Jewish Community Center of the North Shore · 2020-01-31 · 0 Jewish Community Center of the North...
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0 Jewish Community Center of the North Shore • Summer at the J: 2020 Jewish Community Center of the North Shore Summer at the J: 2020 – CAMPER FORMS PACKET All forms must be returned by June 1, 2020 CAMPER REGISTRATION IS NOT COMPLETE UNTIL ALL FORMS HAVE BEEN PROCESSED Please send or scan and email forms to: [email protected] JCCNS Summer at the J 4 Community Road Marblehead, MA 01945 Questions? Please contact: KinderCamp Director: Heather Greenberg – [email protected] Camp Simchah Director: Jessie Stephens – [email protected] Inclusion Camp Director: Melissa Caplan – [email protected] Camp Controller: Scott Kaplan – [email protected]
Transcript of Jewish Community Center of the North Shore · 2020-01-31 · 0 Jewish Community Center of the North...
0 Jewish Community Center of the North Shore • Summer at the J: 2020
Jewish Community Center of the North Shore
Summer at the J: 2020 – CAMPER FORMS PACKET
All forms must be returned by June 1, 2020
CAMPER REGISTRATION IS NOT COMPLETE UNTIL
ALL FORMS HAVE BEEN PROCESSED
Please send or scan and email forms to: [email protected]
JCCNS Summer at the J
4 Community Road Marblehead, MA 01945
Questions? Please contact: KinderCamp Director: Heather Greenberg – [email protected]
Camp Simchah Director: Jessie Stephens – [email protected] Inclusion Camp Director: Melissa Caplan – [email protected]
Camp Controller: Scott Kaplan – [email protected]
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CONFIDENTIAL CAMPER INFORMATION This form is required and must be completed by a parent/guardian for each camper and/or LIT. The information in this form is kept confidential. Its sole purpose is to help camp our staff to better understand your child.
Camper Name: _____________________________ Preferred Name/Nickname: _____________
Date of Birth: / / School/District: __________ Grade entering Fall 2020: ____
Address: ____________________________________________ Home Phone: ______
Town/City: _________________________ Zip Code: _________
*Please attach a recent photo of your child to be kept in his/her file.*
Parent/Guardian 1 Name: ________________________________________________________
Day Phone: _______________ Evening Phone: _______________ Cell Phone: ______________
Address: ______________________________________________ Email: __________________
Parent/Guardian 2 Name: ________________________________________________________
Day Phone: _______________ Evening Phone: _______________ Cell Phone: ______________
Address: ______________________________________________ Email: __________________
Parent/Guardians’ Marital Status: _______________ Camper lives with: ___________________
Siblings: Name: _______________ Age: _____ Grade entering 2020 (if applicable): _____
Name: _______________ Age: _____ Grade entering 2020 (if applicable): _____
Name: _______________ Age: _____ Grade entering 2020 (if applicable): _____
1. Has your child attended any camp before? If yes, please list the name of the camp andhow many years.
2. What did your child enjoy most/least about camp (activities, staff, special events, etc.)?
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CONFIDENTIAL INFORMATION CONTINUED… (attach separate page if needed)
3. What is your child looking forward to most about this summer at camp?
4. Is there anything your child is nervous or not looking forward to at camp this summer?
5. What are your child's favorite interests and hobbies?
6. Are there any specific emotional triggers for your child? Please explain.
7. What are your child’s abilities and comfort level regarding swimming?
8. Please list all that apply for your child: a. Fears: b. Restrictions (physical, sensory, emotional, etc): c. Allergies: d. Health problems:
9. Does your child have an IEP, 504b, individual health plan, or support services? If yes, please register through our Inclusion Program to ensure proper support at camp.
_____ yes* _____ no *Any child on an IEP, 504b, who has a medical or developmental diagnosis or who receives specialized services should register through our Inclusion Program. Once camp begins, if it is determined that your child requires additional support at camp, the Camp Leadership Team may pause participation and your child will be put on a waitlist until support can be provided.
