Time Traveler. Day Camp 5B June 11 15, 2018 Kathryn Stagge Marr Community Park 9:00 a.m. 3:45 p.m. Camper Registration Packet

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1 Time Traveler Day Camp 5B June 11 15, 2018 Kathryn Stagge Marr Community Park 9:00 a.m. 3:45 p.m. Camper Registration Packet Registration Opens: Sunday, April 1, 2018 Registration Deadline: Monday, April 30, 2018 Registration Drop-Off/Questions see page 2 OPEN FOR NEWS ABOUT DAY CAMP! 1

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3 Dear Caregiver: Thank you for your interest in sending your Girl Scout to volunteer day camp. At camp, girls will discover their values and talents through a variety of outdoor activities. Girls will also connect with other girls and adults, learn how to work together as a team, and use that teamwork to take action and make the world a better place. Please complete and return a Camper Registration, Health History, Photo Release and Code of Conduct Forms found in this packet, for each camper. Also, for this year only, we are including a permission slip for Bus Ride which relates to lunch time. On the next page, you will find basic information about day camp. Detailed information and instructions will be sent in a confirmation packet after you have registered. For additional questions or concerns, please contact the day camp directors. Day Camp Director: Bobbie Spaulding PA & Outdoor Program Director: Elizabeth Erb Business Director: Jennifer Horning Registrar: Melissa Rutter Program Director: Alisa Hill Or the committee at DayCamp5Bisfun@gmail.com Looking for additional outdoor activities for your Girl Scout? All of our summer camp and outdoor activities are listed on our website at gswo.org/camp. Adult Volunteers Needed: Day camp is staffed entirely by adult volunteers. Volunteer-led day camps are run by a dedicated team of specially trained volunteer directors who work year round to make this enriching opportunity possible. Each camp recruits and trains their own volunteers to help lead units, activities, and offer support at camp. We welcome moms, dads, aunts, uncles, grandparents and other adult friends to volunteer, without the support of volunteer s camp is not possible. A background in Girl Scouting is not necessary. Space at camp is limited by the number of adult volunteers. Campers who register with an adult volunteer will be given preference To make life easier on the volunteer, units for non-girl Scout children are available at a nominal fee while our adult volunteers are at camp. Your non-girl Scout children, ages 2 (toilet trained) to12, will attend camp in their own units. Girl Scouts of unit leaders working five full days will receive a reduced rate on their day camp fees. Please see the adult registration packet for more information. Camp Details: Transportation: Transportation is the responsibility of the caregiver. Drop off and pickup location and times will be detailed in the confirmation packet. Directions to camp: Kathryn Stagge-Marr Community Park is located at 6662 Goshen Road. Traveling from State Route 28, turn south on Goshen Road. The park is located on the left side of the road, almost immediately after passing Goshen Middle School. Drop off is at the Goshen Middle School. Food: Lunch will be provided for the campers at the school again this year. See confirmation for updates. Caregivers: If you feel this camp is unsafe or a hazard to children you, should contact Clermont County Children's Services Department at or Clermont County Combined Health District at /2018 1

