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Page 1: 2020 for Summer Camp - Carroll Community College · 2018-04-04 · Getting Ready for Camp . This handbook contains important information about our procedures to help ensure an enjoyable

for Summer Camp

2020

carrollcc.edu/summerkids

Page 2: 2020 for Summer Camp - Carroll Community College · 2018-04-04 · Getting Ready for Camp . This handbook contains important information about our procedures to help ensure an enjoyable

Welcome and thank you for choosing Carroll Community College for your child’s summer enrichment activities!

Kids@Carroll is for children ages 5 – 11

Email: [email protected]

Web: www.carrollcc.edu/summerkids

Phone: 410-386-8100

Fax: 410-386-8111

KidsatCarroll

Table of Contents Getting Ready for Camp

This handbook contains important information about our procedures to help ensure an enjoyable and safe experience for everyone.

The summer enrichment camps at Carroll Community College are designed for two diferent age groups.

and Teen College is for ages 12 – 15.

Summer Kids@Carroll/Teen College complies with day camp licensure requirements of the Maryland Department of Health.

Communicating With Us

(Monday – Thursday, 8:30 a.m. – 6 p.m. and Friday, 8:30 a.m. – 4:30 p.m.)

Facebook: www.facebook.com/

Camp Checklist ....................................................................................................................................... 1

Health Information ................................................................................................................................ 1

Safety ........................................................................................................................................................... 1

Unexpected College Closings ........................................................................................................... 1

Medication ................................................................................................................................................ 1

Nut Allergies ............................................................................................................................................. 1

Special Camper Needs ......................................................................................................................... 1

Coming to Camp First Day of Camp (Monday) ..............................................................................................................2

Drop-Of Procedures ............................................................................................................................2

Pick-Up Procedures ...............................................................................................................................2

Start-Up/Wind-Down Time ................................................................................................................3

Lunch and Snacks ..................................................................................................................................3

Behavior .....................................................................................................................................................3

Cell Phones and Electronic Games ..................................................................................................3

Field Trips ...................................................................................................................................................3

Camp Cancellations and Refunds ....................................................................................................3

Camp/Location-Specifc Information Carroll County Career and Technology Center ..........................................................................4

Forms Campus Map ............................................................................................................................................5

Self-Sign Out Authorization ...............................................................................................................6

Health and Emergency Contact ....................................................................................................... 7

Medication Administration Authorization ...................................................................................9

091-12-20-1219 KID

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Camp Checklist ❑ Verify that the confrmation statement emailed at

registration is correct. Call us right away if you see a discrepancy. You will not receive any other reminders; this is the only confrmation you will receive.

Getting Ready for Camp

❑ Sign and return a completed Health and Emergency Form (see p. 7) to the College BEFORE Monday, June 1.

❑ Make sure everyone authorized to pick up your camper is listed. You may also add names later.

❑ If your child needs to take medication during camp, send a completed Medication Administration Authorization Form (included on p. 9 and at carrollcc.edu/summerkids) two weeks before the frst day of camp. Be sure your health care provider has signed it. Medication must be in original containers.

❑ Review the procedures in this handbook, especially Drop-Of and Pick-Up, to make your frst day go smoothly.

❑ If your child is attending a camp held at Winters Mills High School (cooking), review the Camp/Location-Specifc Information section in this handbook for special procedures.

Health Information Maryland state regulations require that a current Health and Emergency Contact Form be on fle for each participating camper. You need to complete this year’s form even if your child/teen attended camp here in the past.

Please submit your form BEFORE Monday, June 1.

Without this completed form on the frst day, your child will not be able to participate! If the College receives the form prior to the second session, he/she may attend beginning with the this form on page 9, at www.carrollcc.edu/summerkids and, second session. If the College does not receive the Health and during the summer, at the administration table in the gym. Emergency Contact Form prior to the second session, your child will not be eligible to participate and you will not be eligible for Nut Allergies a refund. We do not knowingly include nuts or nut products in any of

the snacks served as part of the program. However, the College A camp nurse is on call during most camp hours. Indicate any medical concerns on the Health and Emergency Contact Form. If the nurse has any questions, you will be called the week before your camp. Examples of medical concerns include, but are not limited to: medications used during the camp day, asthma, diabetes, epilepsy, seizures or heart defects. Campers who are required to carry an Epi pen must indicate so on the form. If you are unsure about anything medically related, contact us!

