Thank you for choosing our Teen Winter Caravan. This Parent/Camper Info packet should answer many of your questions. If you have any additional questions, please contact Jessie Bringelson at 805-480-0309 or [email protected]. W INTER CARAVAN January 2 – 5 Teens entering 9-12 grade CAMPER/PARENT RALLY NIGHT (Mandatory for each camper and one parent or guardian) Get information, meet other program participants and advisors and have all your questions answered. Location: Miller Family YMCA 320 Via Las Brisas Newbury Park, CA, 91320 Departure: Thursday, January 2nd at 7:00am Pick-up: Sunday, January 5th at 4:00pm Campers must be dropped off by their legal parents or guardians for winter Caravan sign-in process. Camper may not sign themselves in or out. Please ensure your camper arrives no later than 6:45am. Clothing (make sure you have warm clothing suitable for the snow) o Long Pants o Shirts (t-shirts, long sleeve shirts, thermals) o Underwear/socks o Swimsuit (for Jacuzzi) o Clothed Toe Shoes (multiple pairs advised) o Sweatshirts o Warm Jacket o Pajamas o Snow boots o Snow pants/snow jacket o Beanie/ear muffs o Sack lunch for first day o Spending money o Flashlight o Refillable water bottle o Pillow o Sleeping bag o Laundry bag o Camera o Book o Air mattress; with air pump (there are enough beds for all kids but some children may choose to sleep on air mattress depending on which room they want to be in) Tech-Free Zone: YMCA Caravan Directors recognize that kids need time away from technology to build friendships, explore the outside world and experience new adventures. Our YMCA Caravan is a “Tech-Free Zone” in which we ask campers not to bring cell phones, portable music or video players or video games. Caravaners can bring digital cameras, as long as they are not paired with cell phones or texting technology. In the event the caravaners need a cell phone before or after the caravan, caravan staff will provide access to a mobile phone. This number will also be available to parents at time of drop-off in case of emergencies. Camper’s Name: _______________________________________________________________________________________ Prescription medication must be in a prescription bottle with the doctor’s instructions on the label. All over-the-counter medication must be in original packaging. Please administer the following medication(s) to the above named child, as directed: MEDICATION The following over-the-counter medication may be given to your child during camp under the recommendation of our staff. Please cross out any medications you do not wish to be administered to your child. Chloraseptic I authorize the medications listed above, or their equivalent, to be administered as needed. Legal Guardian’s Signature: _________________________________________________________ Date: ________________________ Emergency Phone #: _______________________________________________ Child’s Name: ______________________________________________________________________________________________________ D.O.B. ______/_______/ ___________ Illness or Accidents? Has your child had any serious or severe illnesses or accidents in the last 3 years? ___________Yes ______________No If yes, explain: ____________________________________________________________________________________________________________ ____________________________ ___________________________________________________________________________________________________________________________________________________________ Medication? Does the child take any medication during the day? _____________Yes ______________No If yes, Medication Release form is required. Please list medications: ____________________________________________________________________ _____________________________________________________________________________________________________________________________ _______________________________ Family Physician: __________________________________________________________________________ Doctor’s phone: ______________________________________ Family Dentist: _____________________________________________________________________________ Dentist’s phone: _____________________________________ Medical Insurance Company: ________________________________________________________________________________________ Policy #: __________________ Immunization History (include dates): Tetanus Booster: __________ Tuberculin (TB) Test:_________ MMR:__________ DPT:___________ List all allergies here: _____________________________________________________________________________________________________________________________ __ List dietary restrictions here: _________________________________________________________________________________________________________________ ____ Any reason to restrict strenuous activity such as swimming, hikes, strenuous games, roller coaster rides? _____YES _____NO If yes, please explain _________________________________________________________________________________________________________ ______________________ I hereby give permission to the Miller Family YMCA and it’s employees and volunteers to release any and all of the above health history to any medical personal rendering emergency medical aid or treatment to my child. Parent/Guardian Signature: _______________________________________________________________________________ Date: ________________________________ Camper’s Name: ________________________________________________________________________________________________ (Initial each line below) _____________ Possession and/or consumption of alcoholic beverages or illegal drugs are strictly prohibited. _____________ Weapons of any kind and items that could cause injury or damage to participants and/or property are strictly forbidden. _____________ Any violation of State or Federal laws will be treated as such and the proper authorities may be notified. _____________ Activities which endanger the health and safety of the individual or others are prohibited. _____________ Inappropriate or uninvited physical contact between any camp participants is not allowed. _____________ Possession and/or the use of any tobacco products is not permitted. By signing this form, campers and parents are agreeing to abide by the above listed rules. Serious or repeated disregard for camp rules or the directions of the camp staff may result in dismissal from camp. Parents/Guardians will be responsible for arranging or paying for camper’s transportation home. Camper’s Signature: ___________________________________________________________________________________________ Parent’s Signature: ____________________________________________________________________________________________ Date: ____________________________________________ Campers need to bring a sack lunch with their name on it for the ride up. Please do not pack coolers, ice chests, etc. that may be hard to pack. Camper should bring at least one refillable water bottle to have the entire trip. Do not pack lunch or medication in suitcase or bag. Camper may not have access to Camp staff will collect all prescription medications the morning of departure. Please make sure to fill out a Medication Release Form. Sleeping bags all look the same to campers when we get to camp. Please mark your campers name on the outside of their sleeping bag. All belongings need to be permanently and clearly marked with your camper’s name. The YMCA is not responsible for any lost articles. We are working hard to keep this trip a tech-free zone, so please have your camper leave all cell phones, ipods, ipads, video games, etc. at home. Campers will be provided meals and event admissions, which is included in the cost of the trip. Campers should bring some additional spending money for extras at their discretion such as souvenirs, snacks at certain locations, any shopping they may do, etc. Campers are not required to bring extra money but it is recommended. Medication Form (bring day of departure) Emergency/Medication Release Form Parent & Camper Agreement Form Please complete all forms, sign and return to the Miller Family YMCA on or before camp rally night on December 13, 2013. We are here and happy to help with any questions or concerns you may have. Please contact Jessie Bringelson at 805-480-0309 ex. 104 or [email protected] for more information.


Cbt 443 altered mental states

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