Butler YMCA
CAMP KEYSTONE at ARMCO Park
Butler YMCA Child Care ■ 339 N Washington Street ■ Butler, PA 16001
P 724 287 0045 F 724 287 1007 www.bcfymca.org
YMCA MISSION STATEMENT: To put Christian principles into practice through programs
that build healthy spirit, mind, and body for all.
PARENT HANDBOOK
Dear Parents,
Welcome to Camp Keystone! As part of the Butler YMCA,
Camp Keystone offers a summer day camp for children who have
completed Kindergarten through 6th grade.
This camp program is designed to provide challenging activities in
both large and small group settings under the guidance of caring,
well-trained staff members. We hope that the time your child
spends with us will be a positive experience and that your child
will grow in body, mind and spirit.
Please read your Parent Handbook carefully. If at any time you
have any questions, suggestions, or concerns, please let us know
by calling 724-287-0045. A parent’s input is always valued!
We are looking forward to meeting you and your child!
Sincerely,
Morgan McMillen
Summer Camp Coordinator
(724)287-0045 x137
Camp Keystone cell phones
(724)290-1340
(724)290-1813
TABLE OF CONTENTS
YMCA MISSION ..................................................................................................... 1 PROGRAM GOALS ................................................................................................. 1
CHILD CARE LICENSE ............................................................................................ 1 EQUAL ACCESS .................................................................................................... 1
STAFF QUALIFICATIONS ........................................................................................ 1 MANDATED REPORTERS ........................................................................................ 1
HOURS OF OPERATION .......................................................................................... 1 PHONE NUMBERS ................................................................................................. 2
ARMCO PARK ....................................................................................................... 2 DAILY SCHEDULE .................................................................................................. 3
LUNCHES ............................................................................................................. 5 SNACKS ............................................................................................................... 5
FIELD TRIPS ......................................................................................................... 5 T-SHIRTS............................................................................................................. 5
SIGN IN/OUT INFORMATION .................................................................................. 5
DROP OFF PROCEDURE .......................................................................................... 5 PICK-UP PROCEDURE ............................................................................................ 6
LATE PICK-UP ....................................................................................................... 6 DELAYED RELEASE OF CHILDREN ........................................................................... 6
PERSONAL BELONGINGS ....................................................................................... 6 DRESS CODE ........................................................................................................ 6
CELL PHONES ....................................................................................................... 7 SUNSCREEN ......................................................................................................... 7
ABSENT CHILD ..................................................................................................... 7 DISCIPLINE POLICY .............................................................................................. 7
REMOVAL FROM THE PROGRAM .............................................................................. 8 EMERGENCY PROCEDURES ..................................................................................... 8
ADMINISTRATION OF MEDICATION ......................................................................... 8 ILLNESSES ........................................................................................................... 8
PHYSICALS ........................................................................................................ 10
RAINY DAYS ....................................................................................................... 10 EXTREMELY HOT DAYS ........................................................................................ 10
PHOTOGRAPHY ................................................................................................... 10 PARENTAL CONCERNS ......................................................................................... 10
REMIND TEXT & EMAIL SERVICE ........................................................................... 10 PAYMENT POLICY ................................................................................................ 12
ESTABLISHING PROGRAM FEES.......................................................................... 12 FEE AGREEMENT .............................................................................................. 12
PAYMENT OPTIONS ........................................................................................... 12 NON-SUFFICIENT FUNDS ................................................................................... 12
COUNSELOR IN TRAINING FOR GRADES 7-11 ........................................................ 13 STAFF:CHILD RATIO ........................................................................................... 13
SWIM POLICY ..................................................................................................... 13 TEST.MARK.PROTECT .......................................................................................... 14
TEST.MARK.PROTECT FAQs .................................................................................. 15
TEST.MARK.PROTECT ZONE REFERENCE GUIDE ..................................................... 16 BABYSITTING CLAUSE ......................................................................................... 17
PARENT STATEMENT OF UNDERSTANDING ............................................................ 18
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YMCA MISSION
To put Christian principles into practice through programs that build healthy spirit, mind, and body for all. The YMCA is a community service organization which promotes
positive values and welcomes all people. The Butler YMCA is a nationally affiliated character-building social service agency focusing on program services for individuals and
families. Christian in its heritage, it is nondenominational in its delivery of services and membership. The YMCA offers programs and services to individuals and families
regardless of age, sex, religion, or national origin.
