SRI 2013 Forms to return - Ruffing Montessori School

2013SUMMER RUFFING ITFORMS TO RETURN•CONTACT INFORMATION AND RELEASE FORM•EMERGENCY INFORMATION FORM•SERIOUS ALLERGY MANAGEMENT PLAN•BEFORE/AFTER CARE•CLASS CHOICE (GRADES 1-8 ONLY)2013 SUMMER RUFFING ITRUFFING MONTESSORI SCHOOL3380 FAIRMOUNT BOULEVARDCLEVELAND HEIGHTS, OH 44118www.ruffingmontessori.net/sri

2013 CONTACT INFORMATION & RELEASE FORMJune 17-July 26, 2013Child’s Name________________________________________________M____F____Birthdate_________________________Entering Grade Fall 2013_________________________________School Attending_____________________________ParentGuardianName(s)_________________________________ Home Phone__________________________Street Address__________________________________________Work Phone Mom ______________________City/Zip________________________________________________Work Phone Dad_______________________Cell/Pager /Dad ______________________________________ Cell/Pager /Mom__________________________E-mail _____________________________________ T-Shirt Size: ______________________________________Child S M L Adult S M L XL XXLFIELD TRIP PERMISSIONI hereby grant permission for my child to participate in nature walks and other similar nearby excursions (e.g., library)as part of the Summer Ruffing It program. I understand that appropriate notice will be provided in advance of anyfield trip requiring transportation. I understand my child may engage in all activities encountered during fi eld tripsexcept as stated below:________________________________________________________________________________________________________For and on behalf of myself and the child named, I hereby release Ruffing Montessori School, Fairmount MontessoriAssociation, its trustees, officers, teachers, employees, agents and representatives of and from any and all claims,causes of actions, demands, liabilities, damages and responsibilities arising out of, relating to, or in any mannerconnected with school sponsored field trips or any occurrences, accidents, or omissions of any and all types duringsuch trips from their commencement through their termination.PICK UP/ RELEASE INFORMATIONThe following people other than parents or legal guardian are allowed to pick up my child(ren) from the summerprogram:Name_______________________________________________________________Relationship________________________Name_______________________________________________________________Relationship________________________My child may ___ walk home ___ ride a bike homePHOTO AUTHORIZATIONThroughout the camp, students will be involved in special projects, programs, and classroom work that may havepotential interest to the community at large and therefore may be photographed. Photographs may be of individualsor groups for use on the Ruffing Web site, in the newsletter, in school ceremonial slideshows, on bulletin boards, inpromotional materials, in media publications, or used in other ways as deemed appropriate by the Head of School.Because we share your concern for the privacy and security of your family members, the policy of the Schoolis NOT to include student names with published photographs. If you wish to withhold permission for the use ofphotographic images of your child(ren), you must notify the School in writing by June 1, 2013.

2013 EMERGENCY INFORMATION FORMRuffing Montessori School 3380 Fairmount Boulevard, Cleveland Heights, OH 44118 216.932.7866An Emergency Information form must be completed for each child entering our camp programsand submitted by the first day of camp. Children will not be permitted to attend without this form.Child______________________________________________________________ __________________________________Last Name First Middle Program AttendingAddress _________________________________________________________________________________ ____________Street and Number City/State ZipHome Telephone_____________________________________________ Date of Birth__________ Male ____ Female____PARENTS/GUARDIANS: EACH TO BE LISTED SEPARATELY.Name __________________________________________________ Relationship ___________________________________Address ________________________________________________ Home Phone ___________________________________Employer ________________________________________________ Office Phone __________________________________Cell Phone____________________________ Beeper ___________________________Other __________________________Name __________________________________________________ Relationship ___________________________________Address ________________________________________________ Home Phone ___________________________________Employer ________________________________________________ Office Phone __________________________________Cell Phone____________________________ Beeper ___________________________Other __________________________IN THE EVENT GUARDIANS CANNOT BE REACHED:Name/Relationship ________________________________________________Phone ________________________________Name/Relationship ________________________________________________Phone ________________________________Name/Relationship ________________________________________________Phone ________________________________Should none of the above contacts be available, I hereby authorize the administration of any treatment deemed necessary by:Preferred Physician’s Name ________________________________________________Phone _________________________Preferred Dentist’s Name __________________________________________________Phone _________________________In the event of a life-threatening emergency or unavailability of preferred doctors, I authorize another licensed physician ordentist and/or the transfer of my child to the following hospital or any hospital reasonably accessible:Preferred Hospital______________________________________________________________________________This authorization does not cover major surgery unless the medical opinion of two licensed physicians or dentists,concurring for the necessity for such surgery, are obtained prior to the performance of surgery. All doctors should be alertedto the information on this form concerning my child’s medical history (allergies, medications, physical impairments, etc.)Signature of Parent ____________________________________________Date________________________________________Please print name: ___________________________________________________________________________________FORM CONTINUED ON NEXT PAGE

