Camper Forms Checklist-Camp Menzies If you have difficulty opening the forms, contact customer care at 916.452.9181/800.322.4475 or customercare@ Forms Tips Use the following checklist and review the information found on pages 30-34 of the Resident Camp Parent Handbook when completing the forms. Return forms by June 1, 2017 Write camper s name and the session number on every page and any additional pages you attach. Parent Letter to Counselors (Form #CM 21) Camper Letter to Counselors (Form #CM 31) Horseback Riding Release** (Form #CM 29) (For Camp Menzies campers only) Parent Handbook Acknowledgement/Contact Information (Form #CM 28) Transportation Information and Release Authorization (Form #CM 26) Camper Health History (Form #CM 23) * Camper Medical Information* (Form #CM 34) * Campers with medical conditions, injuries and/or behavioral issues being treated by a psychiatrist or psychologist are asked to complete this form in consultation with their medical care provider and submit it four weeks prior to camp. If your camper experiences an illness or injury less than four weeks prior to the start of the session, please notify the camp director about the condition and bring form CM 34 with you to the bus/van stop. Specific forms are available for campers with asthma, diabetes or who experience anaphylactic reactions. A general form is available for use for all other medical conditions. These forms can be found in the forms section of our website. Note for campers attending more than one camp session: It is not necessary for you to complete all the forms for each session your camper is attending. You only need to complete one copy of CM 23-Camper Health History, CM 20-Camper Medical Information*, CM 28-Parent Handbook Acknowledgement/ Contact Information and CM 29- Horseback Riding Release. On each of these forms please include the Program names and session numbers of all programs your camper is attending. Please complete a different copy of CM 21-Parent Letter to Counselor, CM 26-Transportation Information and Release Authorization and CM 31-Letter to My Counselors for each program the camper is attending (photo copies are acceptable but please include a copy for each program your camper is attending, noting correct program name and session number).
Parent Letter to the Camp Counselor Camper Name: Program and/or Session #: Camp: Troop # (if any): To be completed by parent/guardian Please complete the information requested below. This will help camp staff get acquainted with each camper and know what both girls and parents/guardians expect from this camp experience. Detailed information and honesty are greatly appreciated. Please attach additional sheets if necessary. Camper s Name Prefers to be called Birthdate Girl Scout Grade Level in the fall. (circle one) Daisy Brownie Junior Cadette Senior Ambassador Why have you and your camper chosen a Girl Scout Heart of Central California resident camp program? Returning camper from (year) Friend attending Saw newspaper article or ad First time resident camper Specialty program offered Previously attended a day camp Heard about it from previous camper Other (list) What other Girl Scout or non-girl Scout camps has she attended? Did you (the adult) ever go to camp? Yes No Have older brothers or sisters gone to camp? Yes No Has your camper ever been away from home for a week or more without members of the family? Yes No After talking with your camper, list two to three things she wants to do at camp. What are your expectations? Does your camper have any special physical needs of which the camp staff should be aware? (such as diet, sleepwalking, bedwetting,, mobility problems, retainer instructions, contact lens instructions, etc.) Does your camper have any special behavior needs of which the camp staff should be aware? (such as learning problems, hyperactivity, attention problems, etc.) How does your camper react to new situations? Is there anything else you would like the camp staff to know? Are there questions you would like camp staff to answer about your camper s experience at camp in their letter home to you? Is your camper attending camp with a friend? Yes No Did you request she be in your daughter s living unit? Yes No If yes, please list her/their name(s) Thank You! Signature of Parent/Guardian #CM 21 - rev 3/17 - HT:js Date
Camper Letter to Counselors Camper Name: Program and/or Session #: Camp: Troop # (if any): Dear Counselors: (to be completed by camper) Hi! My name is (first) (last) I am years old and will be in the grade in the fall. I decided to go to camp because I want to learn how to One thing you need to know about me is..... I have/haven t been to camp before. My favorite part was I like doing these activities..... Some things I don t like doing as much are..... I m really looking forward to seeing you at camp! I can hardly wait!!! Camper s signature: Date #CM 31 - rev 3/17 - HT:js