Safety Safety is a top priority! Children age 12 and under are supervised at all times and may not travel through the campus without a staf escort. In addition, at the end of the camp day they must be signed out by an authorized adult. However, teens age 13 and over are given a little more independence and may visit restrooms without staf escort and, with parent approval, may sign themselves out at the end of camp (see Pick-Up Procedures). All other movement through the campus and at lunch is supervised.

In compliance with MDH regulations, a background check is conducted for all staf, volunteers and instructors (including those who are teaching for our partners). For the children’s safety, the College also prohibits the enrollment of individuals listed on any State Services Sex Ofender registry and/or Maryland Department of Public Safety and Correctional Services Sex Ofender registry. (Of-site contract training for clients may be exempt.)

Unexpected College Closings Staf will contact each family directly with instructions. Campers will remain supervised until picked up. Register for the College’s free Emergency Notifcation System at www.carrollcc.edu/alerts. Messages about any emergency closings will be sent directly to your email and/or cell phone.

Medication No medication will be administered without the Medication Authorization Form signed by the health care provider. Medication must be in original containers. This includes campers with insulin pumps, asthma inhalers and Epi pens. Find

cannot guarantee a nut-free environment.

Special Camper Needs Summer!Kids@Carroll + Teen College is committed to providing accessible education and a supportive learning environment for all students. To help us meet this goal, after you have registered, please contact our Disability Support Services, 410-386-8329, at least four weeks before the start of the earliest camp to inform the College of any physical disabilities or behavioral/social challenges your child has and to arrange for reasonable accommodations. A staf member will contact you to discuss your child’s individual needs and determine what reasonable accommodations can be made. Carroll Community College does not provide medical assistants or personal care attendants. Campers are expected to exhibit independence and ability for self-care. Parents are not permitted to attend camp with their child.

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First Day of Camp (Monday) Note: See Camp/Location-Specifc Information (p. 4) for special procedures for camps held at Winters Mills High School.

1. Park near the yellow Kids@Carroll banner near the K building (Map p. 5) and look for camp staf wearing staf t-shirts. They will provide direction and be happy to answer your questions.

2. Accompany your camper down the service road to the gym and fnd the sign for your camp.

3. Sign in with the instructor, get your child’s name badge then pick up your t-shirt (Kids@Carroll) or bag (Teen College). Campers will be escorted to classrooms as a group by their instructor.

Drop-Of Procedures: Tuesday – Friday Note: See Camp-Specifc Information for special procedures for camps held at Winters Mills High School.

• Park your car and bring campers to the gym the same as the frst day (Monday).

OR • Drop camper(s) of at the designated Kids@Carroll Drop-

Of yellow banner near the K building (Map p. 5). Camp staf will be there to greet you.

• Camp staf will be stationed along the route to supervise. • If you arrive late and no greeters are present, please

walk your child or teen to the Continuing Education and Training ofce, Room A115 (see map), to be checked in. Do NOT go to the classroom. The College cannot be responsible for campers dropped of without a staf member present. Children cannot be supervised for morning programs before 8:45 a.m. unless they are registered for the Start-Up Time. We cannot supervise afternoon participants before 1 p.m.

Handicap Parking Ample handicapped parking is available close to the gym. If this is needed, please let one of the program staf know and they will move the cones blocking the road so that you can park close to the building.

Coming to Camp

Pick-Up Procedures Note: See Camp-Specifc Information for special procedures for camps held at Winters Mills High School.

Be sure to review your pick-up plan with your camper and arrange to pick them up promptly at the end of the camp, either at noon or 4:15 p.m. If you are delayed, call us at 410-386-8100 and we will let you know where to pick up your camper.

For children age 5 – 12

authorized adult. Children must be signed out from the gym by an

The College will only release your camper to those listed as ‘authorized’ on the Health and Emergency Contact Form. We do not check IDs when the campers are picked up.

For teens age 13 and over With a signed Self-Sign Out Authorization Form (see p. 6) on fle, teen campers may sign themselves out. Self-Sign Out Authorization Forms are in this handbook, at carrollcc.edu/summerkids and will also be available from the instructor and at the administration table in the gym throughout the summer. Pick up teen campers at the yellow Kids@Carroll banner. During inclement weather they may wait in the lobby of the K building. Without a signed Self-Sign Out Authorization Form on fle, teens must be signed out from the gym by an authorized adult (see procedure for children age 5 – 12).

Early Pick-Up For Kids@Carroll and Teen College: Complete an Early Pick-Up Form (available in the gym and at carrollcc.edu/summerkids) and provide it to program staf or instructor.

