Reservations are on a first come and paid, first served basis. Make checks payable to: Bonneville School District #93

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1 Pine Basin Outdoor Education Camp 2016 Application Form Thank you for your interest in Bonneville School District s Pine Basin Summer Camp! The camp is for students who have completed 4 th, 5 th or 6 th grade. You have a choice between six camp weeks. They are June 13 th, 20 nd, 27 th and July 11 th, 18 th, and 25th. The cost is $175 plus state tax of $10.50 (includes Pine Basin Summer Camp T-shirt). Listed below is a tentative overview of the program: Monday leave Bonneville High School (BHS) Please arrive just before 8:00 am. We will be pulling out of the parking lot at 8:30 a.m. There is a quick parents meeting at 8:20 to get last minute information. Mondays activities will be learning songs, and receive orientation, environment class, flag hike, swimming, small group organization, group activities with group counselor, Pine Basin Olympics, and free time and campfire activities. Tuesday outdoor education classes, nature hike, free time, swimming, staff skit night, and night hike. Wednesday trappers history day at Grand Teton National Park, an hour of free time at Jackson City Square, see the famous old time Jackson shoot out, and evening at the theatre. (Can bring spending money) Thursday outdoor education classes, mountain crafts, water (creek) hike, free time for swimming, clean up and get ready for Parent s Night program (starts at 7:00 pm but parents can visit an hour earlier), staff chase, Indian lore, astronomy, and end of week party. Friday outdoor activity and get ready to go home. Arrive at BHS at 3:00 p.m. Please Print and Mail all 5 pages of the application. After the application and funds have been received, an acceptance letter for the chosen week will be ED to you immediately. Please provide your below for this courtesy. If you plan to bring cash to the District Office, please bring exact change. Pine Basin Outdoor Education Summer Camp Reservations Attn: Samantha Williams 3497 N. Ammon Rd. Idaho Falls, ID Reservations are on a first come and paid, first served basis. Make checks payable to: Bonneville School District #93 You will receive a confirmation letter as soon as your fees are paid. If you have questions call ***************************************************************************************** Name: Grade completed this year: School: Circle one: Boy / Girl Mailing Address City/State/Zip Home Phone: Emergency Phone: Cell Phone: Student Signature Parent Signature Write 1 in blank of your first choice, 2 in blank of your second choice. Week 1, June Week 2, June Week 3, June 27-July 1 Week 4, July Week 5, July Week 6, July25-29 T-Shirt Size: Youth (S) Youth (M) Youth (L) Adult (M) Other

2 Pine Basin Outdoor Education Camp 2016 Medical Form Print Name: Boy Girl Address: City: Zip: Physician: Physician s phone: Health Insurance Provider: Policy #: Does your child have any of the following medical conditions? Asthma Yes No Fainting Yes No Seizures Yes No Heart Condition Yes No Diabetes Yes No Hayfever Yes No Glasses/contacts Yes No Kidney or Urinary Problems Yes No Handicaps (hearing, vision etc.) Yes No Inhaler Yes No If YES to any of the above, Please explain Allergies or reactions to any medications, food, plants, animals, insects, toxins, etc. Restrictions for medical reasons: Please explain: Any condition that may require special medical diet: Medications Yes No If yes, name of medication(s): Any and all prescription drugs entering the camp must be checked in upon arrival on Monday morning unless otherwise prescribed by physician. The form on the reverse side must be completely filled out and signed by your physician in order for a camp counselor to administer prescription drugs. Also, if your child self-administers their medication, you must have your physician complete the form on the reverse side and then return it to the medical counselor. Date of last tetanus inoculation: Doctor: Phone: Parent authorization: This health history is correct so far as I know. The person herein described has permission to engage in all prescribed activities, except as noted by me. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the adult leader in charge to hospitalize, secure proper anesthesia, order injections or other medical treatment deemed necessary by the physician and adult leader for my child. Signature of Parent or Guardian: Date: Individual to contact if parent/guardian cannot be reached: Phone:

3 PHYSICIAN S AND PARENTS REQUEST FOR ADMINISTRATION OF MEDICINE BY PINE BASIN MEDICAL COUNSELOR Or AUTHORIZATION FOR SELF-ADMINISTERED and EMERGENCY MEDICATION (One Release per Medication) Student Name: Birth Date Address: Parent/Guardian: Home Phone: Cell Phone: Work Phone: I give permission for administration of medication as described below, by physician. I shall indemnify and hold harmless the district and its employees or agents from all legal fees or costs and any potential damages arising out of any claims brought by the above named child or anyone else regarding self-administration of this medication. Parent/Guardian s Signature: Date: ************************************************************************************ THE FOLLOWING ARE TO BE COMPLETED BY THE PHYSICIAN: I am recommending that the above named student be allowed to self-administer the following medication. Name and purpose of medication: Identification of chronic medical problem: Prescribed dosage to be taken: Possible side effects and/or special precautions to be taken: Conditions under which self-medication will take place (Please Check One) Under the supervision of Pine Basin Medical Counselor Independently (Child must have had training and be proficient in self-administering medication) Medication should be (Please Check One) Stored in Pine Basin office In the possession of the student Type or Print Physician s Name: Phone: Physician s Signature: Date: Pine Basin Camp Director signature: Date: Medication must be clearly marked with identification, placed in a plastic zip lock sandwich bag and given to the camp director prior to getting on the bus.

4 3497 North Ammon Road, Idaho Falls, Idaho, (208) Fax (208) Dr. Charles J. Shackett, Superintendent Marjean McConnell, Deputy Superintendent Scott Woolstenhulme, Assistant Superintendent STUDENT CONDUCT Bonneville Joint School District No. 93 students on any school premises or at any school sponsored activity, regardless of location, are expected to obey District officials, protect property, maintain order and decorum, avoid excessive physical contact, fighting, and public displays of affection and conduct themselves in a positive manner. Guidelines 1. Principals are directed to establish reasonable rules and regulations regarding appropriate student behavior in school and at school activities. 2. Disciplinary action for violation of this policy may involve up to and including suspension and/or expulsion. DEFINITION On any school premises or at any school sponsored activity, regardless of location: shall include, but not be limited to buildings, facilities, and grounds on the school campus, school busses, school parking areas; and the location of any school sponsored activity. This includes instances in which the conduct occurs off the school premises but impacts a school related activity. HAZING, HARASSMENT, INTIMIDATION, BULLYING, CYBER BULLYING, MENACING The Bonneville Joint School District No. 93 Board of Trustees is committed to maintaining an educational environment that protects and promotes dignity, individual worth, and mutual respect for each individual. Therefore, bullying, cyber bullying, hazing, harassment, intimidation, or menacing by students, staff, or third parties is strictly prohibited and shall not be tolerated. The Superintendent is directed to develop administrative procedures that include descriptions of prohibited conduct, reporting and investigative procedures, as needed, and provisions to ensure that notice of this policy is provided to students, staff, and third parties. Both the parent and the child have read the Code of Conduct, understand it, and will comply with it. Parent Signature Student Signature Board of Trustees Brian McBride Paul Jenkins Amy Landers Jeff Bird Greg Calder Bonneville Joint School District No. 93 is an Equal Opportunity Employer

5 3497 North Ammon Road, Idaho Falls, Idaho, (208) Fax (208) Dr. Charles J. Shackett, Superintendent Marjean McConnell, Deputy Superintendent Scott Woolstenhulme, Assistant Superintendent Student Participant Video Release Form I hereby give my permission, as a student 18 years of age or older, or as the parent/legal guardian of the student named below, to Bonneville Joint School District No. 93 for the use and reproduction of video footage, photographs, voice recordings, or writings of, and/or created by the District. I understand that the use of the participant's image and voice will be primarily for the purposes of education, trainings, and/or promotion by Bonneville School District. I hereby waive any right that I may have to inspect or approve the finished student product that may be used in connection herein. By signing this release form, each student and student s parent/legal guardian hereby assigns, transfers, or otherwise conveys all rights, titles, and interests in and to the video created, including without limitation all copyrights and other intellectual property rights therein. Video footage may be used for the following purposes: Presentation in public theater(s) or public locations. Educational presentations. Informational presentations at conferences or trade shows. Promotional video for Bonneville School District sponsored programs that may be included in a television or Internet broadcast. There is no time-limit on the validity of this release nor is there any geographic specification of where these materials may be distributed. Student and student s parent/legal guardian agree to indemnify and hold harmless Bonneville Joint School District No. 93, its officers, employees and agents from and against any and all claims, actions, costs, judgments or damages of any type relating to the production, reproduction, distribution, or use of the video footage, photographs, voice recordings, or writings of, and/or created by the District. Student Name (Please Print) Student Signature Address: Phone: School Date: Participating students under 18 years of age must have parental signature indicating permission. Parent/Legal Guardian Name (Please Print) Parent/Legal Guardian Signature: Date: Board of Trustees Brian McBride Paul Jenkins Amy Landers Jeff Bird Greg Calder Bonneville Joint School District No. 93 is an Equal Opportunity Employer