2019 Summer Leadership Camp Parental Release / Medical Information / Code of Conduct

2019 Summer Leadership Camp Parental Release / Medical Information / Code of Conduct
Step 1: Complete this online form. You will need the student present for the Code of Conduct section. Step 2: When you receive the email confirmation, forward that email to the student's teacher.
General Information
Student Name*
First NameLast Name
Student Home Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Male/Female*
MaleFemale
School Name*
Example:
High School or Middle School*
High SchoolMiddle School
Teacher Name*
First NameLast Name
Which week is your child attending?*
Week 1: May 20-24Week 2: May 27-31Week 3: June 3-7Week 4: June 10-14Week 5: June 17-21Week 6: June 24-28
Parental Consent
The Undersigned, Being a Parent or Guardian of the above named minor releases the Georgia FFA-FCCLA Center and Camp John Hope FFA-FCCLA Center, henceforth referred to as "FFA-FCCLA Centers", its representatives, agents, servants, and employees from liability for any injury to said minor, resulting from any cause whatsoever occurring to said minor at any time while attending the FFA-FCCLA Centers, including travel to and from camp and any field trips, excepting only injury or damage resulting from willful acts of such representatives, agents, servants and employees. The FFA-FCCLA Centers are also released of any expenses resulting from the injury.
Your child will have the opportunity to participate in optional high adventure activities, including but not limited to horseback riding, high ropes course, shooting sports, giant slip and slide, mud obstacle course, zip line, and the blob. The FFA-FCCLA Centers will provide trained staff who will conduct these activities in the safest manner possible. Under Georgia Law, an equine activity sponsor or equine professional is not liable for an injury to or death of a participant in equine activities resulting from the inherent risks of equine activities, pursuit to Chapter 12 of title 4 of the official Code of Georgia annotated.
This event is a school function. Students and parents are expected to be familiar with all school policies and camp policies. To protect the safety of all students, the FFA-FCCLA Centers have no-tolerance policies that could immediately result in students being sent home. These policies include but are not limited to:
1.      Use of violence or possession of weapons
2.      Use of alcohol or drugs
3.      Entering the cabin of the opposite sex
4.      Being outside the cabin after curfew
Parents or guardians of students who violate policies will be notified to pick up their child.
During the week of camp, we will be taking pictures of teams and students that will be used in the Week-in-Review slide show and for camp promotional material. There may also be surveys conducted pertaining to FFA, FCCLA, and/or the camping program. Please contact the main office if you have a need for exclusion.
The FFA-FCCLA Centers will have medical staff on site that will treat for basic injuries and illnesses. Campers may be sent to a local hospital or physician if needed. The camper fee includes a small insurance policy that will help cover illness and injury that occur while at camp. For this insurance to apply it must be authorized by camp personnel and properly filed as the primary insurance. Reports must be filed before the student leaves camp, and within 24 hours for an illness and 48 hours for an accident. Medical fees above the maximum limit, fees denied by this insurance, or charges that are not properly authorized and filed will be the responsibility of the patient, parent, or guardian.
Parental Consent: Parent/Guardian Signature*
Clear
Date of Signature*
MonthDayYear
Date
Student Medical Information
Student Date of Birth*
MonthDayYear
Date
Do you have Health Insurance coverage for the camper?*
YesNo
Health Insurance Company
Health Insurance Policy Number
Does the camper have any allergies?*
YesNo
List all allergies and the type of reaction they cause
Does the camper have an epi-pen? If so, they must keep it with them at all times!
YesNo
Does the camper have any special food restrictions?*
YesNo
Please list any special food restrictions
Does the camper take any medications they will take during the week of camp?*
YesNo
IMPORTANT: All medications must be in the original package (daily sorters/pill keepers are not permitted.)
Please only send enough medication for the week of camp.
List medications and when they must be taken (example: At Breakfast, At Lunch, Before Bed, As Needed)
Has the the camper been diagnosed with asthma by a physician?*
YesNo
IMPORTANT: If your child has been diagnosed with asthma by a physician and has medication including tablets, nebulizers, or inhalers, they MUST bring such treatment wtih them to camp or they will not be allowed to stay at camp!