• Pick up your camper at the designated time from the Continuing Education and Training ofce, Room A115 (see map). Do NOT go to the classroom.

For camps at Winters Mills High School: • Complete the Early Pick-Up Form and give it to camp staf. • Pick up your camper at the curb in front of the building at

the designated time.

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Page 5: 2020 for Summer Camp - Carroll Community College · 2018-04-04 · Getting Ready for Camp . This handbook contains important information about our procedures to help ensure an enjoyable

Start-Up and Wind-Down Time Your camper may start their day with us at 7:30 a.m. and end their day at 6 p.m. Campers age 5 – 15 will be supervised at all times and may choose from a variety of unstructured activities or bring their own games.

If your camper needs to be here before 8:45 a.m. or after 4:30 p.m., they must be registered for Start-Up or Wind-Down time.

Space for cooking campers is limited.

Lunch and Snacks Light snacks (i.e. popcorn, pretzels, crackers and water) are provided for both morning and afternoon programs. Children age 5 – 11 are NOT given the opportunity to purchase snacks from the vending machines.

Teens age 12 and up may purchase snacks from the vending machines. Campers of any age may also bring their own unrefrigerated snacks from home.

Campers who are registered for full-day camps or are here for both morning and afternoon camps are automatically supervised during the lunch period. Campers age 5 – 11 should bring a lunch and drink that do not need refrigeration. Purchased meals at the café or vending machines are not allowed for this age. Teens age 12 and up may purchase lunch from the College café. No camper may purchase from the Starbucks kiosk.

Cell Phones and Electronic Games We hope the campers in our programs are too engaged to think about cell phones and electronic games. Help us maintain a fun learning environment by reminding campers of the following:

• Cell phones must remain of during camp sessions. If you need to reach your child while camp is in session, please call our ofce (410-386-8100) and a message will immediately be delivered to your child.

• Cell phones, electronic devices and small games may be used during recess, Start-Up and Wind-Down periods, but not during camp sessions.

Field Trips Some camps include special trips as an enhancement to learning. You will receive a permission form that must be returned before the trip. We must have the signed permission form before a camper is allowed to participate in the feld trip. Campers are supervised at all times during feld trips.

Camp Cancellations, Withdrawals and Refunds The College expects all programs to be presented as scheduled, but a program could be canceled due to insufcient enrollment. Cancellation decisions are made at least two weeks in advance and you will be contacted directly by email.

In the event that a program is canceled, every efort will be made to either place your child in another program of his/her interest or provide a full refund. The College will make every

Cooking campers must bring a lunch to eat at Winters Mills High School.

Sorry, we cannot supervise children during lunch who are only here a half day.

Behavior We ask all campers to remember that college is in session and administrative ofces are open for business. Campers are expected to respect the rules, demonstrate appropriate behavior, language, and…

• Behave in a friendly, cooperative and reasonable manner toward other campers, instructors and staf

• Respect the ideas and property of others • Be able to work independently • Be able to focus on a task to completion • Follow camp rules and guidelines

Disruptive and inappropriate behavior may result in dismissal.

efort to ensure that all programs are presented as scheduled.

We understand that plans sometimes change. If you need to withdraw your camper, the following refund schedule will be applied:

10 business days before camp start date: . . . . . . . . . . 100% refund

Less than 10 business days before camp start date: . . . . . . . . . . . . . . . . . . . . . . . . . . .Partial refund

After camp begins: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .0 refund

3

Page 6: 2020 for Summer Camp - Carroll Community College · 2018-04-04 · Getting Ready for Camp . This handbook contains important information about our procedures to help ensure an enjoyable

Camp/Location-Specific Information

Cooking Camps These camps are held of-campus at Winters Mills High School located on Gorsuch Road north of MD -140. Camps held at Winters Mills High School are full day and are held from 9:15 a.m. – 4 p.m. Note that camps begin 15 minutes later and end 15 minutes earlier than camps held on campus. Campers will have a 45 minute lunch break and must bring their own non-refrigerated lunch.

Drop-Of (Monday – Friday) • Go directly to Winters Mills High School no more than

15 minutes before the camp is scheduled to begin. Camp begins at 9:15 a.m.

• Camp staf will greet campers at the curb outside the front entrance of the school and will escort them to their classroom. Look for staf wearing staf t-shirts.

• If your camper is already on campus for Start-Up time, adult staf will automatically provide transportation, in the College van, to Winters Mills High School at the appropriate time. Space is limited.

