STUDENT
APPLICATION
PACKAGE
M A Y 2 3 - M A Y 3 0, 2015
2015
INSTRUCTIONS FOR SUBMISSION OF ARTS CAMP 2015 APPLICATIONS
To offer the Arts Camp experience to as many students as possible, a number of
changes have been made to the application and selection process.
For elementary and secondary students applying to Arts Camp:
1.Completed applications (including payment of two post-dated cheques of $250.00 each) are to be
returned to the Principal/ Vice Principal no later than Friday, February 13, 2015.
2. Students require parental/guardian consent and the signed endorsement of their teacher and principal to
apply to Arts Camp.
3. There is no limit to the number of student applications a school may submit provided that each student
applicant has met the following 4 criteria:
o
student demonstrates positive character in the school;
o
student does not show significant behavioural concerns in the school;
o
student would benefit from an arts program in an inclusive community; and
o
student is prepared and mature enough to spend a week away from home.
4. New for Secondary Students - First time applicants will be given priority. Secondary students can apply
for a second, third or fourth year at camp, and will be accepted only after first time applicants have been
placed.
5. Students will be selected through a random draw process.
6. Offers of acceptance will be mailed to students at their homes by early April.
7. Students not offered acceptance will have applications and deposit cheques sent to their home schools
by early April.
8. The Arts Camp Leadership Team has final approval of the roster of students accepted to Arts Camp 2015.
PLEASE KEEP THE INSTRUCTION PAGES AS WELL AS THE PROGRAM DESCRIPTIONS
FOR FUTURE REFERENCE.
PLEASE BE SURE TO CLEARLY MARK THE INFORMATION UNDER “FEES PAYABLE”,
CHECK THE CORRECT SIZES FOR CLOTHING AND TOTAL THE AMOUNT PAID ON
THE APPROPRIATE LINE.
Please read the instruction pages carefully before
you fill in the attached application form.
The Arts Camp Program consists of 2 programs of 2.5 hours each and 1 workshop session of 1 hour.
All applicants must be currently enrolled in Grade 7 - 12 at a school administered by The York Region
District School Board.
Camper FEE: $500.00
Counsellor In Training (C.I.T.) FEE: $400.00
Counsellor FEE: $300.00
TRANSPORTATION (optional): $50.00 return or $25.00 one way
Arts Camp is held at Camp White Pine in Haliburton, ON
PAYMENT OPTIONS: PAYMENT OF ALL FEES MUST BE SUBMITTED WITH APPLICATION
Payment in full with application.
OR
Two cheques with application.
- Cheque # 1 dated April 1st.
- Cheque # 2 dated May 1st (dividing the payments equally).
Make cheque(s) payable to: YORK REGION DISTRICT SCHOOL BOARD
CANCELLATION POLICY
●
●
Cancellations must be in writing.
Cancellations for medical reasons must be accompanied by a medical note.
HEALTH
●
●
Please ensure that any medical concerns are listed on the Health Certificate.
Although a first aid health centre and nursing staff are provided, the cost of any treatment or drugs, not
ordinarily supplied by the camp, must be borne by the parents, if such instance should arise.
SUBMIT THE ATTACHED HEALTH CERTIFICATE WITH THIS APPLICATION FORM
BEHAVIOUR
●
Directors may at any time send home campers without refund for violation of Arts Camp regulations. These
regulations will be distributed in the Student Handbook on Family Information Night. Arts Camp cannot be
held responsible for the loss, damage, or theft of any personal belongings brought to camp.
TRANSPORTATION
●
●
Buses will leave from the Education Centre Aurora, 60 Wellington Street West at 8:00 a.m. sharp on
Saturday, May 23, 2015, and will arrive back in Aurora at approximately 4:30 p.m. Saturday May 30, 2015.
Please be prompt.
Late requests for bus transportation may not be accepted. Carefully consider transportation plans at time
of application.
WATER SAFETY
Before participating in any water activities/sports the camper must meet the following swim requirements:
●
minimum Aqua Quest Level 7 certificate or pass the pre-camp swim test consisting of 150 yards of
continuous swim (any stroke), followed by treading water for 6 minutes, and completed by assuming
the HELP position in a life jacket.
