FFA-FCCLA Events Template

Georgia FFA-FCCLA Center : FCCLA Middle School Culinary Bootcamp
Parental Release / Medical Information / Code of Conduct
General Information
School Name*
Ex. Madison County High School. No abbreviations.
Student Name*
First NameLast Name
Student Home Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Male/Female*
MaleFemale
Teacher Name*
Teacher Email Address*
example@example.com
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 may have the opportunity to participate in optional high adventure activities. The FFA-FCCLA Centers will provide trained staff who will conduct these activities in the safest manner possible.
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.
Campers may be sent to a local hospital, urgent care, 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.
Student Medical Information
Student Date of Birth*
MonthDayYear
Do you have Health Insurance coverage for the camper?*
YesNo
Health Insurance Company*
Health Insurance Policy Number*
Food Allergies
Use this section for foods that your student is allergic to. Note: There is a section later for other food restrictions, such as vegetarian.
Food Allergies?*
YesNo
Food Allergy 1 *
Allergen Name
Food Allergy 1 : Details *
Food Allergy 2
Allergen Name
Food Allergy 2 : Details
Food Allergy 3
Allergen Name
Food Allergy 3 : Details
Food Allergy 4
Allergen Name
Food Allergy 4 : Details
Food Allergy 5
Allergen Name
Food Allergy 5 : Details
Food Restrictions
List any food restrictions that are NOT an allergy. Example: Vegetarian, Vegan.
Food Restrictions?*
YesNo
Food Restriction 1*
Restriction Name
Food Restriction 2
Restriction Name
Food Restriction 3
Restriction Name
Food Restriction 4
Restriction Name
Food Restriction 5
Restriction Name
Medication / Drug Allergies
Medication / Drug Allergies?*
YesNo
Medication / Drug Allergy 1*
Allergen Name
Medication / Drug Allergy 1 : Details*
Medication / Drug Allergy 2
Allergen Name
Medication / Drug Allergy 2 : Details
Medication / Drug Allergy 3
Allergen Name
Medication / Drug Allergy 3 : Details
Medication / Drug Allergy 4
Allergen Name
Medication / Drug Allergy 4 : Details
Medication / Drug Allergy 5
Allergen Name
Medication / Drug Allergy 5 : Details
Seasonal / Other Allergies
Seasonal / Other Allergies?*
YesNo
Allergy 1*
Allergen Name
Allergy 1 Details*
Allergy 2
Allergen Name
Allergy 2 Details
Allergy 3
Allergen Name
Allergy 3 Details
Allergy 4
Allergen Name
Allergy 4 Details
Allergy 5
Allergen Name
Allergy 5 Details
Medications
IMPORTANT:
All medications must be in the original package.
Daily sorters/pill keepers are NOT permitted.
Please only send enough medication for the duration of the conference.
Does the camper take any medications they will take during the conference?*
YesNo
Medication 1*
Medication Name
Medication 1 : Details*
Medication 2
Medication Name
Medication 2 : Details
Medication 3
Medication Name
Medication 3 : Details
Medication 4
Medication Name
Medication 4 : Details
Medication 5
Medication Name
Medication 5 : Details
Does the camper have an epi-pen? If so, they must keep it with them at all times!*
YesNo
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 with 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!

If the camper requires an epi-pen, they must keep it with them at ALL TIMES!
Health History
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
Visine?*
YesNo
Tussin Cough Syrup?*
YesNo
Glucose Tabs?*
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
In case of emergency, please provide contact information so that you can be notified at all times.
Primary Contact: In case of emergency, please contact the following person:*
Secondary Contact: In case of emergency, please contact the following person:
Student Code of Conduct
This section must be read by both the student and a Parent/Guardian.
As an FFA or FCCLA Member attending the Georgia FFA-FCCLA Center, I agree that:
- I understand that I am attending a Leadership Event and will conduct myself in a manner that positively represents me, my school, my chapter, and my organization.
- I understand that this 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.
Signatures
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.
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.
Student Signature:*
Clear
Parent/Guardian Signature:*
Clear
Date of Signature*
MM-DD-YYYY
Parent/Guardian Email Address:*
example@example.com
Should be Empty:

Georgia FFA-FCCLA Center : FCCLA Middle School Culinary Bootcamp

General Information

Parental Consent

Student Medical Information

Food Allergies

Food Restrictions

Medication / Drug Allergies

Seasonal / Other Allergies

Medications

Health History

Over the Counter Medications Permitted

Emergency Contacts

Student Code of Conduct

Signatures