2500 Wellness Drive, Harrisonburg, VA 22801 • RMHWellnessCenter.com

3/17

at the Sentara RMH Wellness CenterSummer Camp

Animal Land Summer CampsVenture into the wild this summer! Campers will experience an

action-packed adventure exploring the world of wildlife

with crafts, games and activities, and afternoon swimming. It’ll be a ROARING good time!

Camps held Mondays-Fridays for kids ages *5-12.

June 12-16 Winged WondersJune 19-23 Outstanding OceanAugust 7-11 Jungle JamAugust 14-18 Amazing Arctic

To register, call 1-800-SENTARA or 540-564-7200. Register by May 12 and save!

Full day and half day options available.

order to receive a refund or credit to your member account. Please notify us of your cancellation, by calling 540-564-5684. A $5 fee per child will be charged if payment is not received 2 business days prior to the day of the program.

WHAT TO BRING: Lunch • Sneakers (closed-toe with rubber soles)• Water bottle • Sunscreen • Book or magazine • Hat

BEHAVIOR: We expect participants to respect others, harmoniously participate in games and activities, and cooperate with the staff persons. We will report any incidents of unacceptable behavior to the parents/guardians of all children involved. We reserve the right to release a child for unacceptable behavior. Refunds will not be issued for children released for unacceptable behavior.

SNACKS: We will provide an afternoon snack for the children. Please note any food allergies on the sign-in sheet each day.

LUNCH: Lunch may be ordered at the Trackside Café, located inside the Wellness Center. Please complete an order form and payment at the Café each morning. If you plan on packing a bagged lunch for your child, please pack perishable items with a cold pack. Please do not bring food items that require heating. Please label the bagged lunch with the date and your child’s first and last name. Out of concern for the health of other children, please refrain from bringing items containing nuts.

SWIMMING: Children will be swimming every afternoon from 3pm - 4pm and must have a completed and signed Acknowledgment of Pool Rules before they can swim. If the child has not passed a swim test, they will be required to wear a life jacket.

ILLNESS: We reserve the right to release a child if he/she appears ill, if they are considered contagious, or if an emergency arises. We will notify the child’s parent/guardian or emergency contact, and request the child be picked up within the hour. Parents are required to inform the Center within 24 hours or the next business day after his/her child or any member of the immediate household has developed any reportable communicable disease (see below), as defined by the State Board of Health: Diarrhea, difficult or rapid breathing, elevated temperature, pink eye, severe or whooping cough, severe itching of body or scalp, head lice, severe headache with elevated temperature, vomiting, unusual spots, sores or rashes, yellow skin or eyes, cranky or unusual behavior, infected skin patches, swelling, discharge, pus, and/or sore throat with elevated temperature.

MEDICATIONS, ASTHMA INHALERS AND EPI–PEN: We request that parents administer necessary medications to their children before or after hours. The Sentara RMH Wellness Center will administer medication to participants only in situations that are absolutely necessary for a participant’s health. Medication must be in the original, labeled container supplied by pharmacist. The Asthma Inhaler and EPI–Pen Permission Form is required for EPI–Pens, inhalers and other long term medications. Include written instructions concerning the administration times and dosages. Leftover medication must be picked up on your child’s final day of the program. All remaining medication will be destroyed. Please speak with a staff person about medication and any special concerns.

CONTACT INFORMATION: If you have questions, please contact Children's Programming Coordinator, Debbie Pattison at 540-564-5684.

CAMP POLICIES & PROCEDURES

PER WEEK : On or before May 12 After May 12 Drop Off Pick Up Opt Before Care

Full day 9am-5pm $135 $145 8-9am 5-6pm 7-8am / $20 / week

Morning 9am-12pm $75 $85 8-9am 12-1pm 7-8am / $20 / week

Afternoon 1pm-5pm $100 $110 12-1pm 5-6pm

PER DAY :

Full day 9am-5pm $40 8-9am 5-6pm 7-8am / $5 / day

Morning 9am-12pm $25 8-9am 12-1pm 7-8am / $5 / day

Afternoon 1pm-5pm $35 12-1pm 5-6pm

Drop Off Pick Up Opt Before Care

Camp themes:June 12-16 Winged Wonders: imaginations soar as we take flight into a week of exploration and excitement!

June 19 - 23 Outstanding Ocean: Dive to the depths of the ocean to discover underwater creatures and explore the beautiful coral reef.

August 7 - 11 Jungle Jam: There will be plenty of monkey business as we swing into the wild.

August 14 – 18 Amazing Arctic: Chilling out in a frozen wonderland with our frosty animal friends is snow much fun!

Camp Options:

AGE REQUIREMENT: *5 year olds are eligible to participate in camp if they were age 5 on or before September 30, 2016.

REGISTRATION: Registration and full payment must be received in order to hold your child’s spot. Please register by calling 540-564-7200. If the registration forms are not available in this packet, please request the forms when you register. Please review and complete all forms and bring them when you drop off your child. Important: If you print the forms online, it is still necessary to call 540-564-7200 to complete your child’s registration.

CANCELLATIONS, REFUNDS & LATE REGISTRATION: Cancellations and transfer requests must be received by us within 5 business days prior to the first day of the program in order to receive a refund or credit to your member account. Please notify us of your cancellation, by calling 540-564-5684. A $5 fee per child will be charged if payment is not received 2 business days prior to the day of the program.

BEFORE CARE: If you need to bring your child before the specified drop off time, please contact 540-564-5684 to register for before care.

DROP-OFF: Please walk your child to the activity studio room where you will sign them in. If someone other than the person bringing the child is picking them up, please notify the staff and write the name of the person who will be picking up your child on the sign-in sheet.

PICK-UP: Guardians must sign the child out with the staff by the specified time. For safety reasons, we will not release any child to an individual not listed on the sign-in sheet. It is our policy to ask for a valid photo identification card if someone other than the parent/guardian is picking up your child.

WHAT TO BRING: Lunch • Sneakers (closed-toe with rubber soles)• Water bottle • Book or magazine • Hat • Hair Brush or comb • Swim suit and water shoes or flip flops. Afternoon & full day

campers: Bring each day. Morning campers: Fridays only. Please put all items in a book bag with your child's name on it. Please do NOT bring any toys from home.

Sentara RMH Wellness Center Camp Acknowledgement Statement

Please read all information included in the registration process. Please complete all forms and bring them to your child’s first day of camp.

Sentara RMH Wellness Center Camp Guide / Camp Policies & Procedures

Child Information Form

Virginia School Entrance Health Forms

Certificate of Religious Exemption Form (if applicable)

Copy of Birth Certificate or Passport

Medication/Asthma/EPI-Pen Permission Form (if applicable)

Acknowledgement of Pool Rules Form (required for full day and afternoon campers only)

Sunscreen Authorization Form

By signing below I acknowledge that I have read, completed and will adhere to the policies and procedures outlined in the forms listed above.

Parent or Guardian’s Signature Date

Child’s Name

SENTARA RMH WELLNESS CENTER SUMMER CAMP CHILD INFORMATION FORM

Age:

Nickname: Gender:

SRMH WC Child Member: YES or NO

State: Zip Code:

Child’s Name:

Date of Birth:

Parent/Guardian Name(s):

Address:

City:

Telephone Numbers: ( ) ( )

E-mail address:

EMERGENCY INFORMATION Please use reverse side of form if necessary

Parent/Guardian Information

Mother/Guardian: Address:

Work Phone: Cell Phone:

Father/Guardian: Address:

Work Phone: Cell Phone:

In the event of an emergency, we will contact the parents/guardians listed above. Please list local emergency contacts below who may be reached if we are not able to reach the parents/guardians.

Emergency Contacts/Persons Authorized to Pick Up Child

1.) Name: Address:

Home Phone: Work Phone:

2.) Name: Address:

Home Phone: Work Phone:

Parent/Guardian Consent and Agreement

I am requesting that the above child be admitted to the summer program, and I understand the nature and the scope of theprogram listed above and will adhere to all policies and procedures of the program. I understand that the summer program operates no more than 20 days during the course of a calendar year.

I understand that there are risks and dangers associated with the program. I understand that it is not the function of the Sentara RMH Wellness Center, its employees, agents, operators, or instructors to guarantee the safety of participants with respect to this program. I also understand that each participant has the responsibility to exercise due care in the performance of the program for the safety of himself/herself and other participants. In the event that I cannot be reached in an emergency involving the above named participant, I hereby give permission to the personnel to provide medical treatment deemed necessary.

In the consideration of the participant being permitted to enroll in the program, I hereby release, indemnify, and hold harmless Sentara RMH Wellness Center, its employees, operators, counselors, and instructors from any and all claims and demands, costs, charges, and expenses for harm, injury, damage, or loss which may be sustained by the participant as a result of or relating to participation in the program.

I HAVE READ AND UNDERSTAND THE CONDITIONS OF THIS CONSENT AND AGREEMENT.

Parent/Guardian Signature Date

Administrator of Center Signature Date

MCH 213G reviewed 03/2014 1

COMMONWEALTH OF VIRGINIA SCHOOL ENTRANCE HEALTH FORM

Health Information Form/Comprehensive Physical Examination Report/Certification of Immunization

Part I – HEALTH INFORMATION FORM State law (Ref. Code of Virginia § 22.1-270) requires that your child is immunized and receives a comprehensive physical examination before entering public kindergarten or elementary school. The parent or guardian completes this page (Part I) of the form. The Medical Provider completes Part II and Part III of the form. This form must be completed no longer than one year before your child’s entry into school.

Name of School: ____________________________________________________________________________________ Current Grade: _______________________

Student’s Name: _________________________________________________________________________________________________________________________ Last First Middle

Student’s Date of Birth: _____/_____/_______ Sex: _______ State or Country of Birth: ________________________ Main Language Spoken: ______________

Student’s Address: ______________________________________________________ City: ____________________ State: _______________ Zip: _______________

Name of Parent or Legal Guardian 1: ____________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______

Name of Parent or Legal Guardian 2: ____________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______

Emergency Contact: __________________________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______

Condition Yes Comments Condition Yes Comments Allergies (food, insects, drugs, latex) Diabetes Allergies (seasonal) Head injury, concussions Asthma or breathing problems Hearing problems or deafness Attention-Deficit/Hyperactivity Disorder Heart problems Behavioral problems Lead poisoning Developmental problems Muscle problems Bladder problem Seizures Bleeding problem Sickle Cell Disease (not trait) Bowel problem Speech problems Cerebral Palsy Spinal injury Cystic fibrosis Surgery Dental problems Vision problems

Describe any other important health-related information about your child (for example; feeding tube, hospitalizations, oxygen support, hearing aid, dental appliance,

etc.):__________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

List all prescription, over-the-counter, and herbal medications your child takes regularly:

_______________________________________________________________________________________________________________________________________

Check here if you want to discuss confidential information with the school nurse or other school authority. Yes No

Please provide the following information:

Name Phone Date of Last Appointment Pediatrician/primary care provider

Specialist

Dentist

Case Worker (if applicable)

Child’s Health Insurance: ____ None ____ FAMIS Plus (Medicaid) _____ FAMIS _____ Private/Commercial/Employer sponsored

I, ______________________________________ (do___) (do not___) authorize my child’s health care provider and designated provider of health care in the school setting to discuss my child’s health concerns and/or exchange information pertaining to this form. This authorization will be in place until or unless you withdraw it. You may withdraw your authorization at any time by contacting your child’s school. When information is released from your child’s record, documentation of the disclosure is maintained in your child’s health or scholastic record.

Signature of Parent or Legal Guardian: ______________________________________________________________________Date: _______/________/ __________

Signature of person completing this form: ____________________________________________________________________Date:_______/________/___________

Signature of Interpreter: __________________________________________________________________________________Date: ______/_____/_______

MCH 213G reviewed 03/2014 2

COMMONWEALTH OF VIRGINIA SCHOOL ENTRANCE HEALTH FORM

Part II - Certification of Immunization

Section I To be completed by a physician or his designee, registered nurse, or health department official.

See Section II for conditional enrollment and exemptions.

A copy of the immunization record signed or stamped by a physician or designee, registered nurse, or health department official indicating the dates of administration including month, day, and year of the required vaccines shall be acceptable in lieu of recording these dates on this form as long as the record is attached to this form. Only vaccines marked with an asterisk are currently required for school entry. Form must be signed and dated by the Medical Provider or Health Department Official in the appropriate box.

Certification of Immunization 11/06

Student’s Name: Date of Birth: |____|____|____| Last First Middle Mo. Day Yr.

