June 10, 2020
Re: 2020 Summer Recreation Program
Dear Recreation Parent,
The 2020 school year has ended and the time to prepare for the Summer Program is now.
Registration for the 2020 Summer Recreation Program will begin on Thursday June 11,
2020, and will be accepted at City Hall, 1401 Draper Street starting Friday June 12, 2020.
To enroll in the Kingsburg Summer Recreation Program, you will need: The Summer
Recreation registration form, health history form, medical consent form and payment. Your
child may not be registered without all of these items. For those of you that submitted an
application already, all you are required to bring in is the payment.
NOTICE: This years program has been altered due to COVID-19 and staff has developed a
plan to ensure the health and safety of our students and staff to the best of our ability. A
breakdown schedule is included in this packet (next page) for parents to familiarize
themselves with the new layout. An additional COVID-19 waiver will need to be signed prior
to the program start date.
If you have any questions about registration, please feel free to call 897-5328 or email me at
acastaneda@cityofkingsburg-ca.gov.
Thank you,
Adam Castaneda
Community Services Director
City of Kingsburg
City of Kingsburg
1401 Draper Street, Kingsburg, CA 93631-1908
(559) 897-5821 (559) 897-5568
Michelle Roman
Mayor
Laura North
Mayor Pro Tem
COUNCIL MEMBERS
Sherman Dix
Jewell Hurtado
Vince Palomar
Alexander J. Henderson
City Manager
City of Kingsburg
Summer Recreation Daily Breakdown
7:45 ALL STAFF ARRIVES TO OPEN UP THE SCHOOL SITE
Prepare Temperature Check Station and Hand Sanitizer Station
Note: One teacher will be assigned to each of the classrooms. This teacher will be given a list of 10 students
that will make up a cohort for the entire summer program. Students will be grouped together based on age
or grade. (Siblings will be assigned to the same rooms)
8:00 STUDENTS ARRIVE AT THE SCHOOL SITE
Students Will Be Dropped Off at The Cafeteria
Staff Will Take Students Temperature
Students Will Be Directed to Sanitize Hands
Note: Parents will drive up to the cafeteria but will not be asked to exit their vehicle. A staff member will
walk up to the window and verbally sign your child in. When your child exits the vehicle, their temperature
will be taken. If the child’s temperature is at 100 degrees or higher, they will not be allowed to stay that day.
Parents should not leave before temperatures are taken.
8:30 - 9:00 EOC BREAKFAST SERVED IN EACH CLASSROOM
Students May Bring Their Own Food or Eat Before They Arrive
Breakfast Usually Consists of Cereal, Fruit and Milk
9:00 - 10:00 ART/CRAFT OR ENRINCHMENT PROJECT OR ACTIVITY
10:00- 10:45 OUTDOOR PLAYTIME
Each Class Will Rotate Between 5 Different Stations Throughout the Week
Student Can Bring Their Own Toys and Games from Home
Note: Students can bring their own toys, books and games from home, including electronics. Students will
not be allowed to share toys or sports equipment, so anything brought must be for individual play. Each
student will be provided their own box to keep all their supplies, this box will be kept by the teacher.
10:45 - 11:45 CLASSROOM ACTIVITY, MOVIE, READING, OR FREE PLAY
11:45 12:00 BATHROOM AND HANDWASHING FOR LUNCH
Each Class Will Be Assigned a Restroom and Hands Will Be Sanitized Before and After
Use.
12:00 -1:00 LUNCH TIME
Lunch Will Be Served in Each Classroom (Lunch Can Be Eaten Inside or Outside)
Students Can Bring Their Own Lunch
EOC Lunch Usually Consist of a Half a Sandwich, Fruit, Milk, and String Cheese
1:00 - 2:00 FREE TIME OR FUN ACTIVITY
Possible Outdoor Water Activity, Cooking Class, Painting, or Downtown Field Trip
2:00 - 2:15 END OF DAY STUDENT PICK UP
Students Will Be Called by Walkie as Parents Begin to Arrive
Students Will Sanitizer Their Hands Before Entering the Vehicle
2:15 2:30 SITE SANITATION & CLEANING
Staff Will Wipe Down All Toys, Games, Door Handles and Restrooms
Staff Will Utilize a Medical Grade Chemical Fogging System to Sanitize All Rooms
TK 6th Grade
PROGRAM RUNS FROM
Monday, June 22nd to Friday, August 14th
ONLY ONE PROGRAM THIS SUMMER
8am to 2pm
COST
There are two payment options:
(1) Pay monthly (4 week period):
$276.00-Payment due June 22 (4 weeks)
$276.00-Payment due July 20 (4 weeks)
(2) Pay in full (8 week period)
$522.00- Payment due June 22 (8 weeks)
**$10.00 discount per sibling**
Activities include: arts & crafts, movies, outdoor play,
snack & much more!
