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  • Livonia Franklin Marching Patriots

    31000 Joy Road, Livonia, Michigan 48150 Band Office 734-744-2655 ext. 47862

    June 6, 2019

    Enclosed in this Marching Band Camp Staff/Chaperone packet are the following items:

    1. Chaperone Agreement

    2. YMCA Risk Waiver

    3. YMCA Dietary Concerns form

    4. YMCA Health Form

    5. Adult Health Form

    6. Central Registry Clearance form (MUST attach copy of driver’s license!)

    7. Chaperone Reference Letter forms (first timers only!)

    8. Personnel Record

    9. Web/Media Authorization-Adult

    10. Band Camp Theme Days information

    11. LPS iChat Adult Volunteer/Kroger-Amazon Instruction Sheet

    Please read complete all items thoroughly. These forms are required by either the State of Michigan Licensing

    Board and/or Franklin High School. If you need more information about any of these items, please feel free to

    contact me at 734.233.8099 or monicafulton@sbcglobal.net.

    Please return all forms to:

    Livonia Franklin Band Boosters ATTN: Corresponding Secretary PO Box 51427

    Livonia, MI 48151-1427

    Forms can also be dropped in the locked box in the Band Director’s office.

    All Forms Must Be Returned No Later Than Friday, July 19, 2019.

    Thank you,

    Monica Fulton

    Monica Fulton Corresponding Secretary

    Franklin Band Boosters

    mailto:monicafulton@sbcglobal.net

  • Livonia Franklin Marching Patriots

    31000 Joy Road, Livonia, Michigan 48150 Band Office 734-744-2655 ext. 47862

    June 6, 2019

    Dear Parent / Guardian:

    If you are interested in chaperoning for the week of band camp (August 19-24, 2019), or even part of

    the week, please fill out the enclosed Chaperone Agreement, Chaperone Health Form (with a

    copy of front and back of health insurance card), Personnel Record, YMCA Camp Risk Waiver

    Form, YMCA Special Dietary Concerns, YMCA Health Form, Website/Media Authorization and

    complete the Livonia Public Schools ICHAT form on line. In addition, we require all first-time parent

    chaperones to provide three (3) character references on their behalf (relatives do not qualify). If you

    have chaperoned Band Camp in the past, you do NOT need to submit character references.

    Lastly, the State of Michigan requires all camp chaperones to apply for Central Registry Clearance.

    Please complete the Central Registry Clearance Request Form and attach a copy of your driver’s

    license to the form in upper right corner.

    Adult chaperones will be considered once all forms and references have been evaluated. Parents of

    senior students will be given first consideration. The cost for adult chaperones for the week will be

    $80 (the cost of meals). Your spot is not guaranteed until fee is paid; all payments are to be submitted

    to our Comptroller.

    Return ALL forms to Livonia Franklin Band Boosters, ATTN: Corresponding Secretary, PO Box

    51427, Livonia, MI 48151-1427 no later than Friday, July 19, 2019. Forms can also be dropped in

    the locked drop box in the Band Director’s office. Please mark envelopes ATTN: Corresponding

    Secretary. All forms must be completed and the fee paid, even if you are only spending one night as

    a chaperone. If you have any questions, please feel free to contact me as follows:

    monicafulton@sbcglobal.net or 734-233-8099.

    Regards,

    Monica Fulton

    Monica Fulton

    Corresponding Secretary Franklin Band Boosters

    Enclosures

    mailto:monicafulton@sbcglobal.net

  • Adult Health Form Rule 125 (1) & (2)

    (Attach copy of front and back of health insurance card)

    NAME: ___________________________________ PHONE: ____________________

    ADDRESS: _________________________________________________________________

    HEALTH INSURANCE CARRIER: _______________________________________________

    POLICY #: __________________________________________________________________

    PERSON TO CONTACT IN AN EMERGENCY:

    NAME: _________________________________ PHONE: _____________________

    LIST CURRENT MEDICAL CONDITIONS: (hypertension, diabetes, infectious diseases, etc.)