IMMUNIZATION RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN

*Diphtheria, Tetanus, Pertussis (DTP, DTaP) 1 2 3 4 5

*Diphtheria, Tetanus (DT) or Td (given after 7 years of age)

1 2 3 4 5

*Tdap booster (6th grade entry) 1

*Poliomyelitis (IPV, OPV) 1 2 3 4

*Haemophilus influenzae Type b(Hib conjugate) *only for children <60 months of age

1 2 3 4

*Pneumococcal (PCV conjugate)*only for children <60 months of age

1 2 3 4

Measles, Mumps, Rubella (MMR vaccine) 1 2

*Measles (Rubeola) 1 2 Serological Confirmation of Measles Immunity:

*Rubella 1 Serological Confirmation of Rubella Immunity:

*Mumps 1 2

*Hepatitis B Vaccine (HBV) Merck adult formulation used

1 2 3

*Varicella Vaccine 1 2 Date of Varicella Disease OR Serological Confirmation of Varicella Immunity:

Hepatitis A Vaccine 1 2

Meningococcal Vaccine 1

Human Papillomavirus Vaccine 1 2 3

Other 1 2 3 4 5

Other 1 2 3 4 5

Other 1 2 3 4 5

* Required vaccine I certify that this child is ADEQUATELY OR AGE APPROPRIATELY IMMUNIZED in accordance with the MINIMUM requirements for attending school, child care or preschool prescribed by the State Board of Health’s Regulations for the Immunization of School Children (Reference Section III).

Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):___/___/____

MCH 213G reviewed 03/2014 3

Student’s Name: Date of Birth: |____ |_ ___|___ _|

Section II Conditional Enrollment and Exemptions

Complete the medical exemption or conditional enrollment section as appropriate to include signature and date.

Certification of Immunization 03/2014

MEDICAL EXEMPTION: As specified in the Code of Virginia § 22.1-271.2, C (ii), I certify that administration of the vaccine(s) designated below would be detrimental to this student’s health. The vaccine(s) is (are) specifically contraindicated because (please specify): ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

DTP/DTaP/Tdap:[ ]; DT/Td:[ ]; OPV/IPV:[ ]; Hib:[ ]; Pneum:[ ]; Measles:[ ]; Rubella:[ ]; Mumps:[ ]; HBV:[ ]; Varicella:[ ]

This contraindication is permanent: [ ], or temporary [ ] and expected to preclude immunizations until: Date (Mo., Day, Yr.): |___|___|___|.

Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):|___|___|___|

RELIGIOUS EXEMPTION: The Code of Virginia allows a child an exemption from receiving immunizations required for school attendance if the student or the student’s parent/guardian submits an affidavit to the school’s admitting official stating that the administration of immunizing agents conflicts with the student’s religious tenets or practices. Any student entering school must submit this affidavit on a CERTIFICATE OF RELIGIOUS EXEMPTION (Form CRE-1), which may be obtained at any local health department, school division superintendent’s office or local department of social services. Ref. Code of Virginia § 22.1-271.2, C (i).

CONDITIONAL ENROLLMENT: As specified in the Code of Virginia § 22.1-271.2, B, I certify that this child has received at least one dose of each of the vaccines required by the State Board of Health for attending school and that this child has a plan for the completion of his/her requirements within the next 90 calendar days. Next immunization due on __________________.

Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):|___|___|___|

For Minimum Immunization Requirements for Entry into School and Day Care, consult the Division of Immunization web site at

http://www.vdh.virginia.gov/epidemiology/immunization

Children shall be immunized in accordance with the Immunization Schedule developed and published by the Centers for Disease Control (CDC), Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP),

otherwise known as ACIP recommendations (Ref. Code of Virginia § 32.1-46(a)). (Requirements are subject to change.)

Section III Requirements

MCH 213G reviewed 03/2014 4

Part III -- COMPREHENSIVE PHYSICAL EXAMINATION REPORT A qualified licensed physician, nurse practitioner, or physician assistant must complete Part III. The exam must be done no longer than one year before entry into kindergarten or elementary school (Ref. Code of Virginia § 22.1-270). Instructions for completing this form can be found at www.vahealth.org/schoolhealth.Student’s Name: _______________________________________________ Date of Birth: _____/_____/__________ Sex: □ M □ F

Hea

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smen

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Date of Assessment: _____/_____/_______

Weight: ________lbs. Height: _______ ft. ______ in.