Summer breakfast & lunch program provided by
Fresno County EOC
For more information, please call 559-897-5328
Kingsburg Summer Recreation
Registration Form
Program Begins: Monday, June 22, 2020
Name of Participant: Age: ____________
PLEASE PRINT
Mother’s Name: ______________________ Father’s Name: _______________________
Residence Address:
Mailing Address:
City: State:
Home Phone #:
Father’s Work #: Mother's Cell
Father’s Cell #: Additional #:
Zip:
Mother’s Work #:
#:
e-mail (father) ________________________ e-mail (mother) _______________________
EMERGENCY CONTACT PERSON (Someone other than parent):
Name:
Phone #’s:
Relationship to Participant:
I/We, the parents of the above named child, hereby give my/our approval of his/her participation in the above
identified Program. I/We are fully aware and understand that the City of Kingsburg will not provide any insurance
coverage for our child during his/her participation in the Program. I/We will be responsible to provide all insurance
including, without limitation, liability, accident or health insurance and assume all risk and hazards incidental to our
child’s participation in the Program and all activities associated with the Program, including, without limitation,
transportation to and from the Program.
For and in consideration
of permitting our child to participate in the Program and the activities associated therewith,
the undersigned(s), on behalf of myself/ourselves and my/our minor child hereby voluntarily release, discharge,
waive and relinquish any and all actions or causes of action for personal injury, property damage or wrongful death
occurring to our child arising as a result of observing, participating or engaging in the Program or any activities,
operations or functions incidental or related thereto, wherever or however the same may occur and for whatever
period the Program and activities, operations and functions related thereto may continue and I/we do for
myself/ourselves and our child and our and the child’s respective heirs, executors, administrators and assigns hereby
release, waive, discharge and relinquish any action or cause of action, which may hereafter arise for
myself/ourselves or our child or our respective estate and agree that under no circumstances will we or our heirs,
executors, administrators or assigns or our child’s heirs, executors, administrators or assigns prosecute or present
any claim for personal injury, property damage
or wrongful death against the City of Kingsburg or any of its
officers, officials, agents, employees or volunteers for any cause of action whether the same shall be for the
negligence of any said persons or otherwise. I/We for myself/ourselves and our heirs, executors, administrators and
assigns and our child’s heirs, executors, administrators and assigns agree that in the event any claim for personal
injury, property damage or wrongful death shall be prosecuted against the City of Kingsburg, or any of its officers,
officials, agents, employees or volunteers, I/we shall indemnify and save harmless the City of Kingsburg, or any of
its officers, officials, agents, employees or volunteers from any and all claims or causes of action by whomever or
wherever made or presented for personal injuries, property damage or wrongful death. I/We acknowledge that I/we
have read the foregoing waiver, release and indemnity agreement and fully understand and know the content thereof.
Parent/Guardian Signature
Date
MY SON/DAUGHTER HAS MY PERMISSION TO:
Walk home at any time Be picked up by the following persons:
1.Name:
Address:
Home Phone:
Cell Phone:
2. Name:
Address:
Home Phone:
Cell
Phone:
3. Name:
Address:
Home Phone:
Cell Phone:
CITY OF KINGSBURG
COMMUNITY SERVICES DEPARTMENT
HEALTH HISTORY
Child’s Name:_______________________________________________ Date of Birth:_______________
Address:____________________________________________________ Phone#:____________________
Parent/Guardian Name:______________________________________ Phone#:____________________
Recent Exposure to Contagious Disease: ________YES ________NO
If yes, give name of disease:____________________________________ Date of Exposure:_____________
Is there a history of any of the following illnesses or allergies? Check those that apply:
_____ Asthma* _____ Fainting Spells* _____ Convulsions* _____ Nose Bleeds*
_____ Epilepsy* _____ Upset Stomach _____ Heart Trouble* _____ Plant Allergies*
_____ Medication Allergies* _____ Food Allergies* _____ Kidney Trouble _____ Cramps
_____ Rheumatic Fever _____Behavior Problems* _____ Diabetes* _____Sinus Infections
_____ Insect Bites _____ Headaches*
*Explain problem and give details on how to handle:_____________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Is the child taking medication, which must be taken every day? _____YES _____ NO
If yes, explain fully the dosage, time to be taken and reason for the medication:
PLEASE NOTE THAT ALL MEDICATIONS ARE TO BE LISTED REGUARLESS OF WHEN THEY ARE ADMINISTERED.