REFUSAL OF CONSENT/MEDICAL TREATMENTI DO NOT GIVE CONSENT FOR EMERGENCY MEDICAL TREATMENT OF MY CHILD. IN THE EVENT OF ILLNESS ORINJURY REQUIRING TREATMENT, I WISH THE SUMMER PROGRAM TO TAKE NO ACTION OR TO:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Date _________________________________________________________________Parent/Guardian SignatureMEDICAL INFORMATIONIt is the sole responsibility of the Parent/Guardian to provide accurate medical information and updates in writing.PLEASE PROVIDE CLEAR AND LEGIBLE INFORMATION concerning the following, if applicable: health, allergies,medication.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________MEDICAL INSURANCE CARD INFORMATIONName of Insurer: ______________________________________________Name of Beneficiary:___________________________________________Medical ID # _________________________________________________

2013 SRI SERIOUS ALLERGY MANAGEMENT PLANChild’s Name: ________________________________ D.O.B:__________PROGRAM:_____________________Approximate Weight:____________________Child’s Mother: _______________________________________________________________________________Home Phone:_________________ Priority Call Order:___Cell Phone:__________________ Priority Call Order:___Work Phone:_________________ Priority Call Order:___Child’s Father: ________________________________________________________________________________Home Phone:_________________ Priority Call Order:___Cell Phone:__________________ Priority Call Order:___Work Phone:_________________ Priority Call Order:___***In the event of an allergic reaction 911, will be called immediately and then parents will be notified.The student listed above has a potentially life-threatening reaction/allergy to:_____________________________________________________________________________________________CHECK WHICH APPLY TO YOUR CHILD___Itching or tightness of mouth or throat___Swelling of the lips, mouth, tongue___Hives___Sudden onset of persistent cough___Sudden onset of wheezing___Shortness of breath or difficulty breathing___Fainting or feeling like “passing out”___Apparent disorientationINSTRUCTIONS FOR CAMP STAFFEpiPen should be administered FIRSTAdminister EpiPen FIRST, if ingestion or contact occurs, even if NO SYMPTOMS are presentFollow with Benadryl Benadryl dosage:_________Benadryl should be administered FIRST Benadryl dosage:_________Follow with EpiPenAdditional comments:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Signature of parent/guardian:________________________________________ Date:_____________________

