Parent Permission for Educational Enrichment Activities (white) Challenge/Adventure Program Waiver Camp Campbell Gard (tan)

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1 We hope everyone is as excited as we are for our Camp Campbell Gard trip on May 15th and 16th. The leaders at Camp Campbell Gard have many fun activities planned for us including: a hayride, night hikes, Human Clue, and the high ropes course! Included in this packet is important pieces of information that will help make this experience enjoyable and safe for all involved. Please read over all pieces of information with your camper to ensure all parties are in agreement and understand expectations. Information Checklist Below is a checklist of all the information included in this packet. At the end, you and your camper will both be asked sign stating you have carefully read through the attached materials. Parent Permission for Educational Enrichment Activities (white) Challenge/Adventure Program Waiver Camp Campbell Gard (tan) Student Information/Medical Emergency Form (yellow) Picture Release Form (pink) Important Contact Information (green) ****Please keep this paper at home **** Items to Consider Packing (green) ****Suggestions given; keep at home**** Important Times The times for drop off and pick up are very important. Please respect other campers by showing up on time. Drop off and pick up will both take place at: Miami Valley Regional Center 4801 Springfield Street Dayton * Friday, May 15th Please arrive at the Miami Valley Regional Center no later than 4:30 p.m. * Saturday, May 16th We will leave Camp Campbell Gard no later than 2:00 p.m.. We will send text messages to parents when we leave Camp Campbell Gard. Please bring ALL signed forms with you when you drop off your camper on Friday, May 15th.

2 Montgomery County Educational Service Center High School Parent Permission for Community Training and Educational Enrichment Activities Community Training and Educational Enrichment activities are important parts of our curriculum. During the school year, students may be involved in training opportunities and field trips away from school grounds. Our goal is to foster independent living skills and hands on participation. Community Training and Educational Enrichment activities include trips to area museums, theaters, restaurants, shopping, volunteer community service in parks, homeless shelters, and nursing homes, libraries, public transportation training, and recreation experiences such as golf, bowling, swimming, and skating. The mode of transportation will depend on the activity and will include RTA, school bus, cabs, or walking. You will receive a phone call or a note on your child s daily or weekly communication sheet notifying you of the place, date, and time of each trip that occurs. Supervision will be provided in the following manner: A. Full supervision by teacher or educational assistant. (May be individual or small group.) B. Semi-independent a teacher or educational assistant, spot-checking students. Supervision will be gradually and systematically reduced. I,, give permission for Parent/Guardian Student to be involved in the above Community Training and Educational Enrichment Activities. Parent/Guardian Signature Date *The above signature must be signed by the student s legal guardian. I,, agree to be involved in the above-described Student Community Training and Educational Enrichment Activities. Student s Signature Date

3 YMCA CAMP CAMPBELL GARD Challenge / Adventure Program Participation Agreement print participant name print name of group Instructions: Please read this form carefully. Each participant and/or their parent must sign this agreement before the program begins. Without all appropriate signatures, the individual may not be permitted to participate in the program. I understand that my participation in programs offered by the Challenge Adventure Program at YMCA Camp Campbell Gard is based on the Challenge by Choice philosophy. I recognize that the program is designed to use experiential, engaging teaching techniques but, that my participation is purely voluntary. At all times I will choose my level of participation in any activity. I understand the employees of YMCA Camp Campbell Gard have received extensive training, and will work to protect the emotional and physical safety of myself and/or my child. I understand that climbing, high ropes courses, ground initiatives, low ropes courses, boating, archery, hayrides, Jumping Pillow, hiking, and other activities in the Challenge Adventure Program for which I and/or my child have enrolled, entails certain risks. I elect to participate in spite of these risks. Therefore, for myself / my child, I knowingly and voluntarily assume all risks involved in my participation, and do hereby release YMCA Camp Campbell Gard and its members, trustees, officers, employees, independent contractors and agents from any and all liability, damages, costs, and expenses arising out of or relating to bodily or psychological injury, loss of life or personal property that may occur as a result of visiting YMCA Camp Campbell Gard. I have read and understand and accept the terms and conditions stated herein and acknowledge that this agreement shall be effective and binding upon the parties during the entire period of participation in the said program. I grant the YMCA, and persons acting through them, the right to use, reproduce, assign and/or distribute photographs, films, videotapes, and sound recordings of myself or my child for use in materials they may create. signature of participant (required) date if participant is under 18 (signature of parent or guardian) age: address city state zip phone number Person to be contacted in case of emergency: Name: Home Phone: Business Phone

4 MONTGOMERY COUNTY LEARNING CENTERS STUDENT INFORMATION/EMERGENCY MEDICAL FORM DATE Student First Name School Year Student Last Name Birthdate StreetAddress City State Zip Parent/Guardian Information: Mother s/guardian Name StreetAddress City State Zip Home Phone Cell Phone Work Phone Father s/guardian Name StreetAddress City State Zip Home Phone Cell Phone Work Phone Is there a legal custody order that applies to this child? Please circle) Yes or No If yes, please give details: Emergency Contacts: Please list three people to be contacted in the event of an emergency (only if the parent cannot be contacted). Emergency Contacts will be called in the order given below if the parent/guardian CAN NOT be reached. 1. Name: Relationship: Phone: Cell: 2. Name: Relationship: Phone: Cell: 3. Name: Relationship: Phone: Cell: Emergency Care Information Preferred Physician: Phone: Fax: Preferred Dentist: Phone: Fax: Preferred Hospital: Phone: Fax: Allergies and/or Specific Health Considerations: CONSENT In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for the administration of any treatment deemed necessary by the above mentioned doctors, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists concurring in the necessity for such surgery are obtained prior to performance of such surgery. In addition to the aforementioned information, I give my permission for any and all medical information to be shared with all school personnel that interact with my child. Parent/Guardian Signature: Date Student Signature (if 18 yrs of age or older): Date REFUSAL TO CONSENT I DO NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take no action or to: (please explain) Parent/Guardian Signature: Date

5 PICTURE RELEASE FORM Please print: Name of Student Hearing Intervention Services Camp Campbell Gard School/Site I give permission for my child to be photographed and for the pictures to be distributed and/or used by MCESC. I do not give permission for my child to be photographed. Parent/Guardian Signature Date

6 Items to Consider Packing *Pack in a duffle/mesh bag. All items go through a heating process to ensure Camp Campbell Gard remains a bed bug free environment for its campers! Listening Equipment Hearing aid(s) / Cochlear implant(s) Hearing aid / Cochlear implant batteries Night Time Sleeping bag Pillow Sheet(s) Toiletries Toothbrush Toothpaste Contact Case Contact Solution Glasses Case Brush Ponytail holders Feminine products Deodorant Soap Shampoo/Conditioner Shower sandals Washcloth Clothing 2 T-shirts 2 pairs of shorts 2 long sleeved T-shirts 2 sweatshirts 2 pairs of underwear 3 pairs of socks 2 pairs of shorts 2 pairs of pants Pajamas Bras/sports bras Outdoors Extra pair of shoes Sunscreen Bug repellant Extras Disposable camera Cellphone Cellphone charger Plastic bags (for dirty laundry) Warm jacket / hoodie/poncho Towel