If your child has an inhaler, they must keep it with them at ALL TIMES during camp!
Does the camper have any other significant health history (heart condition, diabetes, any injury) or does the camper have any restrictions/medical conditions that the nurse needs to be aware of?*
YesNo
If Yes, please explain
Over the Counter Medications Permitted
Please select Yes or No to the following medications your child may or may not be given at camp
May we give your child...
Tylenol?*
YesNo
Ibuprofen?*
YesNo
Pepto Bismol?*
YesNo
Tums?*
YesNo
Claritin?*
YesNo
Benadryl?*
YesNo
Maalox?*
YesNo
Immodium?*
YesNo
Tussin Cough Syrup?*
YesNo
Glucose Tabs?*
YesNo
Visine?*
YesNo
Neosporin?*
YesNo
Polysporin?*
YesNo
Hydrocortisone Cream?*
YesNo
Mucinex?*
YesNo
Milk of Magnesia?*
YesNo
Zantac?*
YesNo
Midol?*
YesNo
GasX?*
YesNo
Orajel?*
YesNo
Ducolax?*
YesNo
Aleve?*
YesNo
OTC Ear Drops?*
YesNo
Campho-Phenique?*
YesNo
Emergency Contacts
Primary Contact: In case of emergency, please contact the following person *
First NameLast Name
Primary Contact relationship to student*
Primary Contact Home Phone Number*
Area CodePhone Number
Primary Contact Cell Phone Number*
Area CodePhone Number
Primary Contact Work Number
Area CodePhone Number
Secondary Contact: In case of emergency, please contact the following person *
First NameLast Name
Secondary Contact relationship to student*
Secondary Contact Home Phone Number*
Area CodePhone Number
Secondary Contact Cell Phone Number*
Area CodePhone Number
Secondary Contact Work Number
Area CodePhone Number
Medical Information Signature
I have read and understand the statements in this release form. I understand that should a health problem arise, I will be notified but if I cannot be reached by telephone I consent to emergency medical treatment, which may include surgery for my child as deemed necessary by competent medical personnel. I also consent to the release of information for insurance purposes.
Parent/Guardian Name*
First NameLast Name
Medical Information: Parent/Guardian Signature*
Clear
Date of Signature*
MonthDayYear
Date
Student Code of Conduct
This section must be completed by both the student and a Parent/Guardian. Please read this section together.
Student: If you agree and are willing to comply with all of the expectations of the Code of Conduct and Summer Leadership Camp Program, please sign at the bottom of the page.
Parent/Guardian: Please sign the bottom of this form to show your intent to support the implementation of this Code of Conduct in regards to your child.
As an FFA or FCCLA Member attending Summer Leadership Camp, I agree that:
- I understand that I am attending a Leadership Camp and will conduct myself in a manner that positively represents me, my school, my chapter, and my organization.
- I understand that Summer Leadership Camp is a school event, so school policies apply. If there is a discrepancy between school policies and camp policies, the strictest rule will apply.
- I will participate in the camp program, display a positive attitude, and conduct myself appropriately at all times.
- I will respect all campers, advisors, and staff. I will follow instructions from all adults and camp staff.
- I will not use a cell phone during camp programs and activities.
- I will follow the dress code.
- I will not enter a cabin of the opposite sex or be on the wrong side of the camp.
- I will not enter any other cabins or buildings that I am not assigned to.
- I will remain in my assigned cabin after curfew.
- I will not bring highly valuable items to camp. If I do bring valuables, I accept full responsibility for those items.
- I will not use language or behavior that is obscene, violent, or racially or sexually inappropriate.
- I will not possess or use tobacco products, alcohol and/or drugs.
- I will not possess or use firearms, weapons, pocket knives and/or firecrackers.
- I will not bring skateboards, scooters, or roller blades.
- I will respect camp property by keeping the facilities clean, not creating graffiti, and not using items such as water balloons, shaving cream, and toilet paper for destructive purposes. I accept responsibility for damages I cause.
I understand that failure to meet with these standards will result in these steps:
1. I will call my parents/guardians and report my conduct not in compliance with these guidelines.
2. At the Director’s discretion, this may result in my parents/guardians arranging transportation home.
3. My school’s administration may take further disciplinary action.
4. My chapter will be billed for damages that I cause.
I also understand that if I fail to follow no-tolerance policies, including but not limited to use of violence or possession of weapons, use of alcohol or drugs, entering the cabin of the opposite sex, being outside the cabin after curfew, or harassment of another camper or staff, then the following steps may be taken:
1. I will be removed from the facilities.
2. Law enforcement will be contacted.
3. A letter will be sent to my school administrator.
4. I will be suspended from all activities at FFA-FCCLA Centers for up to 18 months.
Student Commitment:
I have read and understand the Code of Conduct above. I agree to abide by it for the safety and enjoyment of myself and of other campers. I understand the consequences of failing to meet these guidelines.
Code of Conduct: Student Signature:*
Clear
Code of Conduct: Parent/Guardian Signature:*
Clear
Date of Signature*
MonthDayYear
Date
Parent/Guardian Email Address:
example@example.com
Should be Empty:

2019 Summer Leadership Camp Parental Release / Medical Information / Code of Conduct

General Information

Parental Consent

Student Medical Information

Over the Counter Medications Permitted

Emergency Contacts

Medical Information Signature

Student Code of Conduct