4 Health: A nurse or first aider will be available at camp. Check with your physician to see if a tetanus booster or any immunizations are necessary. Medications are the responsibility of the caregiver. Campers should give any medications the camper may need to the health supervisor or unit leader in the original container on the first day of camp. Be sure to include written instructions. Ensure any allergies or dietary restrictions are recorded on your Girl Scout s Health History form. Clothing: Proper dress for the weather is necessary. No halters or sandals. Wear sturdy shoes, socks, and head cover and bring rain gear. Camp is not cancelled because of rain. Insurance: Every registered Girl Scout and registered adult member is automatically covered under the basic plan by Girl Scouts of the USA. This plan is effective from October to the following October. This insurance provides up to a specified maximum for medical expenses incurred as a result of an accident while a member is participating in an approved Girl Scout activity, after the individual s primary insurance pays out. Activity Costs: (Note: Patches are included for any attending child) Girl Scout Daisies/Brownies/Juniors/Cadettes $ 60 (T-shirt included) Girl Scout Daisies/Brownies/Juniors (Related child of five day volunteers) $ 40 (T-shirt included) Girl Scout Cadettes (non PA s) (Overnight Fee) $ 10 PAT Unit requires a pre-camp training to be held on Saturday, May 19, 2018, 9:00 a.m. 3:00 p.m. Contact us if this is a conflict. Program Aides (going into grades 8-12) and earned their PA pin-do not fill out this form. Use the PA registration packet. Adult volunteers please complete adult registration packet. Membership fee for non-registered girls and adults $ 25 (All school age girls and adults participating in camp must register as Girl Scouts.) Boys (12 and under)/pixies (children 5 and under and potty trained) $10 (T-shirt not included) T-shirt for boys/pixies/or extra T-shirt $10 each (optional) Make checks payable to Girl Scouts of Western Ohio. Complete the registration, additional information and release forms and return with payment to: Melissa Rutter 1422 Lela Lane Milford, Ohio Do not put directly in Melissa s mailbox! Use provided bin on her porch. Do not send registrations to the Girl Scout Center. All registration received at the Girl Scout Center will be forwarded to the appropriate day camp on a weekly basis and may cause your child to be closed out of camp. In-Person Registration: Thursday, April 5, 2018, 6:00 8:00 p.m. at Panera, 1066 State Route 28, Milford, OH Come sign-up, ask questions, and get help with registration and/or turn in forms and payment. Financial Assistance: Financial assistance may be available for girls who want to attend but are unable to do so because of limited family income. Applicants must pay at least $24 (40 percent) of the day camp fee. Please include payment for the total amount your family can pay with the registration form. Refund Policy: Money may be refunded for the following reasons only: 1. Moving out of town. 2. Illness or exposure to a communicable disease. 3. Required attendance at summer school. 4. Camp capacity is reached and no other camp is attended; refund will be sent within four weeks of registration date. To request a refund send a written request within ten business days (by June 29, 2018) from the end of camp to: DayCamp5Bisfun@gmail.com. Please use subject of Day Camp 2018 refund. 2

5 2018 Day Camp 5B Time Traveler Camper Application Camper s Name: Phone: Address: City: State: Zip: School: County: DOB: Age: Grade in Fall: Caregiver s Name: Phone: Caregiver s Troop Leader s Name or Troop #: Service Unit Name or #: Check box if not currently registered as a Girl Scout. (Please submit your $25 registration fee to be a Girl Scout with your camp fee.) Custodial Care: Mother only, Father only Both, Other Re-registering Girl Scout New Girl Scout Units: Girl Scout Daisies (Grade 1 in fall 2018) Girl Scout Brownies (Grades 2 3 in fall 2018) Girl Scout Juniors (Grades 4 5 in fall 2018) Girl Scout Cadettes LiA (Grades 6 8 in fall 2018)-Girls will earn their LiA and spend the night on Wednesday night. * Girl Scout Cadettes (Grades 7 8 in fall 2018)-this unit will earn their PA pin and spend the night on Thursday night. * I earned my LiA award. No Yes * $10 additional fee for overnight. Boys (Age 6-12) Pixies (girls and boys up to age 5 and potty trained Girl Scouts going into grade 8 and above that have earned their PA pin should complete the PA registration packet. 1 Buddy Name: T-Shirt Sizes: ( Adult Youth), ( SM, MED, LRG, XL, XXL) Check Youth or Adult and preferred size Camp Finances (Box must be completed entirely to be accepted) TOTAL FEES 1 Check if Financial Assistance is requested* 2 A Day Camp Fee $ *Families must pay a minimum of 40% of the camp fee Membership Fee for B + $ Day Camp Fee (Box 1A) $ non-girl Scouts (if applicable-$25) C Overnight Fee for LIA and PAT) $10 + $ Amount family can pay ( 40% of Box 1A) - $ D Cookie Dough* - $ Amount Requested (Box 1A Box 2C) = $ E T-shirt (opt for boy/pixie/extras)-$10 + $ F Financial Assistance (if requested is equal to box 2D) - $ G Late Fee ($10) after 4/30/ $ TOTAL Due = $ Membership Fee: Family must complete Request For Financial Assistance: Individual Membership form found at gswo.org Financial assistance is not available to cover additional camp items not included in camp fee. Financial Assistance (if needed): Please complete below. To be answered by a caregiver: How would this girl benefit from day camp? I give full permission for my daughter/son to attend day camp and participate in all phases of activities, except those noted. I have read the Day Camp flier and agree to cooperate with the guidelines listed. I understand that my camper must have written permission to leave camp early or with someone other than a caregiver. If I cannot be reached in an emergency, I give permission to give emergency treatment to my child. Caregiver Signature: Date: Mail completed Registration Form, Additional Information, Release, Heath Form, Photo Release, Code of Conduct and Bus Form with fee to: Melissa Rutter 1422 Lela Lane Milford, Ohio Deadline: Registrations will be accepted from April 1 30, Girls will be accepted on a first come, first served basis based on the number of volunteers available and according to postmark. Priority will be given to girls with caregivers who are volunteering. After April 30, 2018, registrations will only be accepted based on unit availability, and a $10 Late Fee will be charged. Camp fee must be received to confirm spot.. *Cookie Dough Must fill out the form at: gswo.org/cookiedough. Enter your Cookie Dough redemption code in the Cookie Dough Code box and your camp code in the Event/Camp Details box. Camp ID: 5bcamp 3