Please explain:
10. Are there any special issues the camp should be aware of in order to help your child enjoy his/her summer experience? (Recent family move, death, new school, birth, separation, divorce.) If so, please describe the situation.
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CONFIDENTIAL INFORMATION CONTINUED… (please attach separate page, if needed)
11. How does your child establish new relationships with:
a. peers: _____ with ease _____ slowly _____ with difficulty please explain:
b. adults: _____ with ease _____ slowly _____ with difficulty please explain:
12. Is there any additional information about your child’s social interactions that you’d like us to know:
13. How does your child follow directions in a group setting: _____ with ease _____ slowly _____ with difficulty please explain:
14. How does your child transition from one activity to the next: _____ with ease _____ slowly _____ with difficulty please explain:
15. Is there anything else that would help us get to know your child better? Parent/Guardian Signature Date Printed Parent/Guardian Name
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Health History (PLEASE PRINT)
NAME _________________________________________________________________ Last First M.I. Date of Birth ______/________/_______
Any other disease, illness, past surgeries, permanent disabilities, or explanations of any marked concerns from the list above? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Are you currently being treated by a health care professional? If yes, explain__________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you had? (Check box) No Yes Have you had? (Check box) No Yes Recurrent Headache Asthma Eye Problem Epilepsy/Seizures Ear Problem Dizziness/Fainting with Exercise Nose Problem Head Injury/Concussion Throat Problem Bone/Joint Injuries Thyroid Disorder Stomach/Intestinal Problems Heart Murmur/Heart Disease Diabetes Heart Palpitations Eating Disorder High/Low Blood Pressure ADD/ADHD Anemia/Sickle Cell Chicken Pox/Immunization Bleeding Disorders: Hemophilia/Other Mononucleosis Hepatitis Alcohol Abuse Kidney/Bladder Disorders Drug Abuse Pneumonia/Bronchitis Sexual Assault/Violence Tuberculosis Emotional Problems-Specify Below: Seasonal Allergies/Hay Fever Surgeries: Hospitalizations: Allergies: Medication Allergies: Medication currently taking:
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PERMISSIONS Child’s Name: ______________________________ Date of Birth: _________ Permission Slip to RIDE IN CAMP VEHICLES I give permission to have my child, _____________________, ride in camp vehicles for transport to and from camp, and in private vehicles in case of emergency evacuation. (Simchah and LITs only) I give permission to have my child, _____________________, ride in camp, hired, and private vehicles for transport to and from camp and field trips. Permission Slip for HEAD LICE CHECK I do_____ do not_____ give permission to have my child’s, ____________________, head checked for lice. Permission Slip for SUNSCREEN USE AT CAMP I do_____ do not_____ give permission for my child's counselor (or if appropriate, my child) to apply the following: SUNSCREEN_________________________________ (Brand name or ANY) I do_____ do not_____ give permission for my child's counselor (or if appropriate, my child) to apply ANY BRAND of sunscreen if my child runs out of the above brand.
Please label any containers of sunscreen with your child's name. Special instructions: ______________ Parent/Guardian Signature Date
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TO BE COMPLETED FOR KINDERCAMP ENRICHMENT CAMPERS ONLY
Dear KinderCamp Enrichment parent/guardian,
This letter is to inform you that the JCCNS outdoor pool will be open to our membership during the time that your child is in a KinderCamp enrichment. We ensure that the following conditions be met to keep campers safe, comfortable, and in a closely contained group:
1) All enrichment campers will be in their bathing suits before the end of the regularKinderCamp day.
2) All lifeguards responsible for the enrichment campers will be regular camplifeguards.
3) After the enrichment swim, all campers will change in a closed room, one that is notaccessible to the general membership.
Please sign and return the bottom of this form indicating your receipt of this note and acceptance of these conditions.
Thank you for your understanding. Please let me know if you have any questions or concerns regarding the KinderCamp enrichments.