Body Mass Index (BMI): ___________ BP____________

Age / gender appropriate history completed

Anticipatory guidance provided

Physical Examination

1 = Within normal 2 = Abnormal finding 3 = Referred for evaluation or treatment

1 2 3 1 2 3 1 2 3

HEENT □ □ □ Neurological □ □ □ Skin □ □ □

Lungs □ □ □ Abdomen □ □ □ Genital □ □ □

Heart □ □ □ Extremities □ □ □ Urinary □ □ □

TB Screening: □ No risk for TB infection identified □ No symptoms compatible with active TB disease□ Risk for TB infection or symptoms identified

Test for TB Infection: TST IGRA Date:_______ TST Reading _____mm TST/IGRA Result: □ Positive □ Negative CXR required if positive test for TB infection or TB symptoms. CXR Date: __________ □ Normal □ Abnormal EPSDT Screens Required for Head Start – include specific results and date: Blood Lead:___________________________________________ Hct/Hgb ____________________________________________

Dev

elop

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tal

Scre

en

Assessed for: Assessment Method: Within normal Concern identified: Referred for Evaluation Emotional/Social

Problem Solving

Language/Communication

Fine Motor Skills

Gross Motor Skills

Hea

ring

Sc

reen

Screened at 20dB: Indicate Pass (P) or Refer (R) in each box.

1000 2000 4000 R L

Screened by OAE (Otoacoustic Emissions): □ Pass □ Refer

□ Referred to Audiologist/ENT □ Unable to test – needs rescreen

□ Permanent Hearing Loss Previously identified: ___Left ___Right

□ Hearing aid or other assistive device

Vis

ion

Scre

en

With Corrective Lenses (check if yes)Stereopsis Pass Fail Not tested Distance Both R L Test used:

20/ 20/ 20/

Pass Referred to eye doctor Unable to test – needs rescreen

Den

tal

Scre

en

Problem Identified: Referred for treatment

No Problem: Referred for prevention

No Referral: Already receiving dental care

Rec

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Summary of Findings (check one): □ Well child; no conditions identified of concern to school program activities□ Conditions identified that are important to schooling or physical activity (complete sections below and/or explain here): ____________________________________________________________________________________________________________________________________________________

___ Allergy □ food: _____________________ □ insect: _____________________ □ medicine: _____________________ □ other: _________________ Type of allergic reaction: □ anaphylaxis □ local reaction Response required: □ none □ epinephrine auto-injector □ other: ________________

___Individualized Health Care Plan needed (e.g., asthma, diabetes, seizure disorder, severe allergy, etc)

___ Restricted Activity Specify: _________________________________________________________________________________________________

___ Developmental Evaluation □ Has IEP □ Further evaluation needed for: ___________________________________________________________

___ Medication. Child takes medicine for specific health condition(s). □ Medication must be given and/or available at school.

___ Special Diet Specify: ______________________________________________________________________________________________________

___ Special Needs Specify: ______________________________________________________________________________________________________

Other Comments: _____________________________________________________________________________________________________________

Health Care Professional’s Certification (Write legibly or stamp) □ By checking this box, I certify with an electronic signature that all of

the information entered above is accurate (enter name and date on signature and date lines below). Name: _____________________________________ Signature: ________________________________________ Date: ____/_____/______

Practice/Clinic Name: __________________________________________ Address: ____________________________________________________________

Phone: _______-_______-____________________ Fax: _______-_______-______________ Email: ______________________________________________

COMMONWEALTH OF VIRGINIACERTIFICATE OF RELIGIOUS EXEMPTION

Name ____________________________________ Birth Date _______________________

Student I.D. Number __________________________________

The administration of immunizing agents conflicts with the above namedstudent's/my religious tenets or practices. I understand, that in the occurrence of anoutbreak, potential epidemic or epidemic of a vaccine-preventable disease in my/mychild's school, the State Health Commissioner may order my/my child's exclusionfrom school, for my/my child's own protection, until the danger has passed.

_______________________________________________ ___________________________Signature of parent/guardian/student Date

I hereby affirm that this affidavit was signed in my presence on

This ____________________________________________ Day of _____________________

Notary Public Seal

Form CRE-1; Rev. 00/92

MEDICATION, ASTHMA INHALER & EPI-PEN

PERMISSION FORM

Child’s Name Date of Birth

The Sentara RMH Wellness Center requires that all participants in camp who possess and/or self-administer, Medication, Asthma Inhaler or EPI-Pen must have a signed permission form from the child’s parent and health care professional.