PROGRAM GOALS The Butler YMCA Camp Keystone seeks to provide a safe, fun-filled, creative and
educational day camp experience in which children can forge friendships while challenging themselves to experience personal growth.
CHILD CARE LICENSE
Camp Keystone is licensed by the Pennsylvania Department of Public Welfare. Our
license is posted in the child care department on the 2nd floor of the YMCA. DPW regulations can be found at http://www.pacode.com/secure/data/055/chapter3270/
chap3270toc.html.
EQUAL ACCESS The Butler YMCA, in keeping with its mission to help all people realize their fullest
potential, encourages and supports the participation of all children in YMCA programs. We serve all children regardless of gender, race, color, nationality, religion, ethnicity, or
disability. Whether a child is non-disabled or has special needs, consideration is given to the individual needs of every child and the ability of the program to meet those needs.
STAFF QUALIFICATIONS
We pride ourselves on our thorough selection of camp staff to ensure safety and fun for your child. Camp counselors have an education degree or are currently enrolled in a
college program in the fields of child development or education. Camp counselors have Act 33/34 clearances, FBI fingerprint clearances, and current CPR/Pediatric First Aid
certification. The staff has completed camp training regarding the children’s activities.
MANDATED REPORTERS Employees of Pennsylvania state licensed childcare centers are mandated reporters of
child abuse or neglect. As such, the YMCA staff is legally required to contact the PA
State hotline if there is reasonable cause to suspect physical, sexual, or emotional abuse, neglect, or maltreatment of any child enrolled in the center.
HOURS OF OPERATION
Camp Keystone Day Camp | 6:30am – 5:30pm
6:30am – 8:45am at Butler YMCA ** Second Floor 9:30am – 3:45pm at ARMCO Park
4:15pm – 5:30pm at Butler YMCA ** Second Floor
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PHONE NUMBERS
Child Care Offices
(724)287-0045
Camp Keystone cell phones (724)290-1340
(724)290-1813
Main YMCA (724)287-4733
Ext 110 for Phillips’ Hall
ARMCO PARK
Camp Keystone uses ARMCO Park for daily excursions.
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DAILY SCHEDULE Monday - Wednesday
TIME Purple Green Orange Pink Blue BREAK
6:30 - 7:15 GYM
7:15 - 8:45 Youth Gym 1 - S1 Gym 1 - S1 Gym 2 - S2 Gym 2 - S2
8:45 BUS
9:30 - 10:00 Bathroom/Sunscreen Opening Ceremony 10:00- 10:10
10:15 - 10:45
Environment Music Art Games
Change 10:10 - 10:30
Swim 10:30 - 11:20
10:50 - 11:20
Games
Environment Music Art Change 11:20 -
11:40
11:20 - 11:30 Bathroom/Wash Hands
LUNCH 11:30 - 12:00
12:05 - 12:30
Music
Games Environment
Change 12:05-12:25
Playground
12:35 - 12:55
Change 12:30 - 1:05
Art Games Swim 12:25 - 1:05 Music
1:00 - 1:25 Swim 1:05-1:45
Counselor Directed
Playground
Change 1:05 - 1:25
Environment
Change 1:25 - 1:45
1:30 - 1:55 Change 1:45 - 2:05 Swim 1:45 - 2:25 SNACK Playground Games
2:00 - 2:25 Playground Change 2:25 - 2:45
Change 2:05 - 2:25
Music
Art
2:30 - 2:55 Art Playground Swim 2:25 - 3:05
Environment
Snack Set up
3:00 - 3:20 SNACK
Change 3:05 -
3:20
SNACK
Closing Ceremony 3:25 - 3:35
3:35 Bus DEPART AT 3:45
4:15 - 5:30 Dismissal from Child Care
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DAILY SCHEDULE Thursday
TIME Purple Green Orange Pink Blue BREAK
6:30 -7:15 GYM
7:15 - 8:45 Gym 1 - S1 Gym 1 - S1 Gym 1 - S2 Youth Gym 1 - S2
8:45 BUS
9:30 - 10:00 Bathroom/Sunscreen Opening Ceremony 10:00- 10:10
10:15 - 10:45 Camp-Wide Activity
10:50 - 11:20
11:20 - 11:30 Bathroom/Wash Hands LUNCH 11:30 - 12:00
12:05 - 12:35 Specials Rotation Team Building Boy Scouts Playground Water Games
12:40 - 1:10 Boy Scouts Special Rotation Playground Water Games Team Building
1:15 - 1:45 Playground Boy Scouts Water Games Team Building Specials Rotation
1:50 - 2:20 Water Games Playground Team Building Specials Rotation Boy Scouts
2:25 - 2:55 Team Building Water Games Specials Rotation Boy Scouts Playground
3:00 - 3:20 SNACK
Snack SNACK
Closing Ceremony 3:25 - 3:35
3:35 Bus DEPART AT 3:45
4:15 - 5:30 Dismissal from Child Care
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LUNCHES
Lunch is 11:10-11:40am daily. A healthy lunch must be packed daily in a lunch container marked with your child’s name. We do not have any way to provide a lunch for
a child while we are at ARMCO Park. The parent will be notified to bring a lunch. We do not have the ability to refrigerate or heat up lunch items. Campers may not share lunch
items with other campers. On field trip day, please send a disposable brown bag lunch so the children can throw away items. The YMCA is not responsible for lost lunch
containers.
