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

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

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 products. 10. I will not possess weapons.

Violation of this agreement may result in prohibition from serving as a chaperone in future events, and in some cases, individual liability.

I have read and understand the above rules and safety procedures. Chaperone/Parent Signature: _______________________________ Date: _____________ Dates I will be attending Camp: ___________________________ Student’s Name: ________________________________________ Chaperone/Parent T-Shirt Size: ______________ (Adult S-3XL)

Livonia Franklin Marching Patriots

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

Date: _________________

To Whom It May Concern:

This is a letter of good reference on behalf of__________________________________________

whom I have known for __________ years.

He/She is of good character and upstanding reputation in the community. He/She is loyal and reflects

high moral values. I would recommend him /her to be trusted in whatever position or responsibility for

which he/she has applied, including working with children at marching band camp.

If you have questions, please feel free to contact me. My phone number is (_____) _______________

Sincerely,

Livonia Franklin Marching Band

iChat Instructions

Livonia Franklin Marching Band depends deeply on parent volunteers throughout the year. Parents are

needed to help transport students to and from competitions during the competition season and to volunteer

for events such as Solo & Ensemble Festivals, band concerts and other special events and field trips.

All parents volunteering for Livonia Public Schools must have a completed iChat background check on file.

The iChat form is now completed on-line. It can be completed after July 1, 2019 by going to

www.livoniapublicschools.org. Scroll down to Quick Links and click on the iChat Form link; follow the

instructions to submit your information.

All parents are asked to complete an iChat form by August 9, 2019; we may need your help during pre-

camp week!

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Livonia Franklin Marching Band

Kroger and Amazon Smile Fundraiser Instructions

You can help Livonia Franklin Marching Band earn money by signing up with Kroger and Amazon Smile! A

percentage of every purchase you make will be sent to the Livonia Franklin Band Boosters and will support

the Marching Patriots. If you already shop at Kroger or Amazon, your purchases can now have the power to

help the band!

Kroger Community Rewards

Go to www.KrogerCommunityRewads.com and sign-in to your account (or create one!). Link your Kroger

card to Franklin High School Band #90859. Kroger will send a check to the Livonia Franklin Band Boosters

every quarter. It’s that easy!

Amazon Smile

Go to www.smile.amazon.com, sign in to your Amazon account, select Livonia Franklin Band Boosters as

your charitable organization and start shopping. Anytime you shop on Amazon, begin with

www.smile.amazon.com and Amazon will send a percentage of your purchase to the Livonia Franklin Band

Boosters.

PERSONNEL RECORDRule 109 (5)

Required as of 6-15-84 by the Department of Social Services, Licensing rules for Children's Camps, State of Michigan.This is required to be on file for each camp staff member and each adult volunteer leader.

NAME:

Position in group/camp

Please identify training and certifications received:

Expiration Date

Life Saving Certificate:Red Cross Basic Water Safety: _Water Safety Instructor:

List previous leadership experience in working with youth:

CPR Certified:Advance First Aid:Adult Leader Training:

Expiration Date

Please list previous camping experience:Number of years/seasons in summer camp as adult leader:Number of years in leadership of short term weekend camping: _

Have you ever been convicted of anything other than a minor traffic violation? NO: _ YES: _If yes, please explain:

Signature: Date:

Reference 1. As a representative of the Franklin High School Marching Band program I recommend the aboveidentified individual to serve as a leader of our youth in camp.

Group Representative Signature Title

Dale

Reference 2. As a representative of the Franklin High School Marching Band program I recommend the aboveidentified individual to serve as a leader of our youth in camp.

Group Representative Signature

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Title

Dale

Livonia Franklin Marching Band

Website / Media Authorization Form

ADULT AUTHORIZATION FORM Adult #1

I, __________________________________ hereby authorize and permit the public and private use, (Print Name)

broadcast, publication, reproduction, release, copyright, exhibition and distribution of my image and or

recording(s), either audio or video as part of the entire marching band as a group and would not be

identified by name. Additionally, unless noted below I hereby authorize and permit the public and private

use, broadcast, publication reproduction, release, copyright, exhibition of the my image and/or recording(s),

either audio or video that may be recognizable and may be identified by my first name only. I will authorize

such disclosure for purposes of providing information regarding the Livonia Franklin Marching Patriots

programs or activities.