Parent Section

Permission is granted to the Sentara RMH Wellness Center to allow my child to possess and use:

Medication Name: Dosage and times to be administered:

Special Instructions:

Parent/Legal Guardian Signature Date

All medication must be presented to the staff in original packaging and accompanied by a note from parent/guardian.

Licensed Medical Personnel Must Complete This Section

Medication

Name of Medication Date

Route and Dosage of Medication

Specific Recommendations for administration (list symptoms that would indicate need for medication)

I hereby verify that (Child listed above) has a valid prescription for the following at the Sentara RMH WellnessCenter.

Medication Asthma Inhaler Epinephrine Auto-Injector

Licensed Medical Personnel Signature

Print Name Date

Business Phone

Emergency Phone

If you or your child’s health care professional has any questions, please contact the Children’s Programming

Coordinator at 564-5684.

SENTARA RMH WELLNESS CENTER ACKNOWLEDGMENT OF POOL RULES

The Sentara RMH Wellness Center wants to provide a safe environment for your child while attending camp. Please take time to review our Pool Rules with your child before he/she attends camp. We also ask that you let us know if your child is unable to swim independently or if he/she has any medical condition(s) and/or are taking any medication(s). After you review the rules with your child and complete the remainder of this form, please be sure to sign and date it. Your child will not be allowed to swim with camp unless this from has been completed. If you have any questions, please call the children’s programming coordinator at 540-564-5684.

RULES TO REVIEW WITH YOUR CHILD PRIOR TO CAMP:

Listen to the staff and the lifeguard(s) on duty.

No running on the pool deck, and no pushing other children into the pool. No diving into the pool, and no dunking other swimmers.

If jumping from the side, look out for others in the pool. Jump in feet first.

Stay with your group and counselor at all times. If you need to leave the pool area for any reason, tell the counselor or alifeguard. Do not go anywhere else without an adult.

You are not allowed in the whirlpool or locker rooms without an adult.

Have fun!

If your child is unable to swim independently, your child MUST wear a personal flotation device (jacket). For the safety ofyour child, an age-appropriate swim test will be given to determine if a flotation device will be required. Also, if you know that your child cannot swim independently, we ask that you inform us. Your child may bring his/her own flotation device(jacket) or we can provide them with one. Please understand that the Sentara RMH Wellness Center may or may not providelifeguard services while your child is in the pool area. Regardless of the presence or absence of a lifeguard, you and your child will be permitted to swim with the understanding that you are swimming at your own risk.

Check here if your child cannot swim independently and needs a flotation device.

If your child has any medical conditions or takes any medications that may affect his/her ability to swim, please be sure to tell the counselor.

ACKNOWLEDGMENT:

I, _, the parent/legal guardian for , acknowledge that I have reviewed the Pool Rules with my child. I have also informed the staff if my child is unable to swim independently or if there is a physical or medical condition that may affect my child’s ability to swim. I acknowledge that swimming can be a strenuous or even hazardous activity, and may involve potential health risks to my child such as leg cramps, bodily injury, drowning, and even death. Understanding these risks, I accept and assume all such risks on behalf of me and my child, whether the risks are known or unknown. I also release and waive on behalf of me and my child any claims, losses, costs, or damages arising from or related to my child’s participation in the pool, whether caused by the negligence of the Sentara RMH Wellness Center or otherwise.

Signature of parent/legal guardian Date

Authorization Form for Sunscreen Products

INSTRUCTIONS: This form must be completed by the parent/guardian to authorize the use of:

Sunscreen

________________________________________________ has my permission to apply non-prescription (Name of Provider)

sunscreen product listed below to my child, ______________________________________.(Child’s name)

Product Name: _________________________________________________________________________

Known Adverse Reactions (if any): __________________________________________________________

_______________________________________________________________________________________

Sunscreen:

This authorization is effective from: _______________________until: ______________________ (Start date) (End date)

Parent’s Signature: ____________________________________ Date: _____________

o Must have a minimum sunburn protection factor (SPF) of 15o Shall be inaccessible to children under 5 yrs. & children in therapeutic or special needs programso Children nine yrs. and older may self administer sunscreen if supervisedo If in the event the child does not bring sunscreen, we will provide sunscreen for application.