SNACKS Camp Keystone provides two snacks daily as part of the program schedule.
AM Snack 7:15-8:20am PM Snack 3:10-3:40pm
FIELD TRIPS
All campers participate in a weekly field trip. Most field trips are scheduled on Fridays.
All children must be at the YMCA by 8:30am. Camp shirts must be worn on field trip days. Please send a disposable lunch and apply sunscreen before arrival. Please do
not send extra spending money. Alternative care is NOT provided on field trip days.
T-SHIRTS Every child attending summer camp will receive a complimentary T-shirt as a gift from
the YMCA. The camp T-shirt should be worn on field trip days. Please label your child’s shirt.
SIGN IN/OUT INFORMATION
Recording attendance is a Title 55 Licensing Regulation 3270.117(a) requirement.
The attendance sheet serves as the main accounting system in the event of an emergency or during an evacuation. Signing the log is essential every day.
When a camper arrives at a Butler YMCA program site, parents and kids must “check in” with a staff member.
Make sure the adult signs the camper in on the attendance sheet. Children should never be dropped off outside the building and allowed to go inside
without an adult.
DROP OFF PROCEDURE Butler YMCA site 6:30-8:45am Mondays, Tuesdays, Wednesdays, and Thursdays
Campers are bused from the Butler YMCA site to ARMCO Park at 8:45am.
ARMCO Park 9:30am-3:45pm Mondays, Tuesdays, Wednesdays, and Thursdays
All campers must be dropped off at the main Butler YMCA site on Fridays for field trips.
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PICK-UP PROCEDURE
Your child will be released only to the persons designated on their Emergency Contact Form. All individuals, including the parents/guardians, will need to show photo
identification. Staff will check the photo on the ID and match the address with what is listed on the Emergency Contact Form. Notify the staff in writing if someone other than
those persons authorized on the Emergency Contact Form is to pick up your child. In an emergency, you may call the YMCA Child Care Office at 724-287-0045 to authorize a
verbal request for release of a child.
Campers may be picked up at ARMCO Park before 3:45pm. There will be no Camp Keystone staff at ARMCO Park after 3:45pm. All campers will be returning to the main
Butler YMCA by 4:14pm daily.
Camp Keystone will be using the Second floor lobby & Gyms as the pick-up location from 4:15-5:30pm. Parents/guardians/other personnel on the ECF must come into the YMCA,
and up to the second floor for pick up and drop off. No child will be accepted or
dismissed without being signed in/out by an identifiable adult.
LATE PICK-UP Anyone picking up their child after 5:30 p.m. will be charged $5.00 for every 5 minutes
that they are late.
DELAYED RELEASE OF CHILDREN The staff reserves the right to delay the release of a child to a parent or other adult if
they have reasonable cause to believe the adult is impaired by alcohol and/or drugs or is in any way incapable of assuming responsibility for the child including not having a car
seat in which to transport the child. Staff shall confer with the Director, contact additional YMCA representatives or call emergency contact persons listed in the child’s
file in order to make an appropriate determination regarding the release of the child.
PERSONAL BELONGINGS
Each child should have his/her own book bag clearly identified with their name for personal belongings. Required daily items are:
Healthy Lunch – No Pop/Soda
Athletic shoes swimsuit and towel
water bottle
DRESS CODE For the welfare of your child, please be sure your child is dressed according to the
weather and always dressed for active play! Please label your child’s items as we have many similar items.
For your child’s safety we ask that you send your child to camp in athletic shoes. Flip
flops can be used in the pool area only. If a child is sent to camp in sandals, they will
not be able to participate in several activities.
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CELL PHONES
No electronic items are permitted to come to camp. We are “unplugged” and play outside all day. Cell phones, any gaming systems, MP3 players, and toys are not allowed
at camp. If these items come to camp, a counselor will take them and return them to an adult at the end of the day. Cameras may come on field trip days at the parent’s
discretion. The YMCA is not responsible for lost, stolen or damaged items.
SUNSCREEN Campers will need waterproof sunscreen SPF30 or above. Please label the sunscreen
bottle with your child’s name. It will be kept in locked bags for daily use. The staff will notify you when your child needs more sunscreen for camp use.
Your child should apply sunscreen before coming to camp each morning. Campers will
be encouraged and monitored by staff to re-apply sunscreen a minimum of three times during our camp day. These designated times are before morning activities, before
swim time, and after swim time. Campers can have another camper help with sunscreen
application. Counselors are NOT permitted to apply sunscreen to campers, but will monitor body application and help with their face.
ABSENT CHILD Please call or email the Camp Keystone staff if your child will not be attending as
scheduled.
DISCIPLINE POLICY There shall be no harsh, cruel, or unusual punishments. Explanations and re-direction is
the standard method of discipline. In severe cases, “time-out” from something or someone may be necessary. Parents are contacted when serious discipline problems
occur with their child. The staff will use a blue Incident Report form to communicate in writing with parents/guardians. If problems continue, children may be asked to leave the
program.
In the event of repeated inappropriate behavior by a child, the following actions will be
taken: To immediately notify the parents in writing at the end of the day so that the
incident can be discussed. Conference with the parent/guardian.
Removal from the program.
Our intent is to work as a team with the parents or guardian for the best care for each child. Working together as a team is a necessary step to correct repeated inappropriate
behavior. Your patience, support, and follow-through are not only appreciated, but necessary.
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REMOVAL FROM THE PROGRAM
The YMCA reserves the right to remove a child from our program for the following reasons:
The camper’s needs are not being met in our small/large group settings. The camper is a safety threat to themselves, other children, or the staff. This
includes behaviors such as fighting, striking others, and wandering away from the program.
The camper has inappropriate conversations or contact, shows disrespect towards staff or other campers, or bullying.
The camper refuses to participate in the whole camp program including work and play values, sharing, and cooperation during daily activities.
Failure to submit a physical as requested.
Failure of a parent or guardian to pay weekly fees. Consistent late pick-up.
Inappropriate behavior conducted by the parent/guardian.
EMERGENCY PROCEDURES In case of a severe emergency or accident, we will:
1. Administer first aid 2. Call emergency medical transportation (911)
3. Contact parents and child's doctor 4. Contact YMCA administration
ADMINISTRATION OF MEDICATION Prescription and non-prescription medication will only be administered with daily written
consent from the parents. MEDICATION MUST BE IN THE ORIGINAL CONTAINER.
Parents need to complete and sign the medicine log before staff will administer any medication. Prescription and non-prescription medication must be labeled with child's
name. DO NOT send medications with the child, it must be given to a staff member by the parent/guardian.
ILLNESSES
List of conditions that indicate a child might need to be temporarily out of child care due to mild illness:
The child has any of the following conditions--fever, lethargy, irritability, persistent
crying, difficult breathing, or other manifestations of possible severe illness.
Fever--Fever is defined as having a temperature of 100°F or higher taken auxiliary, armpit with behavior change or other symptoms.
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Vomiting--Once during the previous 24 hours, unless the vomiting is determined
to be caused by a non-communicable condition and the child is not in danger of dehydration.
Conjunctivitis--Defined as pink eye or red conjunctivitis with white or yellow eye
discharge, often with matted eyelids after sleep and eye pain or redness of the eyelids or skin surrounding the eye. Exclude until examined by a physician and
approved for readmission, with treatment.
Diarrhea--Two loose bowel movements within a close time frame. (1-2 hours or less)
Body rash with fever--or any untreated infected rash
Sore throat--difficulty swallowing, swollen glands
Severe coughing--child gets red or blue in the face or makes high-pitched whooping sound after coughing.
