of 3)

Student Name: ______Date of Birth (MM/DD/YYYY): ______

B. TO BE COMPLETED BY PHYSICIAN/LICENSED PRESCRIBER

1.I request that my patient, listed above, receive the following medication - Prescription & Non-Prescription​​ (​ ex:

Inhaler, Epi-Pen, Insulin)
Physician Initial: / Date:
______/ ______/ Ibuprofen 200 mg 1-2 tablets every 4-6 hours prn for pain
______/ ______/ ES Tylenol 500mg 1-2 tablets every 4-6 hours prn for pain
______/ ______/ Benadryl 25 mg 1-2 tablets 3x/day for abdominal distress
______/ ______/ Dramamine 50mg 1-2 tablets every 4-6 hours prn for motion sickness
______/ ______/ ______
______/ ______/ ______
______/ ______/ ______
______/ ______/ ______

Please use back of form to write additional medications.

2.Please check:

_____ a. I deem this child to be self directed​ and understand that​​ designated staff will administer medication in the​ case of absence of the school nurse, including field trips.

b.Physician /Licensed prescriber (print): ______

c.Physician/Licensed prescriber (signature): ______d.Date: ______

e.Address: ______

f.Phone: ______