2013 Return Form • BEFORE / AFTER CARE• CLASS CHOICE• AHA!Child’s Name_____________________________________Checkwhich programand weeksyour childwill attend.LITTLE EXPLORERS (6.17 - 7.12)A SUMMER TO GROW ONCREATIVE ARTS & SCIENCESEXTREME! SRI6 weeks (6.17 - 7.26)Session 1 (6.17 - 7.5) Session 2 (7.8 - 7.26)BEFORE / AFTER CARE 8-9AM & 1-6PM JUNE 17-JULY 26, 2013No Camp: Holiday Thursday, July 4 No After Care Friday, July 26$10 hr minimum/billed in half hours after the first hour. Sibling discounts 75% for second; 50% for all others.You will be billed later. Statements mailed Monday following week of care.BEFORE CARE: Every Day___ or Mon___ Tues___ Wed___ Thurs___ Fri___ or As needed (will call)____AFTER CARE:Every Day___ or Mon___ Tues___ Wed___ Thurs___ Fri___ or As needed (will call)____CLASS CHOICE Grades 1-8 Number choices 1-5 in order of PreferenceGRADES 1-3You will have four classes on yourschedule: 9, 10, 11 AM & 1:30 PM. You pickfive in the AM and three in the PM fromthe list below. You may take a class twiceonceeach three week session.MORNING: Select 1-5 in order of preference.___ Guitar: Beginner 6 Weeks___ Guitar: Intermediate 6 Weeks___ Jugband Jamboree 6 Weeks___ Life Sz Puppets (Gr 3-5) 6 Weeks___ Loving Language 6 Weeks___ Math Magicians 6 Weeks___ Am. Sign Language Weeks 1-3___ Clay Weeks 1-3___ Felting & Batik Weeks 1-3___ In & Outdoor Sports Weeks 1-3___ Kids’ Kitchen Weeks 1-3___ Outside and Ruffing It Weeks 1-3___ Ruffing It Spa Weeks 1-3___ Theatre Games Weeks 1-3___ Am. Sign Language Weeks 4-6___ Clay Weeks 4-6___ In & Outdoor Sports Weeks 4-6___ Kids’ Kitchen Weeks 4-6___ Outside and Ruffing It Weeks 4-6___ Ruffing It Spa Weeks 4-6___ Theatre Games Weeks 4-6AFTERNOON: Select 1-3 in order ofpreference._____ Jugband Jamboree 6 Weeks_____ MiniMusical6 Weeks_____ Beginning Jewelry Weeks 1-3_____ Knit! Crochet! Weeks 1-3_____ Sports/Nature Center Weeks 1-3_____ Knit! Crochet! Weeks 4-6_____ Sports/Nature Center Weeks 4-6GRADES 4-5You will have four classes on yourschedule: 9, 10, 11 AM & 1:30 PM. You pickfive in the AM and three in the PM fromthe list below. You may take a class twiceonceeach three week session.MORNING: Select 1-5 in order of preference.____Guitar: Beginner 6 Weeks___ Guitar: Intermediate___ Lego Machines 6 Weeks6 Weeks___ Life Sz Puppets 6 Weeks___ Loving Language 6 Weeks___ Math Magicians 6 Weeks___ Clay Weeks 1-3___ Felting & Batik Weeks 1-3___ In & Outdoor Sports Weeks 1-3___ Kids’ Kitchen Weeks 1-3___ Lab Science Weeks 1-3___ Outside and Ruffing It Weeks 1-3___ Ruffing It Spa Weeks 1-3___ Clay Weeks 4-6___ In & Outdoor Sports Weeks 4-6___ Kids’ Kitchen Weeks 4-6___ Lab Science Weeks 4-6___ Outside and Ruffing It Weeks 4-6___ Ruffing It Spa Weeks 4-6AFTERNOON: Select 1-3 in order of preference.___ Mini Musical (Gr 1-4) 6 Weeks___ Parade Puppets 6 Weeks___ Rock Band 6 Weeks___ Baseball Sports Weeks 1-3___ Environmental Tech. Weeks 1-3___ Robots & Masks Weeks 1-3___ Sports/Nature Center Weeks 1-3___ Baseball Sports Weeks 4-6___ DIY Hair Weeks 4-6___ Environmental Tech Weeks 4-6___ Sports/Nature Center Weeks 4-6GRADES 6-8You will have several classes on yourschedule. You will select one a9ernoonclass from the list below.MORNINGWeekly in Extreme! SRI you will engagewith friends in morning workshops ontopics selected by Extreme! SRI camperslast summer. In addition you selecta9ernoon classes to complete yourschedule. Off site Fridays include fieldtrips to various sites linked to the weekto week topics - bakeries, ice creamshops, a local green farm, cliff walls,canoe waterways, outdoor theatre underthe stars, overnight camping and more.You may take an a9ernoon class twiceonceeach three week session.AFTERNOON:Select 1-3 in order of preference.You may take a class twice._____ Adv.Bead/Wirework _____ Improv _____ Parade Puppets6 Weeks6 Weeks6 Weeks_____ Archery Weeks 1-3_____ Baseball Weeks 1-3_____ Environmental Tech. Weeks 1-3_____ Archery Weeks 4-6_____ Baseball Weeks 4-6_____ Environmental Tech. Weeks 4-6AHA! (AFTER HOURS ACTIVITIES) 3:15-4:15PM JUNE 17-JULY 25, 2013$60 per 6 classes. You will be billed after camp begins.___ RockWall 6 Mondays Gr 1-3 ___ RockWall 6 Tuesdays Gr 4-5 ___ RockWall 6 Thursdays Gr 6-8___ Yoga 6 Mondays Gr 1-3 ___ Yoga 6 Tuesdays Gr 4-5 ___Yoga 6 Thursdays Gr 6 -8