Evidence of lice, scabies, or other parasitic infestation
Illness that prevents the child from participating comfortably in program activities-
-Child is irritable, continuously crying, or requires more attention than you can provide without hurting the health and safety of other children in care.
Please note: We will NOT administer fever reducing medication to keep a child’s fever
below 100°F in order to stay in care. Certain conditions do not require that children stay out of childcare unless recommended by the child’s health care provider or the public
health department.
Children may be admitted back into childcare if the following are true statements:
Child has been symptom free for 24 hours = one full day. Symptom free (for 24 hours = one full day) without medicines (Acetaminophen, or
Ibuprofen) Vomiting has stopped (for 24 hours = one full day) and child can eat and keep
food down. If sent home for diarrhea, last bowel movement was normal
If seen by a physician:
Provide a note from the physician’s office stating the child is not contagious and may return to care.
Antibiotics prescribed and 2 doses given, with a note from the physician stating child may return after 2 doses.
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PHYSICALS
Children registered for camp will need a signed Child Health Report on file. Documentation of immunizations is to be included.
RAINY DAYS
Camp Keystone will go to ARMCO Park and on scheduled field trips on rainy days. ARMCO Park has indoor facilities that the campers and staff can use on days of
inclement weather.
EXTREMELY HOT DAYS Camp Keystone will go to ARMCO Park and on scheduled field trips on very hot days. On
such occasions, please send extra water and remember to apply sunscreen. We will conduct activities in the pavilions to provide shade. If your child has asthma, please
remember to give the appropriate medications to your child’s counselor. Please refer to our section ADMINISTRATION OF MEDICATION for further details.
PHOTOGRAPHY Photographs of the children participating in our program may be taken from time-to-
time and may appear in newspapers, magazines, brochures, or other publicity material. These pictures may also appear on the YMCA operated advertiement boards or social
media outlets for promotional purposes. Your permission for photographs including your child(ren) to be used without compensation is a part of this agreement unless otherwise
stated.
PARENTAL CONCERNS If you have any questions or concerns with the Butler YMCA Camp Keystone, please do
not hesitate to inform the camp counselors. If you feel your questions have not been answered or problem resolved, please contact Morgan McMillen or Mitch Hammer, Butler
Camp Coordinatory & School Age Coordinator at [email protected] or [email protected] or Rachel Campbell, Clinical Director of Youth Services at
[email protected] or by phone at (724) 287-0045.
REMIND TEXT & EMAIL SERVICE
Remind is a one-way text messaging and email system. With Remind, all personal
information remains completely confidential. Camp staff will never see your phone number, nor will you ever see theirs. The app helps the staff to connect instantly with
parents/guardians. It is an effective way to alert parents/guardians of program changes or send reminders of upcoming activities. Parents/Guardians must join to receive the
text or email alerts. Complete instructions are included below.
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PAYMENT POLICY
ESTABLISHING PROGRAM FEES
YMCA program fees are established to offset the costs of operation for the program within the following framework:
Because parent income rarely fluctuates, fees are established by a school year, on
a weekly basis, and do not vary during school holidays or vacations. All children in the program share equally in the cost of providing for the fixed cost
of the program, regardless of time usage. Fixed cost include insurance, directing staff, and administrative costs.
Direct costs such as snacks, program supplies, and program leadership are
considered when establishing fees. All participants to the YMCA programs need to pay a non-refundable pre-
registration fee. (Child Care fees are tax deductible, please see the billing administrator for more information.)
FEE AGREEMENT
The required financial agreement (one for each child) stipulates fees, payment due schedule, attendance, and enrollment. Appropriate billing procedures will be enacted. It
is essential that the arrangements of the financial agreement be followed and payments made on time.
Payment may not be deducted for the time a child is not in attendance because of illness, personal reasons, or during family vacations.
Schedule changes must be made in conjunction with the Camp Coordinator. Any questions about payment and/or necessary variances from this contract
should be brought to the billing administrator’s attention before payment is due. A weekly $10.00 non-refundable deposit is due at the time of registration. The
remaining balance is due the Friday prior to attendance in camp. Deposits will not be refunded or transferred to alternate weeks of camp.
PAYMENT OPTIONS
Payment arrangements can be made weekly, bi-weekly, or monthly. Select one of the three payment options on the agreement form along with the fee amount.