MEDICATION/DOSAGE TIME TO BE TAKEN REASON FOR MEDICATION
________________________ ________________________ ______________________________
________________________ ________________________ ______________________________
________________________ ________________________ ______________________________
________________________ ________________________ ______________________________
NAME OF FAMILY PHYSCIAN
Name:________________________________________________________ Phone#:_________________
Consent is hereby given for either person in charge of the activity, or if required, to the attending physician to perform first aid or take
any other emergency action deemed necessary to protect the health and safety of the above named child.
Parent/Guardian Signature:_____________________________________________ Date:_____________
City of Kingsburg
1401 Draper Street
Kingsburg, CA 93631
559-897-5328
www.cityofkingsburg-ca.gov
ADVERTISING PHOTO RELEASE
Permission is hereby granted for the City of Kingsburg or its agents to use my picture for
advertising purposes. The use of this picture by the City of Kingsburg or its agents does not
in any way obligate the company or any third party to me.
Child’s name: _______________________________________
Address: _________________________________________________________________________
Number Street City State Zip
NOTE: CHILDREN’S PHOTOGRAPHS
As parent or guardian of the above named person, I give my consent to the above release in
full.
Printed Name: __________________________ Relationship: ____________________________
Signature: ____________________________________________
Address: _________________________________________________________________________
Number Street City State Zip
PLEASE READ THIS LETTER CAREFULLY
April 1, 2020
Re: New consent form for participant medications
Dear Recreation Parents:
The City of Kingsburg is a member of the San Joaquin Valley Risk Management
Authority (CSJVRMA). This group helps protect the City and other cities like us from
lawsuits. It has recently been brought to their attention that city programs around the
valley are allowing children to take medications while they are on the city’s program site.
As you know, the City of Kingsburg requires participants to have a completed Health
History Form before they can start with the Kingsburg Recreation Program. The
CSJVRMA would like us to have a more in depth form completed by the parents or
guardians of participants that take medications or take medications on site.
Having this information on site is very important for staff to have. If for any reason there
is an emergency, EMS would need to know specific information about any medications
or allergies your child may have.
If your child is on any medications or if they take any medications at the Recreation
Program, you are now required to complete this form in addition to the Health History
Form. I have attached a copy the City of Kingsburg Parental/Guardian Consent &
Direction to Staff for the Self-Administration of Medicines form. Please complete the
form and review the policy. It is very important that you review and understand the
verbiage that is provided in this document.
If at any time your child begins taking any kind of medication, even temporarily, you will
need to complete this form.
CITY OF KINGSBURG
PARENTAL/GUARDIAN CONSENT & DIRECTIONS TO STAFF
FOR THE SELF-ADMINISTRATION OF MEDICINES
Participants name:_______________________________ DOB:___________________
Medical Condition(s):______________________________________________________
Asthmatic: YES NO
Allergies (please note severity, food restriction, etc.):
______________________________________________________
______________________________________________________
______________________________________________________
Location of medication: Kept on sight Brought in daily by participant
Name of medication(s): Form: (liquid, pill, etc.)
______________________________ __________________
______________________________ __________________
______________________________ __________________
All medications, prescription and over the counter, must be provided to the Community Services
department in their original packaging, with your dependents full name written on the container. Remember
to provide medicine cups, spoons or other instruments for the medication’s administration. The medication
dosage must be completed below in the INSTRUCTION section. If additional instructions are required,
please attach another sheet.
INSTRUCTIONS: parents/Guardians – please write specific step by step
instructions for staff to follow in the event your dependent has an allergic reaction
or displays symptoms of a medical condition. You must confirm these steps with
your dependents physician or health care provider. By providing these instructions,
you are consenting to staff’s ASSISTANCE with medicine in the treatment of your
dependent.