Pick-Up • Pick up campers directly from Winters Mills High School at

4 p.m. Note that camps end 15 minutes earlier than camps held on campus.

• Camp staf will bring the campers to the curb outside the main entrance for pick-up and will only release campers to those listed on the Health and Emergency Contact Form as authorized.

• Campers who are scheduled to be on campus for Wind-Down time will automatically be transported in the College van. Space is limited.

4

Page 7: 2020 for Summer Camp - Carroll Community College · 2018-04-04 · Getting Ready for Camp . This handbook contains important information about our procedures to help ensure an enjoyable

Campus Map

····························· ··················

······················· ·························· ····················

••• 095-16-19 KID

2

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Continuing Education and Training Office (A115)

2

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L L-Building (Learning Resources Center)

A A-Building (Adm

inistration/Classroom Building)

C C-Building (Classroom

Building)M

M

-Building (Classroom Building)

P P-Building (Life Fitness Center)

T T-Building (Fine Arts/Business Training Center)

N

N-Building (Allied Health/N

ursing Building)K

K-Building (Classroom Building)

Page 8: 2020 for Summer Camp - Carroll Community College · 2018-04-04 · Getting Ready for Camp . This handbook contains important information about our procedures to help ensure an enjoyable

Summer Teen College Self-Sign Out Authorization Form Teen campers age 13 and over are permitted to sign themselves out of camp if parent authorization is on fle at Carroll Community College. Once signed out, they should go to the Drop-O° banner on the sidewalk at the top of the service road, where they may be picked up.

If you want your child to be released without your presence, please complete and sign this form and return it to the camp instructor or the Administration table in the gym.

You must pick up your camper promptly. Unaccompanied minors will be reported to security.

If the College does not have a signed permission form on fle, an authorized adult must come to the gym in person to sign out your child.

I allow my child, ______________________________________________________________, age 13 or over to sign himself /herself out of camp.

I understand that the College is not responsible for my child once he/she signs out and leaves the gym, and I herein agree to hold the College harmless from any injury or claim of any kind which may occur after leaving the gym.

I also understand that my child is expected to respect the rules and demonstrate appropriate behavior and language as long as he/she is on the College Campus.

Parent/Guardian Authorization Signature ______________________________________________ Date ____________________________

Printed Name of Parent/Guardian ___________________________________________________

091-17-20-1219 KID

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________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

This form must be completed for each child each year and received in Continuing Education & Training oÿce no later than June 1. You may fax the completed form to Continuing Education & Training at 410-386-8111 or email scanned forms to [email protected]. Visit www.carrollcc.edu/summerkids to print additional forms.

Contact Information Child’s Full Legal Name: ___________________________________________ Child’s Preferred Name: ______________________________

College ID#: (if known) ____________________________________ Child’s Date of Birth:_________________________ Gender: ❑ M ❑ F

Street: ___________________________________________________________________________________________________

City: _______________________________________ State: __________________________ Zip: ____________________________

My child is registered for the following weeks: ❑ June 22 ❑ June 29 ❑ July 6 ❑ July 13 ❑ July 20 ❑ July 27 ❑ Aug. 3 ❑ Aug. 10 (may be changed at any time)

Guardian 1 Name: ____________________________________________________________________________________________

Home Phone: ______________________________ Work:___________________________ Cell:____________________________

Email: ________________________________________________________________________________________________

Guardian 2 Name: ____________________________________________________________________________________________

Home Phone: ______________________________ Work: ___________________________ Cell: ___________________________

Email: ________________________________________________________________________________________________

Name(s) of Additional Authorized Adult(s) picking up the student: ❑ Same as above plus:

In an emergency contact: ❑ Guardian(s) as listed above frst, then: (Please supply at least one emergency contact, in case guardians can’t be reached.)

• Name: ______________________________________________ Relation to Child: ______________________________________

Home Phone: ______________________________ Work:___________________________ Cell: ___________________________

• Name: ______________________________________________ Relation to Child: ______________________________________

Home Phone: ______________________________ Work:___________________________ Cell: ___________________________

Immunization/Health Information 1) Camper’s Physician’s Name: _________________________________ Phone Number: ______________________________________

2) For campers who reside WITHIN the United States, a United States Territory or the District of Columbia:

1. State/territory in which child resides: _________________________

2. Is this child exempt from any immunizations? ❑ No ❑ Yes, list them: _________________________________________________________

For campers who reside OUTSIDE the United States, a United States territory or the District of Columbia:

1. Country in which child resides: _____________________________

2. Attach Department form DHMH-896 (record of vaccination or immunity)

(continued on reverse) 7

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Child’s Full Name: ____________________________________________________ College ID (if known) _______________________

Immunization/Health Information (continued)

3) Please tell us about any allergies. Mark all that apply:

❑ None that I know about Is this a life threatening allergy? ❑ My child requires an EpiPen ❑ Bee sting ❑ Yes ❑ No ❑ Peanuts/other nuts ❑ Yes ❑ No ❑ Other: ____________________________________ ❑ Yes ❑ No

4) Please list any medications, dietary restrictions or special needs your child may have so we can ensure a positive camp experience:

❑ None

________________________________________________________________________________________________

________________________________________________________________________________________________

5) Are there any other physical, psychiatric, behavioral or emotional conditions of which we need to be aware? Mark all that apply:

❑ None ❑ Asthma ❑ ADD ❑ Diabetes ❑ Emotional issues ❑ Epilepsy/seizure ❑ Hearing impairment ❑ Asperger’s/autism ❑ Other (please explain) ________________________________________________________________________________

________________________________________________________________________________________________________________________

If your child has needs that require special attention, please e-mail us at [email protected] at least four weeks in advance so we can do our best to accommodate them.

6) If your child must either carry or be given ANY medication during program hours, the Medication Administration Authorization Form is required by the Maryland Department of Health. No medication will be accepted without the completed Authorization form. Access the form at carrollcc.edu/summerkids, in the Parents Handbook that you receive with your confrmation or call 410-356-8100. Medication must be in original containers by law.

IN THE EVENT OF AN EMERGENCY, you agree to release and hold harmless Carroll Community College, whose frst aid certifed sta° may administer frst aid to your child as needed and authorize Carroll Community College sta° to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for your child’s immediate care and agree to be responsible for payment of any and all charges for medical services rendered.

My child has my permission to be photographed, interviewed, or videotaped while attending Kids@Carroll or Teen College programs for possible use in print or web marketing. I release Carroll Community College, its Board of Trustees, oÿcers, agents, directors, faculty/sta˛, and assigns from any and all claims (monetary or otherwise) that you may have related to the use of these images. ❑ Yes ❑ No

Informed Consent/Assumption of Risk I have registered my child for Summer Kids@Carroll classes sponsored by Carroll Community College. I understand that participation in this activity/course involves inherent risks of injury, and that the nature of the risks may vary depending upon the type of activity, instructor, and my child’s physical condition and conduct. I acknowledge that I will either ask for or have been given any information that I need to determine the general risks associated with this camp and its activities. I agree that my child will follow advised precautions and conform to all rules and policies of the department, instructor, and any other sponsor of this course/activity.

I voluntarily assume all risks of loss, damage, illness, or injury which my child may sustain while participating in this camp and its activities, including travel and usage of any equipment or facilities. I will make no claim against and do hereby fully and unconditionally, forever release, waive, discharge, hold harmless and indemnify, on behalf of myself (my child), my personal representatives and my heirs, Carroll Community College and its Board of Trustees, oÿcers, agents, and employees from any and all claims and causes of action for any injury or loss, or for damages, costs, expenses, or compensation that may occur during or result from my child’s participation in this camp and its activities, whether arising through the negligence, omission, default, or other action of any person or event associated with this course or event, including fellow participants.

I certify the above information to be true and correct to the best of my knowledge and I take responsibility for my child’s compliance with the appropriate student behavior. I understand that disruptive and inappropriate behavior may result in dismissal.

I will abide by all terms in the parent handbook.

I have read and understand the above information. I give my permission for my child to participate in this camp and its activities and grant the same informed consent, assumption of risk, and release for myself (for my child), estate, successors, and assigns, and the child’s family.