Payments are due on the Friday prior to the week of service. Make checks payable to
Butler YMCA.
If your payment is not made by the Wednesday during the week of service, you will be charged a $10 late fee and you have until the following Friday to make that payment. If
the payment has not been made by 5:30 p.m. on Friday of the week of service, then services will be denied.
Payments can be given to the child care billing administrator or staff at the Membership
Desk. Do not give payments to the camp counselors.
NON-SUFFICIENT FUNDS A $10.00 charge will be required for checks returned due to non-sufficient funds.
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COUNSELOR IN TRAINING FOR GRADES 7-11
The Counselor In Training (CIT) program promotes leadership in young teenagers by allowing them to take an active part with the campers in a mentor capacity and to train
future counselors by giving them the opportunity to learn about working with children in a camp setting. CITs are scheduled for two week sessions. All teens interested in a CIT
position must schedule an interview with the camp coordinator.
STAFF: CHILD RATIO Young School Age (Kindergarten thru 3rd grade) 1:12
Older School Age (4th thru 6th grade) 1:15
SWIM POLICY Campers will swim at ARMCO Pool in four groups with up to 24 swimmers per group.
Any camper not dressed to swim will be included in the activities with one of the groups not currently in the pool area. The ratio of staff with swimmers in the pool area is 1:6.
Camp Keystone will follow the guidelines of the new Child Aquatic Safety Program that
the Butler YMCA adopted as of December 1, 2014. (Complete information regarding the program is included on the following pages.)
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TEST.MARK.PROTECT
15
TEST.MARK.PROTECT FAQs
16
TEST.MARK.PROTECT ZONE REFERENCE GUIDE
17
BABYSITTING CLAUSE
I ___________________________am employing ______________________________
for a babysitting position for my child(ren)____________________________________
____________________________________________.
Although _________________________is an employee of the Butler County Family
YMCA Child Care department this employment agreement is a personal choice and will
not be in competition with her/his position at the YMCA.
Any arrangements, for care, must be made on personal time and not on the YMCA
property.
If the arrangement above is in need of termination, for poor performance or other
reasons, I __________________________________, agree not to hold liable the Butler
County Family YMCA Child Care.
Parent Signature_______________________________ Date_________________
Employee Signature____________________________ Date_________________
YMCA Supervisor Signature______________________ Date_________________
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PARENT STATEMENT OF UNDERSTANDING
The following information is important for the safety and protection of your child. Please read the information, sign this form and return it to the YMCA.
Please keep and refer to your copy of YMCA Program Policies. Your signature below indicates that you have received them.
I understand that YMCA staff and volunteers are not allowed to babysit or transport children at any time outside of the YMCA programs. The YMCA will take immediate disciplinary action
toward staff & volunteers if a violation is discovered. I understand that I am not to leave my child at the YMCA or program site unless a YMCA staff or
volunteer is there to receive and supervise my child. I understand that my child will not be allowed to leave the program with an unauthorized
person. Any person authorized to pick-up my child must be listed with the YMCA or other arrangements must be made by calling the YMCA office to inform them of a change.
I understand that should a person arrive to pick up my child who appears to be under the influence of drugs or alcohol, staff may have no recourse but to contact the police for the child’s
safety. Please do not put staff in the position where they have to make this judgment call. I understand that state law mandates the YMCA to report any suspected cases of child abuse or
neglect to the appropriate authorities for investigation.
PHOTO RELEASE Photographs of the children participating in our program may be taken from time-to-time and
may appear in newspapers, magazines, brochures, or other publicity material. These pictures may also appear on the YMCA operated advertiement boards or social media outlets for
promotional purposes. Your permission for photographs including your child(ren) to be used without compensation is a part of this agreement unless otherwise stated.
In consideration of gaining membership or being allowed to participate in the activities and programs of the Butler YMCA and to use its facilities, equipment, and
machinery, I do hereby waive, release, and forever discharge the YMCA and its officers, agents, employees, representatives, executors, and all others from any and all responsibilities or liability for injuries or damages resulting from my participation
in any activities or my use of equipment or machinery in the above mentioned facilities or arising out of my participation in any activities at said facility.
I have read and understand the statements above.
_____________________________ ________________________ Parent/Guardian Signature Date
_____________________________ _________________________ Parent/Guardian Printed Name Child’s Name
COPY OF STATEMENT FILED WITH CHILD’S RECORD