Fillable Emergency Contact And Behavior Form 2020 (Town of Milton, Vermont (VT))

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Emergency Contact And Behavior Form 2020 (Town of Milton, Vermont (VT))

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MILTON RECREATION DEPARTMENT
2020 Summer Day Camp
Behavior and Discipline Policies
1. All Campers are expected to respect themselves, their surroundings and those around them.
Be polite and considerate of others
Play fairly and safely during all activities
Promote peace (no fighting, please)
Use appropriate language
Express any concerns to the Senior Camp Counselor, Recreation Coordinator or designee
2. Everyone is expected to respect the property of others, the equipment belonging to the Milton
Recreation Department, Milton Town School District and the Town of Milton.
Use “walking feet” inside all buildings.
Use equipment properly, take care of equipment and leave areas better than you found
them.
Stay in the designated space for your program/activity.
3. Campers are expected to show respect for fellow campers, Camp Counselors, Recreation
Coordinator, other staff, guests, bus drivers, park users and all others who Campers interact with.
Always be cooperative with Camp Counselors and others.
Listen when others are speaking and wait your turn to speak.
4. Everyone is expected to be honest and truthful in all of his or her interactions.
5. Everyone is expected to abide by all reasonable requests/additional rules, which may come up.
6. Any physical contact or bullying, with the intent to hurt another individual physically or
otherwise, will not be tolerated. (Camper will be asked to leave the program).
Discipline:
Each case will be reviewed on an individual basis. All behavior incidents will be documented.
Standard Procedures:
1
st
time Verbal Warning
2
nd
time Time-out; Parent/guardian/caregiver is notified
3
rd
time Time-out; Parent/guardian/caregiver is called, letter sent home and child is sent home.
4
th
time Parent/guardian/caregiver is called, child is sent home and may be dismissed from the program
(last resort)
Milton Recreation Summer Day Camp Mission:
To provide a safe environment for all children where they can experience friendships,
expand their creativity, learn new things and have FUN.
Thank you for your cooperation!
______________________________ ___________________________
Parent/Guardian Signature Child’s Signature
2020 kmd
Camper’s first name:
_______________________________
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MILTON RECREATION DEPARTMENT
2020 Summer Day Camp
Emergency Contact Information:
Child’s Name: ___________________________________________
Emergency Contact: _______________________________________ Phone: ____________________
Emergency Contact: _______________________________________ Phone: ____________________
Dr. Name: _______________________________________________ Phone: ____________________
Medical Considerations: ______________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
(Prescription) Medication Permission: (if applicable)
I give permission for the medication listed below to be administered to my child as directed by Town
of Milton Recreation Department Camp Staff.
Medication: ______________________________________________________________
Medication name, date and time(s) to be administered
Reason for giving: _________________________________________________________
Diagnosis
Beginning date: ________________________________ Ending date: _________________________
*No medication will be given at Camp until the Town of Milton Recreation Department Staff receives this
completed form with the prescribed medication in a container appropriately labeled by the pharmacy or
physician. All medication brought to Camp must be turned in to and administered by Recreation Staff.
**********************************************************************************
Pick Up Release:
I, ___________________________________, give permission for the following people to
pick up my child noted at the top of this form:
Name: Relation: Phone #:______________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Please Note:
The person picking up your child must be at least 18 years of age.
A note must be sent with your child if someone other than the persons listed above will be picking
up your child. If there is no note, the child will not be released.
** The following people are not allowed to pick up my child:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_______________________________________ ____________________________
Parent/Guardian Signature Date
2020 kmd
Camper’s first name:
_______________________________
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Emergency Contact And Behavior Form 2020 (Town of Milton, Vermont (VT))

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Completed 13 July 2020

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