Sincerely,
Heather Greenberg KinderCamp Director [email protected] 781-476-9923
___ I have received the letter informing me that the KinderCamp enrichments will occur while the pool is open to JCCNS members and accept the conditions as outlined.
___________________________________ Name of camper
________________________ DOB
________________________________________ ________________________ Parent/Guardian Signature Date
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TO BE COMPLETED FOR CAMP SIMCHAH and LIT CAMPERS ONLY
Dear Camp Simchah and Leader-in-Training Parent/Guardians,
This letter is to inform you that the JCCNS outdoor pool will be open to our membership during the time that your child may have camp Free Swim. We ensure that the following conditions are met to keep campers safe, comfortable, and in a closely contained group:
1) All Free Swim campers will arrive to the outdoor pool area already in their swimsuits.2) All lifeguards responsible for the Free Swim campers will be regular camp lifeguards.3) After Free Swim, all campers will change in a closed room inaccessible to the general
membership.
Also, the indoor pool will be open to our membership during the time that your child may participate in Free Swim during the mornings on days when weather prohibits our use of the outdoor pool. We ensure that the following conditions are met to keep campers safe, comfortable, and in a closely contained group:
1) All campers participating in Free Swim will change in a closed area, one that is not accessible to the general membership, before use of the pool.
2) All lifeguards responsible for the Free Swim campers will be regular camp lifeguards.3) Free Swim lanes will be delineated from lap swim lanes or lanes used for other
purposes.4) After Free Swim, all campers will change in a closed area, one that is not accessible to
the general membership.
Please sign and return the bottom of this form indicating your receipt of this note and acceptance of these conditions. Please let me know if you have any questions or concerns regarding Free Swim at Camp Simchah.
Sincerely,
Jessie Stephens Camp Simchah Director [email protected] 781-476-9901
___ I have received the letter informing me that the Free Swim will occur while the pool is open to JCCNS members and accept the conditions as outlined.
___________________________________ Camper Name
________________________________________ Parent/Guardian Signature
________________________ DOB
________________________ Date
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EMERGENCY CARE FORM Camper Name: _____________________________ Date of Birth: / / Address: ____________________________________________ Home Phone: ______ Parent/Guardian 1 Name: ________________________________________________________ Day Phone: _______________ Evening Phone: _______________ Cell Phone: ______________ Parent/Guardian 2 Name: ________________________________________________________ Day Phone: _______________ Evening Phone: _______________ Cell Phone: ______________ ADDITIONAL EMERGENCY CONTACT PHONE _______________ Relationship: ______________________________ ADDITIONAL EMERGENCY CONTACT PHONE_______________ Relationship: ______________________________ HEALTH INSURANCE COMPANY: _______ ____________ POLICY NUMBER: _______ Physician’s Name & Phone __________________________________________________ I understand that this release will only be used if I/we cannot be reached by the camp. I give permission to have my child, ____________________, taken to the nearest physician or hospital in case of emergency and to have anesthesia administered if necessary and/or to have a qualified person administer first aid, if necessary. Parent/Guardian Signature Date
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CHILD RELEASE FORM
Camper Name: _____________________________ Date of Birth: / /
I give permission for my child to be picked up from camp by any of the following adults (in addition to the parent/guardians listed on page 1) during this camp season:
1. Name: Phone:
Address:
Relationship:
2. Name: Phone:
Address:
Relationship:
3. Name: Phone:
Address:
Relationship:
Parent/Guardian Signature Date ________________________________________________________________________ Permission Slip to WALK HOME (only for Simchah Campers/LITs who are 9 years old and older)
I give my child, ______________________, permission to WALK home from camp.
Parent/Guardian Signature Date
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ADDITIONAL REQUIRED CAMPER FORMS Camper forms must include a copy of this camper’s:
1) most recent physical exam (including physician’s signature, dated no earlier than February 28, 2019),
2) current immunization record (for requirements, please visit: https://www.mass.gov/info-details/school-immunizations#school-and-camp-requirements-), and
3) (if applicable) IEP, 504b, individual health care plan.