_____________________________________________________________________________________ Signature Print Name Date

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ADULT AUTHORIZATION FORM

Adult #2

I, __________________________________ hereby authorize and permit the public and private use, (Print Name)

broadcast, publication, reproduction, release, copyright, exhibition and distribution of the my image and or

recording(s), either audio or video as part of the entire marching band as a group and would not be

identified by name. Additionally, unless noted below I hereby authorize and permit the public and private

use, broadcast, publication reproduction, release, copyright, exhibition of the my image and/or recording(s),

either audio or video that may be recognizable and may be identified by my first name only. I will authorize

such disclosure for purposes of providing information regarding the Livonia Franklin Marching Patriots

programs or activities.

_____________________________________________________________________________________ Signature Print Name Date

YMCA CAMPING SERVICES RISK WAIVER FORMName of Participant Email

Address City State Zip I understand that, as in ail sports/activities there is a risk of physical injury and damage to property and hereby assumesuch a risk and ail consequences thereof, including the risk of personal injuries to the applicant resulting from participatingin any or all of these sports, and agree to be fully responsible for any personal injury or damage to the property arising outof or in connection with the applicant's use of the facilities at the YMCA Premises and/or YMCA Program Locationregardless of the cause, causes or contributing causes of such injury or damage. To this end l/we, as parents and legalguardian(s) of the applicant, a minor, hereby release, discharge, and covenant to hold harmless the YMCA CampingServices, YMCA Camp Ohiyesa, YMCA Camp Nissokone, and any other entity that is the landlord, or sub landlord of thePremises, and/or YMCA Program Location and all of the employees, officers and directors, agents and successors andassigns of the above from any and all claims, causes of action, actions demands, damages, costs, loss and expenses(including reasonable legal fees, which the applicant, or a third party, may have, suffer or incur which in any way arise outof or in connection with applicant's use of the Premises and/or YMCA Program Location regardless of the cause, causes,or contributing causes of such injury or damage. Said release, discharge and covenant shall apply to all such causes ofaction whether arising or prosecuted before or after said minor applicant has reached his or her age of majority.

l/we further promise and covenant (jointly and severally) for myself/ourselves, individually and as legal guardian(s) of theapplicant, and my/our heirs, administrators and executors, not to sue in any name or capacity (or implied in any action)said YMCA Camping Services, YMCA Camp Ohiyesa, YMCA Camp Nissokone, or any other entity that is the landlord orsub landlord of the Premises and/or YMCA Program Location (and/or employees, officers, agents, or successors, assignsof any of the above) for damages or injury to the property or person of the applicant or to myself/ourselves arising out ofor in connection with the applicant's participation in the activities outlined above at the Premises and/or YMCA ProgramLocation regardless of the cause, causes or contributing causes of such an injury or damage.

i/we/am are the parent(s) and legal guardian(s) of the applicant named above. The health history presented to the campis correct to the best of our/my knowledge, and the applicant described on the admissions application has our/mypermission to engage in any or all of the sports/activities at YMCA Camp Ohiyesa and Camp Nissokone, such as:

1. Skateboarding, roller skating, in-line skating, mountain boards and/or similar activities2. Horseback riding3. Climbing on natural rocks and cliffs, the climbing tower, and/or the climbing center, and/or similar activities4. Water sports, including: swimming, kayaking, canoeing, sailing, windsurfing, and rafting, water skiing, wakeboarding, tubing

and/or similar activities5. Paintball, field and target sports6. Tubing (winter)7. And/or similar activities

YMCA Camping Services and Camp Ohiyesa located at 7300 Hickory Ridge Road, Holly, Michigan ("Premises") or Camp Nissokonelocated at 6836 F-41, Oscoda, Michigan ("Premises") or at any other place while involved in the program of the YMCA ("YMCA ProgramLocation").