Camp Menzies Horseback Riding Release 6601 Elvas Avenue, Sacramento, CA 95819 t 916.452.9181 f 916.452.9182 Camp Menzies will be offering beginning and intermediate horseback rides as well as special horse camp programs. Campers can participate regardless of riding experience (we do not have the staff and equipment available to accommodate riders with significant balance or mobility impairments). All Campers in 2nd grade and older, including those attending a riding program need to complete this form. Campers in 1st grade will have a ground session instead of a riding program. Please Note: For safety reasons, riders need to be able to mount, dismount, and balance on their horse and control the reigns with both hands in order to ride. Only one riding session per camper per camp session is available. For planning purposes, intermediate rides must be requested and paid for at least four weeks prior to the camp session. NO exceptions. Please contact customer care to add an intermediate ride to your registration at 916.452.9181/800.322.4475. All riders must wear long pants and closed toe shoes Due to time constraints, intermediate rides are NOT available during any four, five or six day sessions, which include: Sessions 1, 2, 4, 6, 7, 8, 10, 11, 12, 13 Camp Program Session # Camper s Name Mailing Address City/Zip Day Phone Evening Phone I do not wish for my daughter to ride a horse while at camp. (initial) I understand that horseback riding is classified as a RUGGED ADVENTURE ACTIVITY, and that there are numerous risks always present in such an activity despite safety precautions. I assume full responsibility for the above minor in the event of bodily injury, death, and loss of personal property and expenses thereof as a result of my minor s negligence in said activity. I give the above named minor permission to participate in Girl Scouts Heart of Central California sponsored horseback riding activity. Signature of Parent or Guardian Date #CM 29 - rev 4/17 - HT:js
Acknowledgment Receipt of Parent Handbook/Contact Information Campers Name: Session Number: ACKNOWLEDGE OF RECEIPT OF PARENT HANDBOOK I acknowledge that I have received a copy of the Resident Camp Parent Handbook for Girl Scouts. I have read the handbook, and agree to comply with the guidelines and obligations contained in the handbook. I also understand and agree that Girl Scouts Heart of Central California reserves the right to revise, modify, delete or add to any and all guidelines and procedures stated in this handbook or in any other document. However, any such changes must be in writing and must be authorized by the camp director. CAMPER-STAFF CONTACT INFORMATION: We recognize that campers and counselors develop close, trusting relationships with one another at camp and that these relationships are healthy, wholesome and beneficial to campers and staff alike. However, for the protection of campers and staff, we do not permit the exchange of contact information between campers and our staff, nor do we take responsibility for what may occur as the result of such contact. If a parent or legal guardian wishes their child to exchange such information with a camp staff member, the parent or legal guardian must sign a written form granting this permission and accepting full responsibility for whatever may occur as a result. PARENT PERMISSION FORM As the parent or legal guardian of, (camper s name) I hereby grant permission for my child to exchange contact information with her counselor(s). I understand that by granting this permission I, as the parent or legal guardian, take full responsibility for any action, behavior or situation that may arise from any contact online, in person or otherwise that may occur between my child and a camp staff member. I recognize fully that the camp discourages their staff from having contact with campers after camp; that the camp does not recommend their staff as baby-sitters, Nannies or child companions outside of camp; and that the camp does not take responsibility for the behavior of their staff off-season. I also understand that this permission must be renewed for each camp season. I do not grant permission for my child to exchange contact information with her counselor(s). I recognize that the camp discourages their staff from having contact with campers after camp; that the camp does not recommend their staff as baby-sitters, Nannies or child companions outside of camp; and that the camp does not take responsibility for the behavior of their staff off-season. Parent/Guardian (print name) Parent/Guardian Signature Date #CM 28 rev 4/17 - HT:js
Transportation Information & Release Authorization Camper Name Departing Bus Location Returning Bus Location Please circle session number: 1 2 3 4 5 6 7 8 9 10 11 12 13 CIT/WIT Program Troop # (if any) Buses depart and return to Sacramento, Stockton, Modesto Area and Angels Camp. More details are available in your Resident Camp Parent Handbook. Release Information: Please help us to provide a safe and enjoyable camp experience for your camper. We are asking you to designate those adults, INCLUDING parents, who are authorized to pick up the camper either from camp or at the bus return location. A delay will occur if the camper is being picked up by an adult not on the authorized list. The camper will not be released until proper authorization can be obtained. Finally, identification will be checked at the time of pick up, so please make sure to have a valid driver s license (or similar photo identification) available. Please include additional adults who may pick camper up in case of an emergency. All campers MUST be signed out prior to leaving the return location. Are there any custody situations that we need to be aware of? Yes No If yes, please explain... (additional room on back of form) Authorized adults camper may be released to, parents included: Name Phone Number Relationship to Camper 1. Parent(s)/Guardian 2. Parent(s)/Guardian 3. Other 4. Other 5. Other 6. Other To add additional people to whom campers may be released, please use the back of this form: FOR COUNCIL USE ONLY: #CM 26 rev 4/17 HT:js Signature at pick up Driver s License at pick up
Camper Health History Camper Name: Program and/or Session #: Camp: Troop # (if any): Address Phone City/State/Zip Parents/Guardians: Birthdate (1) Name Phone 1 Place of work Title Phone 2 (2) Name Phone 1 Place of work Title Phone 2 If parents can t be reached, call (Name) Address Name of Family Physician Name of Dentist/Orthodontist Phone Relationship Phone Phone INSURANCE COVERAGE: I understand that my personal insurance will be primary coverage for camper accidents and illnesses and Girl Scouts Heart of Central California s insurance is secondary up to a maximum of $15,000 for accident, $10,000 for illness and $4,000 for dental claims. Exception: if the total claim is less than $130, GSHCC will pay the full amount. On claims above $130, GSHCC will coordinate payments for deductibles and co-pays. If you have questions, please contact GSHCC at 916.452.9181. My insurance company: Policy #: Insurance Company address: _ Not currently insured GSHCC reserves the right to subrogation if it is later determined that personal medical insurance was in place. HEALTH HISTORY: Does the camper have any food allergies or dietary restrictions we should be aware of? Yes No If yes, please also complete form CM 34x, under Forms and Documents on our website Does camper have any other medical conditions we should be aware of? Yes No If yes, please also complete form CM 34x, under Forms and Documents on our website Recent operations or serious injuries Date Hospitalizations Date Any known recent illness or exposure to contagious disease (within the last six weeks)? Yes No Details Is the child currently under the care of a physician or psychologist? Yes No Details Please list any limitations or restrictions to activities while at camp? Has child menstruated? Has she received information on menstruation? Menstrual problems? 1 of 2
Camper Health History Camper Name: Program and/or Session #: Camp: Troop # (if any): MEDICATIONS: The following non-prescription medications are commonly stocked in camp health centers and are used on an as needed basis to manage illness and injury. Cross out those items the camper should not be given. Acetaminophen (Tylenol ) Phenylephrine (Sudafed PE ) Dextromethorphan Chlorpheneramine maleate (cold meds) Ibuprofen (Advil, Motrin ) Hydrocortisone 1% cream Generic cough drops Guaifenesin (Robitussin ) Calcium Carbonate (Tums ) Aloe Chloraseptic (sore throat spray) Lice shampoo or scabies cream (Nix or Elimite ) Topical antibiotic cream (Polysporin ) Calamine lotion Benzocaine (Oragel ) Pseudoephedrine (Sudafed ) Diphenhydramine (Benadryl ) Clotrimazole (Lotrimin ) Lidocaine (Sting Kill/Skeeter Stick ) Sunscreen Insect Repellent (30% Deet or less) Please check here if your camper will be bringing medications with them to camp. Please complete a Medication Administration Record (CM 22) and bring it with you on the first day of camp. Any prescription or over-the-counter medication being sent to camp need to be in the original container with the camper s name and address, plus complete directions for use on the container. California State law DOES NOT allow us to distribute prescription medications to anyone besides the person listed on the medication. ACTIVITIES AND RISKS: Activities vary from program to program, and may include hiking, stewardship activities (for example, plant removal and trail maintenance), horseback riding, archery, canoeing, swimming, outdoor cooking (including the use of knives and propane stoves), fire building, backpacking, kayaking, surfing and sports. Some programs involve travel in camp vehicles driven by Girl Scouts Heart of Central California employees. I understand that by attending camp, my camper can be exposed to a variety of risks and hazards, foreseen and unforeseen, some of which are inherent and cannot be eliminated without fundamentally altering the unique characteristics of the camp program, These inherent risks include, but are not limited to, environmental risks and hazards, including rapidly moving, deep, or cold water; plants, insects, snakes, and predators, including large animals; falling and rolling rock; lightning; and unpredictable forces of nature, including weather that many change to extreme conditions without notice. Possible injuries and illnesses include allergic reactions, anaphylaxis, hypothermia, frostbite, sunburn, heatstroke, dehydration, infectious diseases, musculoskeletal injuries, and other mild or serious conditions or injuries including death. Emergency evacuation and medical care may be delayed thirty minutes or more due to the remote location of some camp activities. The above named camper has my permission to engage in all camp activities, except as noted by me. IMMUNIZATIONS: Is your campers immunizations current? Yes No Please provide the date of most current tetanus shot. MEDICAL: The medical information I have provided above is correct and complete to the best of my knowledge. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. I hereby authorize Girl Scouts, through the appointed camp medical personnel, to provide routine medical health care; to administer medications; and to order X-rays, routine tests as deemed advisable by a licensed physician. It is understood that every effort will be made to contact me or the person noted above before taking this action. I understand that this permission is given in advanced of need to any diagnosis, treatment, or hospitalization. I give permission for this form to be photocopied for trips outside of camp. Date: Parent/Guardian Signature: #CM 23 rev 2/17 - HT: js 2 of 2