    1. ______________________________________________________________________

    2. ______________________________________________________________________

    3. ______________________________________________________________________

    4. ______________________________________________________________________

    MEDICATIONS NEEDED OR USED:

    1. ______________________________________________________________________

    2. ______________________________________________________________________

    3. ______________________________________________________________________

    ALLERGIES: _________________________________________________________________

    ACTIVITY RESTRICTIONS: _____________________________________________________

    Please attach copy of front and back of health insurance card to this form.

    SIGNATURE: _________________________________ DATE: _________________

  • The confidentiality of central registry information is protected by Sections 7 through 7j of the Michigan Child Protection Law (MCL 722-627-722-627). Anyone who

    violates this protection is guilty of a misdemeanor and is civilly liable for damages.

    BCHS-Camps 001 Rev 1/16

    Request for Central Registry Clearance

    Children’s & Adult Foster Care Camp Staff/Volunteer

    Instructions: ALL fields must be completed and legible for processing.

    Complete the following information and submit

    request to:

    Michigan Department of Licensing and Regulatory Affairs

    Bureau of Community and Health Systems

    P.O. Box 30664

    Lansing, MI 48909

    Toll Free: 866-685-0006 Fax: 517-284-9709

    A clear copy of the employee’s/volunteer’s picture

    identification MUST be attached.

    PRINT FULL NAME (Last, First, Middle):

    Maiden Name/AKA (Also Known As)/Other Names Used (First or Last):

    Date of Birth:

    Social Security Number:

    Signature:

    Licensing Rules for Children’s and Adult Foster Care Camps R400.11109 (7) (f) states in part; A camp shall maintain a personnel record…….The record shall include

    “Documentation from the Michigan Department of Human Services, the equivalent state or Canadian provincial agency, or equivalent agency in the country where

    the person usually resides, that any staff person age 21 or over has not been determined to be a perpetrator of child abuse or child neglect.”

    Indicate below how you want to receive the results of the central registry clearance. The results will

    be mailed ONLY to the address on your attached picture identification or the camp’s mailing address:

    Results mailed to the address on my OR Results mailed to the Camp at: attached picture identification.

    Address: Camp Name/Attention/Address:

    Phone: Phone:

    The camp will ONLY receive response of NO central registry if the name being cleared has approved this request with their signature. The camp

    will not receive notification if the name submitted has any central registry history hits per CPL 722.627. This clearance does not identify

    individuals who may have child abuse/neglect history in other states, territories or tribal trust land.

  • CHAPERONE AGREEMENT FOR FRANKLIN HIGH SCHOOL MARCHING BAND CAMP AUGUST 19-24, 2019, YMCA CAMP OHIYESA

    HOLLY, MICHIGAN

    I, , agree to serve as a (Parent Name - please print) chaperone for Franklin High School’s Marching Band Camp August 19-24, 2019 at YMCA Camp Ohiyesa in Holly, Michigan. I understand that students’ health and safety is paramount during all school sponsored events. I understand that I must abide by the District’s Code of Conduct, regulations and policies at all times during the school sponsored event, field trip, or activity, regardless of where the event takes place.

    CODE OF CONDUCT - RULES and SAFETY PROCEDURES TO FOLLOW

    1. I will report any health and/or safety concerns immediately to the supervising chaperone. 2. I will respect the need for absolute confidentiality about sensitive student information that I

    may learn about during the school sponsored event. 3. I will be a positive role model, be engaged and available at all times during the school

    sponsored event. 4. I will not use profanity when addressing students. 5. I will not have any non-participating children accompany me during the school sponsored

    event. 6. I will comply with “2-deep” leadership practices, which state that I will not be alone with any

    student other than my child by always having another student or adult accompany me. 7. I will not deviate from the planned itinerary or assigned group at any time during the event,

    unless directed otherwise by the supervising chaperone. 8. I will not consume or possess alcoholic beverages or illegal substances. 9. I will not smoke and/or use tobacco pr