Authorization for Audio/Visual RecordsI understand that the YMCA may make audio/visual recordings of this camping event. I hereby authorize the YMCA tohave and use photographs, slides, moving pictures, and audio/video tapes of my child (if under 18) and/or myself forpurposes of YMCA records, public relations, and/or advertising.

Release of LiabilityBy signing this form, parent/legal guardian and/or participant acknowledges that they have read and understood the above informationand are signing this form to assure YMCA Camp Ohiyesa/YMCA Camp Nissokone that parent/legal guardian and/or participant assumesall risks during the program. Guardians or participants who do not wish to accept the risks described in this warning should not sign thispermission form.

I hereby give my consent:1. To participate in YMCA Camp Ohiyesa/YMCA Camp Nissokone programs.2. To receive emergency medical care which may become reasonably necessary in the course of such activities or travel.I further agree not to hold YMCA Camp Ohiyesa/YMCA Camp Nissokone or anyone acting in its behalf, responsible for any injuryoccurring to the named participant during YMCA Camp Ohiyesa/YMCA Camp Nissokone programs activities or travel.

DATE Signature of Participant or Parent/Legal Guardian (If participant is under age 18)i have read the aforementioned and will abide by the principles and regulations contained herein.

DATE Signature of Participant

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SPECIAL DIETARY CONCERNS Participant Name

Please complete this form and return to the teacher/group leader with your child,even if they do not have any special dietary concerns.

Does your student have any Special Dietary Concerns? Yes No

If yes, please describe:

Peanut Allergies? Yes No

If yes, please describe:

Other Food Allergies? Yes No

If yes, please describe:

Teacher/Group Leader School/Group

Parent/Guardian Contact Phone

Note to group leaders: Dietary forms should be grouped and/or summarized then faxed at248-887-5203 or mailed to Camping Sen/ices office a minimum of 2 weeks prior to camp.

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HEALTH FORMNote: YMCA Camping Services does NOT carry health/accident insurance for group participants. (In order to participate incamp programs, this form must be signed and must be presented to your group's leader upon your arrival at camp.)

Participant's Full Name Address City State Zip

_ Home Phone (_Participant's Age_

1Birth Date

Name of Parent/Guardian or Spouse Home Phone ( ) Work Phone (_Home Address

Cell Phone

If parents/spouse are not avaiiable in an emergency, please notify:Name Relationship Home Phone (__Home Address

1 Work Phone Cell Phone (_

Family Physician Name of Insurance Subscribe^Name of Insurance Provider

Medicaid ID #

Physician's Phone (_

Policy/HMO #Medicare # BC/BS Contract #

Does your child/the participant have any problems with the following?Yes No Yes No

Asthma [Sleep Walking [Allergies to Food [Hearing Loss [Kidney problems [Bee Allergies [If yes, please explain:

Yes NoSeizuresHigh Blood PressureAllergies to MedicationsBone/Joint ProblemsRespiratory ProblemsInsect Allergies

Heart ProblemsLow Blood PressureDiabetesBedwetiingFear of Heights

Is there any reason your child should not sleep on an upper bunk? (All upper bunks have railings)

Does your child/participant have any other serious medical problems/been under a physician's care recently?[ ]Yes [ ]No If yes, please explain:

Does your child/participant have any dietary restrictions?

List activities limited or prohibited by a physician

Date of last Tetanus shot: Is your child/participant currently on medication? [ ] Yes [ ] NoIf yes, please explain: Can Tylenol be administered to your child if necessary? [ ] Yes [ ] No

Parent's/Participant's AuthorizationAM of the above information is correct to the best of my knowledge and the person herein describedhas permission to engage in all camp activities except as noted. I hereby give permission to order X-rays, routine tests, treatment, and necessary transportation for my child or me. In the event I cannotbe reached in an emergency, I hereby give permission to the physician selected to secure andadminister treatment, including hospitalization, for my child/myself as named above.

Signature Date Adult participant (or parent/guardian if participant is under 18)

Note: This form should be collected by the group leader and kept by your group's Health Officer.

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