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7 Additional Information, Release and Health Form Camper s Name Date of birth Age Address Caregiver s Name Home Phone Work Phone: Cell: Caregiver s Transportation Information I understand that my daughter will only be released to the people listed below with proper ID: Name Relationship to girl Phone # Name Relationship to girl Phone # Medical Information This section must be completed by all girls attending in order to register for camp. Name DOB Date of last injection if this information is no longer available, write C for childhood if immunized as child. DPT: Measles/Mumps: TB: Polio: Tetanus: Hepatitis: Are medications currently being taken: No Yes, please specify: (Medication must be in original container with written instructions and given to the health supervisor at camp.) Are there any special needs or accommodations required? If yes, please explain: Are there any known behavior and/or emotional problems? If yes, please explain: Allergies and/or dietary modifications: 5

8 Is participant in good physical condition with no serious illness or operation since last health exam? Yes No If no, please specify: Physician s Name: Phone #: Insurance Information: Is the participant covered by family medical/hospital insurance? Yes No If so, indicate carrier or plan name: Group #: Name of insured: Relationship to participant: Social security number of policyholder or insurance ID number: Emergency Contact Information Emergency contact in case we can t reach caregiver: Name Relationship to girl Home Phone: Work Phone: Cell: Caregiver Permission and Consent to Treatment (Name of participant) is in good physical health and has had a physical examination in the past 12 months. Participant has my permission to attend Girl Scout day camp and to participate in all activities except those noted. I have read the day camp flier and understand and agree to cooperate with all regulations. I further understand that the deposit is refundable only for the reasons noted on the flier. Emergency Medical Authorization: This health history is correct to the best of my knowledge, and the person herein described has permission to engage in all prescribed Girl Scout activities except as specifically noted. Authorization for Treatment: In the event reasonable attempts to contact me at the provided phone numbers have been unsuccessful, I hereby give my consent to the administration of emergency medical treatment by any licensed physician or dentist and to transfer the child to any reasonably accessible hospital facility. 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 the performance of such surgery. My daughter may be registered as a Girl Scout member through September 30, Caregiver Signature: Date: /2018 6

9 Date(s): June 11 15, 2018 Photo Release Photographer/Producer: Girl Scouts of Western Ohio Assignment: Day Camp 5B June 2018 Location: Kathryn Stagge Marr Community Park Activity: Through day camp, you will have the opportunity to try new things and meet new people in a fun, safe and nurturing environment. Come learn new skills and create new memories that will stay with them long after day camp is over. RELEASE FOR MINORS For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I hereby consent and agree to the following: 1. I hereby grant to Girl Scouts of Western Ohio, and others working for Girl Scouts of Western Ohio or on its behalf, and each of its respective licensees, successors and assigns (each a Releasee ), the irrevocable, royalty-free, perpetual, unlimited right and permission to use, distribute, publish, exhibit, digitize, broadcast, display, modify, create derivative works of, reproduce or otherwise exploit my name, picture, likeness and voice (including any video footage of the same) (collectively, Media ), or to refrain from so doing, anywhere in the world, by any persons or entities deemed appropriate by Girl Scouts of Western Ohio, for any purpose (except defamatory) including, without limitation, any use for educational, advertising, non-commercial or commercial purposes in any manner or media whatsoever (whether known or hereafter devised) including, without limitation, on the internet, in print campaigns, in-store and via television. I agree that I have no interest or ownership in any of the Media. 2. I shall have no right of approval, no claim to compensation and no claim (including, without limitation, claims based upon invasion of privacy, defamation or right of publicity) arising out of any use, alteration, blurring, illusionary effect or use in any composite form of my name, picture, likeness and voice. I agree that nothing in this Release will create any obligation on Girl Scouts of Western Ohio to make any use of the Media or the rights granted in this Release. I hereby release and hold harmless Releasees from any claim for injury, compensation or negligence resulting or arising from any activities authorized by this Release and any use of the Media by Girl Scouts of Western Ohio. Name of Minor (please print): Address: City: State: Zip: Daytime Phone Number: ( ) Additional Phone (optional): ( ) Release for minors (those under the age of eighteen): I, the undersigned, being a parent/caregiver of the minor, hereby consent to the foregoing conditions and warrant that I have the authority to give such consent. Name of Caregiver (please print): Signature of Caregiver (Required): Caregiver Address*: (*will not be used for any other purposes or distributed to third parties) Region: Troop#: Service Unit:

10 DAY CAMPER CAMP CODE OF CONDUCT I, (Camper s name), understand that my attitude and behavior are critical to my success and the success of others during camp. Therefore, for the good of all, I agree to abide by the following: 1. I will be sensitive to the needs of each of my fellow campers by performing my assigned duties, including but not limited to unit kapers, all-camp kapers, mealtime cleanup, participating in all camp activities, etc. 2. I will respect the places and the people with whom I come in contact. This includes not leaving my unit without permission. 3. I understand that the use of profane language and gestures is prohibited. 4. I will be responsible for my personal belongings and equipment and will not hold Girl Scouts of Western Ohio or any other outsider responsible for the loss or damage due to my negligence or neglect. 5. I will treat equipment provided by Girl Scouts of Western Ohio, or any other person, with care. 6. I will use any safety equipment furnished by Girl Scouts of Western Ohio for my own protection. 7. I understand that I will be sent home for any and all acts of physical aggression (including hitting, kicking, biting, hair pulling) and threats or intimidation of physical injury. I understand this can affect my eligibility for 5B camp next year. 8. I understand that the use of alcohol, tobacco or drugs is prohibited. I understand that if I do not abide by this rule, I will be sent home. 9. I understand that if I do not abide by the guidelines listed above, the camp director will notify my caregivers, and I will be sent home. I also understand that if I am sent home early due to misconduct, I will not receive a refund. This form must be signed by both the camper and the caregiver and turned in with registration. Camper s Signature Date I have read and understand and agree with the above responsibilities of my camper. Caregiver s Signature Date

11 Permission Slip Must be completed anytime your troop goes anywhere away from their usual meeting place. Return the bottom portion of this form by (date): With Registration Application for Day Camp5B DC5B is planning is for: All Day Camp 5B Attendees: Bus ride to Spaulding Elementary School for lunch then back to the park. Date(s): June 11 15, 2018 Time: Approximately between 11:00 am and 12:30 pm, Monday Thursday 2:00 pm. On Friday, transport is only to the school. After the ceremonies at the school, they will walk to the Middle School for departure. Location: Day Camp at Community Park and Spaulding Elementary School Phone: Mode of Transportation: Goshen School Transportation Department Place of Departure: Kathryn Stagge Marr Community Park Time:approximately leaving around/after 11:00 a.m. Place of Return: Kathryn Stagge Marr Community Park Time:approximately returning around/by 12:30 p.m. Adults Accompanying the Unit: Name: Day Camp Unit leader the camper is assigned to Phone: Name: Day Camp Unit leader the camper is assigned to Phone: Each Girl Will Need: Expenses $: N/A Equipment: N/A Contact In Case Of Emergency: Name: Bobbie Spaulding Phone: My daughter, (name): Has my permission: To ride Goshen Transportation School bus to have lunch and then return to camp at the park. She is in good physical health and does not have any serious illness or has not recently had an operation. Her updated health form is in the leader s possession or is being returned with this form with information updated (as needed) and signed on the back. During the activity, I may be reached at: Address: Data submitted on page 3 City: Data submitted on page 3 State: Data submitted on page 3 Zip Data submitted on page 3 Cell Phone: Data submitted on pg 3Home Phone: Data submitted on pg 3Work Phone: Data submitted on page 3 If I cannot be reached in the event of an emergency, the following person is authorized to act on my behalf: Name: Data submitted on page 6 Address: Data submitted on pg 6 City: submitted on pg 6 State: submitted on page 6 Zip:submitted on page 6 Cell Phone: submitted on page 6Home Phone: submitted on page 6 Work Phone: submitted on page 6 I understand that my child will not be released to any person other than the above named or myself. I understand that, for my daughter s protection, all persons will be asked for identification. Persons named above should be prepared to provide identification to the satisfaction of the leaders in charge (i.e. current driver s license with photo identification). Print Caregiver s Name Signature of Caregiver Date 9