Ex
ample: 1. Administer Epi-pen 2. Administer 2 teaspoons of liquid Benadryl
3. Call 911 4. Call Parents/Guardians at ----------
1.____________________________________________________________
2.____________________________________________________________
3.____________________________________________________________
4.____________________________________________________________
I
F YOUR CHILD TAKES MEDICATION
AUTHORIZATION, WAIVER AND RELEASE
I authorize the City of Kingsburg employees to perform emergency procedures, including assisting with the
administration of Epi-Pens, injections or self-administered medications (whether over the counter or
prescription) or any other steps that I have described above to treat any illness, medical condition, allergic
reaction, or injury that my dependant may experience.
I reco
gnize and acknowledge that there are certain risks of injury in connection with administration of
medication to any minor child or dependent. Such risks include, but not limited to, failing to properly
administer the medication, failing to observe side effects, failing to assess and recognize an adverse
reaction, failing to assess and/or recognize a medical emergency, and failing to recognize the need to
summon emergency medical services.
I here
by authorize the City of Kingsburg employees to assist in the administration of medication on my
behalf or allow my dependent to self-administer (if permitted by me dependents physician) the lawfully
prescribed Epi-Pen or other medications in the event of an allergic reaction by my dependent.
I acknowledge the assistance in the administration of the Epi-Pen or other medication to my dependent by
an individual who is not a nurse or medical professional may be necessary, and I specifically consent to
such practice. I hereby waive any claim for myself, my heirs, executors, assigns or personal representatives
that I may have against the City of Kingsburg, its officials, officers, employees, agents or volunteers, from
any and all claims for damages arising out of or in any way connected to the self-administration, assist-in-
administration or failure to administer or attempt to administer any medication to my dependent. I further
agree to protect, indemnify, defend and hold harmless the City of Kingsburg, its officers, employees, agents
and volunteers, for any claims for damages, including attorney fees, arising out of or in any way connected
to the self-administration, assist-in administration, failure to administer or attempt to administer medication
to my dependent.
I also
give my permission to the City of Kingsburg staff to contact emergency services or obtain
emergency medical treatment if necessary. I agree to be wholly responsible to payment of any and all
medical and emergency services rendered to my dependent.
__________________________________________ __________________
Signature of Parent/Guardian Date
__________________________________________ __________________
Printed name Relationship
REMINDERS:
Participants are responsible for arriving at the program with all necessary medications, supplies, pumps,
backup medications, and any other equipment necessary for the participant to safely self-administer their
medications.
Medical monitoring of blood sugar levels must be done by parents or guardians prior to attending the
program each day, to ensure that they are within their target range.
Staff will not be responsible for identifying symptoms of hyperglycemia or hypoglycemia, but can assist
the participant in checking blood sugar levels with proper training provided by parents or guardians.
Parents/guardians are responsible for providing all necessary information regarding dietary restrictions,
food allergies or special diet considerations to staff.
Participants and parents/guardians shall be advised and reminded that it is the participant's responsibility
to administer the medication and that staff will only assist as needed. Staff will not give scheduled
injections.
It is the responsibility of the parent/guardian to pick up any medication that remains at the conclusion of
the program. Any medication not picked up will be disposed of in a safe manner.
If your child does not have a medical condition and does not take any
prescribed or over the counter medication on a regular basis, please sign
the bottom and return to City Hall.
If you have any questions, please feel free to contact me by phone at (559) 897-5328 or
by email at acastaneda@cityofkingsburg-ca.gov.
Sincerely,
Adam Castaneda
Community Services Director
City of Kingsburg
I, _________________________ (name) have read the City of Kingsburg
Parental/Guardian Consent & Direction to Staff for the Self-Administration of Medicines
form. I have reviewed it and understand all it entails.
At this time, my child _________________________________ (child’s full name) does
not have any medical conditions and does not take any prescription or over the counter
drugs.
I understand that if my child were to become ill and need to be placed on any
medications, even temporarily, I would have to come in and complete the City of
Kingsburg Parental/Guardian Consent & Direction to Staff for the Self-Administration of
Medicines form.
______________________________________________ __________________
Signature Date
______________________________________________ __________________
Printed name Relationship
IF YOUR CHILD DOES NOT TAKE MEDICATION
CITY OF KINGSBURG AFTER SCHOOL &
SUMMER RECREATION
PICK UP POLICY
Children must be picked up no later than 2:15pm




 
 









 



Child's Name____________________
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome