Schooner SULTANA Middle School 5-Day Trips 2016

Transcription

1 Updated Nov., 2015 Summer Program Forms Packet for Schooner SULTANA Middle School 5-Day Trips 2016 Forms for Your Reference Pick-Up & Drop-Off Information-page 2 Packing List - page 3 Forms That Must Be Signed and Returned Seven Days Prior to Trip Food Preferences / General Release / Photo Release - page 4 Medical Form Part One - page 5 (to be completed by parent/guardian) Medication Form Part Two - page 6 (must be completed by physician) Please return completed forms to: Sultana Education Foundation c/o Liza Brocker / P.O. Box 524 / Chestertown, MD PO Box Chestertown, Maryland Page 1 of 6

2 Drop-Off and Pick-Up Information Five-Day SULTANA Trip TRIP #1 Chestertown to St. Michaels June 20 24, 2016 DROP OFF Date: Monday, June 20, :00 am Cannon Street pier GPS Address: 211 S. Water Street Chestertown, MD PICK UP Date: Friday, June 24, :00 pm Chesapeake Bay Maritime Museum GPS Address: 213 N. Talbot Street Saint Michaels, MD TRIP #2 St. Michaels to Cambridge June 27 July 1, 2016 DROP OFF Date: Monday, June 27, :00 am Chesapeake Bay Maritime Museum GPS Address: 213 N. Talbot Street Saint Michaels, MD PICK UP Date: Friday, July 1, :00 pm Cambridge Long Wharf GPS Address: Foot of High Street Cambridge, MD TRIP #3 Cambridge to Chestertown July 5 9, 2016 DROP OFF Date: Tuesday, July 5, :00 am Cambridge Long Wharf GPS Address: Foot of High Street Cambridge, MD PICK UP Date: Saturday, July 9, :00 pm Cannon Street pier GPS Address: 211 S. Water Street Chestertown, MD PO Box Chestertown, Maryland Page 2 of 6

3 Suggested Packing List Five-Day SULTANA Trip Clothing Bathing Suit (1-2) T-Shirts (6) Shorts (6) Underwear (6) Socks (6) Long Pants (1) Synthetic Swim Shirt (1) Sweatshirt (1) Light Jacket/Windbreaker (1) Foul Weather Gear Jacket & Pants (1) Sleeping Gear Sleeping Bag (in stuff sack) Pillow Accessories Sunscreen (in plastic bag) Head Lamp/Flashlight Towels (2) Toiletries (in separate bag) Hat Refillable Water Bottle Footwear-one of each Sport Sandals or Water Shoes (important) Shoes/Boots that can be tied Recommended Optional Gear Camera Sunglasses Sleepwear/Pajamas Prohibited Items Candy or Snacks Money Electronics (cell phones, ipods, ipads, laptops, etc.) Spray-on Sunscreen Medicine All medicine of any type (prescription or over-the counter) should be brought in a separate zip-lock bag and given to the trip leader upon arrival. ALL MEDICINE MUST BE BROUGHT IN ORIGINAL CONTAINERS. Please pack all gear into a single large duffle bag. Pillow and sleeping bag may travel separately. PO Box Chestertown, Maryland Page 3 of 6

4 Name of Participant Date of Birth Has the child participated in a Sultana Summer Program previously? Yes No If yes, which program: Schooner Sultana 5-day Schooner Sultana 3-day 5-Day Kayak Trip Kayak Camp Canoe Camp Food Preferences & Restrictions During your program we will provide you with healthy meals, snacks, and beverages. It is helpful for us to know in advance if you have special dietary considerations. Please check one of the boxes below so that our staff members can adequately provision your trip with foods that suit each participant s dietary needs. Eating Habits (Please Check One) : Eat Almost Anything Vegetarian Vegan Kosher Please Describe Any Food Allergies: Please Describe Any Other Food Considerations We Should Be Aware Of: Permission & General Release I hereby give permission for (child s name) to participate in a residential educational Summer Program with the Sultana Education Foundation (Sultana). I understand that he/she will be directly involved in a variety of outdoor activities that may include canoing, sailing, and swimming under the direct supervision of Sultana s professionally trained educational staff. In consideration of the Sultana Education Foundation allowing my child to participate in one of its educational Summer Programs, I agree to release and discharge Sultana, its employees, and agents from any injuries sustained by my child as a result of his/her participation. I agree to indemnify and hold harmless Sultana, its employees, and agents against any liability incurred as a result of such injury or loss. However, I shall have no obligation to indemnify Sultana with respect to any injury or loss resulting from, arising out of, or caused by negligence on the part of Sultana. Signature of Parent or Guardian Name of Parent or Guardian (please print) Date Photo Release The Sultana Education Foundation regularly posts photos of its programs on its web site and includes them in newsletters and public relations materials. By signing below, you grant permission for Sultana Education Foundation to use any pictures of the applicant for these non-profit purposes. Photos will NOT be made available to any outside organizations. Signature of Parent or Guardian: Date This Form Must Be Completed and Returned to Sultana Seven Days Prior to Trip Departure Date PO Box Chestertown, Maryland (p) (fax) Page 4 of 6