Parent/Guardian Signature: (required) ___________________________________________ Date: __________________________

Printed name of Parent or Guardian _______________________________________________________________ 091-05-20 -1119 KID

8

Page 11: 2020 for Summer Camp - Carroll Community College · 2018-04-04 · Getting Ready for Camp . This handbook contains important information about our procedures to help ensure an enjoyable

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□ N

o Kn

own

side

eff ec

ts:

4. P

RESC

RIBE

R'S

NAM

E/TI

TLE

This

spac

e m

ay b

e us

ed fo

r the

Pre

scrib

er's

Addr

ess S

tam

pTE

LEPH

ON

E FA

X AD

DRES

SCI

TY

STAT

E ZI

P CO

DE5a

. PRE

SCRI

BER'

S SI

GNAT

URE

(Par

ent/

guar

dian

can

not s

ign

here

) (o

rigin

al si

gnat

ure

or si

gnat

ure

stam

p on

ly)

5b. D

ATE

(mm

/dd/

yyyy

)

Secti

on II

. PAR

ENT/

GU

ARDI

AN A

UTH

ORI

ZATI

ON

I req

uest

the

auth

orize

d yo

uth

cam

p op

erat

or, s

taff

mem

ber o

r vol

unte

er to

adm

inist

er th

e m

edic

ation

or t

o su

perv

ise th

e ca

mpe

r in

self-

adm

inist

ratio

n as

pre

scrib

ed b

y th

e ab

ove

auth

orize

d pr

escr

iber

. I c

erti f

y th

at I

have

lega

l aut

horit

y to

con

sent

to m

edic

al tr

eatm

ent f

or th

e ch

ild n

amed

abo

ve, i

nclu

ding

the

adm

inist

ratio

n of

med

icati

on a

t the

faci

lity.

I un

ders

tand

that

at t

he e

nd o

f the

aut

horiz

ed p

erio

d an

aut

horiz

ed in

divi

dual

mus

t pic

k up

the

med

icati

on; o

ther

wise

, it w

ill b

e di

scar

ded.

Iau

thor

ize c

amp

pers

onne

l and

the

auth

orize

d pr

escr

iber

indi

cate

d on

this

form

to c

omm

unic

ate

in c

ompl

ianc

e w

ith H

IPAA

6a. P

AREN

T/GU

ARDI

AN S

IGN

ATU

RE

6b. D

ATE

(mm

/dd/

yyyy

) 6c

. IN

DIVI

DUAL

S AU

THO

RIZE

D TO

PIC

K U

P M

EDIC

ATIO

N

6d. H

OM

E PH

ON

E #

6e. C

ELL

PHO

NE

# 6f

. WO

RK P

HON

E #

Secti

on II

I. AU

THO

RIZA

TIO

N F

OR

SELF

-ADM

INIS

TRAT

ION

/ S

ELF-

CARR

Y (O

PTIO

NAL

)TH

IS S

ECTI

ON

SHO

ULD

ON

LY B

E CO

MPL

ETED

IF A

NY

MED

ICAT

ION

S IN

THE

AST

HMA

ACTI

ON

PLA

N A

BOVE

ARE

APP

ROVE

D FO

R SE

LF-A

DMIN

ISTR

ATIO

N.

Self-

carr

y is

only

per

mitt

ed fo

r em

erge

ncy

med

icati

ons s

uch

as in

hale

rs a

nd

epin

ephr

ine.

Bot

h th

e pr

escr

iber

and

the

pare

nt/g

uard

ian

mus

t con

sent

to se

lf-ad

min

istra

tion

belo

w.

How

ever

, you

th c

amp

oper

ator

s are

not

requ

ired

to p

erm

it se

lf-ad

min

istra

tion

or se

lf-ca

rry.

I aut

horiz

e se

lf-ad

min

istra

tion

of a

ll of

the

med

icati

ons l

isted

in Se ctio

n I

abov

e th

at a

re c

heck

ed a

s "O

K to

self-

adm

inist

er" o

r "O

K to

self-

adm

inist

er a

nd se

lf-ca

rry"

for t

he c

hild

nam

ed a

bove

und

er th

e su

perv

ision

of t

he y

outh

cam

pop

erat

or, a

des

igna

ted

staff

mem

ber o

r vol

unte

er.

If in

dica

ted

in Se ctio

n I ,

the

child

nam

ed a

bove

may

self-

carr

y em

erge

ncy

med

icati

ons c

heck

ed a

s "O

K to

self-

adm

inist

er a

nd se

lf-ca

rry.

"

7a. P

RESC

RIBE

R'S

SIGN

ATU

RE

FOR

SELF

-ADM

INIS

TRAT

ION

/SEL

F-CA

RRY

7b. D

ATE

8a. P

AREN

T/GU

ARDI

AN'S

SIG

NAT

URE

FO

R SE

LF-A

DMIN

ISTR

ATIO

N/S

ELF-

CARR

Y

8b. D

ATE

MDH

-475

8-A

(01/

2019

) 09

1-03

-20

1119

KID