Peirce Middle School

1314 Burke Road

West Chester, Pa. 19380

484-266-2500

Seventh Grade Outdoor Education Trip

Parent and College Counselor Application

May 22 - 26, 2017

Dear Parents and Adults,

Parental support and adult participation for the outdoor education program is welcomed and encouraged. If you are interested in attending the Henlopen program this year, please fill in the attached application. Chaperones will be selected to attend the portion of the week their child will attend.

Your duties could include help in the kitchen, accompanying groups of students during the various activities, evening security, and assist in overall behavior monitoring. Parents are not expected to handle any discipline or behavior issues, but refer them to a Peirce staff member.

You will sleep in cabins with the students. We try to have two adults assigned to each cabin. There is no cost to adult chaperones. Chaperones will be selected based on space availability, parent skills and experience, and the staffing needs. PLEASE PRINT CLEARLY – ESPECIALLY YOUR EMAIL ADDRESS. All communications will be through email.

It is now a policy of the West Chester Area School District that all adults who attend overnight field trips get proper security clearances and a TB test. Information on these requirements can be found in board policy916, IFCB. Obtaining necessary clearances can take up to six weeks. Please do not start the clearance process until you are notified that you are able to attend – no later than April 1. I must have all applications and clearances by May 15 in order for parents to go to Henlopen this year.

Adult Name: ______

Address: ______

Phone Number: ______E-mail: ______

Name of Pupil: ______I am Male/Female (circle one)

Do you have any outdoor education or camping experiences? ______

______

Student’s science teacher: ______

Are you trained in first aid or CPR?______

Do you have any skills, hobbies, training that may be used in our program this year? ______

______

Smoking is prohibited while in camp
Emergency and Medical Information

In case of illness or accident, notify the following:

Name: ______Relationship:______

Home Phone: ______Other Phone: ______

Family Doctor: ______Phone:______

Other Contact: (name, phones): ______

Accident Insurance Coverage:

Insurance Company: ______Policy # ______

Any physical disabilities or other significant conditions? ______

______

______

______

Date of last tetanus shot: ______

Medications Taken: ______

Permission is granted, at no expense to the school district or its personnel, to take me to the nearest doctor or hospital in case of medical emergency.

______

Signature of Attending AdultDate

We will need help in the following areas. To give us the most flexibility in meeting the program requirements, please note with a check if there are any areas that you WOULD NOT be willing to be assigned to.

I WOULD NOT be willing to work in the following areas marked with a check.

_____ Pine Barrens walk – must be able to walk 2 – 3 miles, twice a day

_____ Seining – will require time be spent on the beach, monitoring students in the water

_____ Beachcombing – will require walking along the beach, collecting items, creating a poster

_____ Adventure challenge – a physical problem solving activity requires monitoring class activities

_____ Kitchen – assist in meal preparation and serving

Is there an area you would especially want to be assigned? ______

It is now a policy of the West Chester Area School District that all adults who attend overnight field trips get proper security clearances and a TB test. The required clearances are a child abuse clearance, criminal check clearance, and an FBI clearance.The FBI clearance will require you get fingerprinted at the Chester County Intermediate Unit. This cost of clearances and tests will be your responsibility. Information on the fingerprinting requirement can be found at Click on the link for Pennsylvania Department of Education. Other information on chaperone requirements can be found in district polity 916, IFCB. Please notify me by March 15 if you are hoping to attend. I will let chaperones know no later than April 1 if they will be able to go. Then start your clearance process, which can take up to six weeks. I must have all applications and clearances by May 15 in order for parents to go to Henlopen this year. Please hold all paperwork until everything is completed.

The three clearances and their links are:

  • Child Abuse Clearance Form Attached
  • Criminal Clearance
  • FBI Clearance

PLEASE NOTIFY ME BY MARCH 15 IF YOU ARE INTERESTED IN ATTENDING