5 Contact & Insurance Information Medical Form Part One to be completed by parent/guardian Child Last Name: First Name Birth Date Age Male Female Date(s) of Trip: Address: City: State: Zip: Name of Guardian/Parent #1 Relationship Home Phone Work Phone Cell Phone Name of Guardian/Parent #2 Relationship Home Phone Work Phone Cell Phone Additional Emergency Contact Relationship Home Phone Work Phone Cell Phone Health Insurance Carrier Group Number ID Number Name of Insured Relationship to Child Basic Health History My child will be bringing medication on his/her trip (medication authorization form must be completed by physician) MEDICINE MUST BE BROUGHT IN ORIGINAL CONTAINERS. DOCTOR S MEDICATION AUTHORIZATION MUST MATCH INSTRUCTIONS ON ALL PRESCRIPTION MEDICINES. Does your child have (check all that apply) ADD/ADHD Asthma Diabetes Heart Condition Seizures Does your child have allergies to Bees Food Medication Other (please describe in detail below or attach additional) Does your child have any physical handicaps or limitations? please describe below Please list any past major illnesses: Please list any operations or serious injuries: Does the child have a chronic or recurring illness: Is there anything else in the child s health history the staff should be aware of? Consent for Medical Treatment I do hereby authorize that all of the above information is correct and that my child is fully able to participate in Sultana Education Foundation Summer Program activities without need of individual or specialized attention or medical regimen. I agree to notify the Sultana Education Foundation of any changes in my child s physical or mental health between the dates of enrollment and the start of the program. I hereby consent and authorize the administration of all medical treatments advisable or necessary under the judgement of emergency room or clinical physicians with the understanding that I will be notified as soon as possible. Signature: Date: Relationship to child: This Form Must Be Completed and Returned to Sultana Seven Days Prior to Trip Departure Date PO Box Chestertown, Maryland (p) (fax) Page 5 of 6

6 Name of Child Participant Date of Last Physical Exam (must be in the last 24 months) Medical Form Part Two must be completed by licensed physician Date of Birth Weight lbs Height ft in Blood Pressure / Hair Color Eye Color Allergies No known allergies Foods Medications Environmental Other (please list and describe below) Diet & Nutrition Eats a regular diet Has a medically prescribed meal plan or dietary restrictions (describe below) The child is undergoing treatment at this time for the following conditions none (describe below) Do you feel this child will require limitations or restrictions during this program No Yes (describe below or attach) Immunization History - please provide confirmation and dates of following Immunizations Yes/No Date Yes/No Date Measles Hepatitis B Mumps Diphtheria Rubella Pertussis Chicken Pox Polio Tetanus PCV7 Medicine Authorization No daily medications, or Will take the following prescribed and OTC medications. Name of Medication Dosage Time/s of Dosage MEDICINE MUST BE BROUGHT IN ORIGINAL CONTAINERS. INFO ABOVE MUST MATCH INSTRUCTIONS ON ALL PRESCRIPTION MEDICINES. This child may take Tylenol if needed. Appropriate dosage: This child may take Benadryl if needed. Appropriate dosage: Physician Authorization I have examined the above listed child, reviewed his/her health history, and it is my opinion that he/she is physically able to participate in all Sultana Education Foundation Summer Programs, except as noted above. Examining Physician s Signature Date of Exam Printed Name of Physician Office Phone Address City State Zip This Form Must Be Completed and Returned to Sultana Seven Days Prior to Trip Departure Date PO Box Chestertown, Maryland (p) (fax) Page 6 of 6