●
If camper possesses Aqua Quest Level 7 (or higher) a photocopy of authorized documentation must
accompany the application
●
Pre-camp swim test will be held at the Aurora Recreational Complex, 1400 Wellington St. E., Aurora, (at
Leslie) on Saturday, May 16, 2015 at 4:00 p.m.
IMPORTANT DATES
Keep the program information for your own reference.
Family Information Night
Tuesday, May 12, 2015 at
Richmond Green Secondary School
1 William F Bell Pkwy, Richmond Hill, ON L4S 2T9 6:30 p.m.
●
Counsellor Interview Session
Thursday, April 16, 2015 at
Community Education Centre North
130 Carlson Drive, Newmarket ON L3Y 5H3
4:00 p.m.
●
Counsellor/C.I.T. Orientation
Tuesday, May 5, 2015 at
Centre for Leadership and Learning
300 Harry Walker Pkwy S, Newmarket ON L3Y 8E2
4:00 p.m.
●
Return only the APPLICATION, the completed HEALTH CERTIFICATE and the signed CONSENT FORMS.
T-Shirts and Sweatshirts will be distributed in the campers’ cabin when they arrive at camp.
All orders must be placed at time of application.
YORK REGION DISTRICT SCHOOL BOARD – ARTS CAMP 2015
PROGRAM DESCRIPTIONS
A.M./P.M. PROGRAMS – 2.5 HOUR CLASSES
A.M.
Vocal and Soundscape Exploration
Do you ever sing in the shower? Hum to the radio? Interested
in beat boxing? If so, this program is for you! Work with fellow
vocalists to explore pitch, tone, dynamics, melody and so much
more! Play games, re-arrange popular songs, and learn from both
new and old styles of music. Build confidence, form bands, be
creative and discover how powerful your voice can be!
Sound of the Drum
Explore the world of West African drumming from the
perspectives of cultural traditions and western composition
techniques. This program is great for all students of any level.
CIT Leadership
CIT’s are a valued part of our dynamic camp team. The CIT
Program provides you with the opportunity to build your
leadership and camp counseling skills in a positive, encouraging
and safe environment. You will facilitate selected camp wide
activities and experience different aspects of leadership,
communication, conflict, group dynamics and self-awareness.
Through various fun and engaging challenges, activities and
discussions you will develop your ability to provide leadership in
our unique camp setting.
Glass with Class
Hone your design skills and fine motor coordination in developing
detailed faux stained glass panels using nature as your inspiration
followed by custom wooden frame construction in your choice
of stains. A focus on line, balance, colour, shape, and unity will
bring your ideas to life and light shining through your art will do
the rest.
Let’s Make a Music Video!
Like making music? Like making movies? Of COURSE you do!
You are Arts Campers! So take this course and learn both. You
will learn how to take a song and tell a visual story to go with it.
You will learn a whole bunch of film techniques, as well as how to
work together on an idea.
Playmaking for Social Justice
Find out how funny you really are! Together we will create a
comedic performance based on the jokes and tricks developed in
the Vaudevillian era. Pie throwing, chair pulling, pratfalls, puns
and jokes combine to make a complete theatrical performance
that includes elements of lighting, stagecraft, scriptwriting,
dialogue and dancing.
The Whimsy and Wonder of Watercolour!
Whether you have used watercolour extensively or you are new to
the medium, this program is for you. You will be given the chance
to explore and experiment with watercolour paint exclusively and/or
combined with other mediums. We will explore various styles and
techniques formally and informally. Come and find out what you
can do with such a versatile medium, stretched watercolour paper
and your imagination!
Printmaking Natural Objects
Learn how to take the surrounding environment and translate
technique of block printing. Together you will discuss how to
create patterns about creating a cohesive collection of patterns that
complement one another.
Charcoal, Chalk, and Faces, Oh My!
Is drawing a person’s face a challenge for you? Do you want to
improve your skills in charcoal and chalk? If you said “yes” to either
of these questions, this is the program for you! Whether you are a
newcomer to portraiture or experienced, together we will overcome
the challenges of realistic features in a fun way. Express yourself
and get ready to get messy while doing it!
Mixed Media
Like mad scientists in our labs, we will mix things that never
should be mixed. We will find things along the way and join,
paste, and sew them together. We will raise the ghosts of
Duchamp, Picasso, and Rauschenberg and, cackling crazily, we
will synthesize our insane assemblages into improvisational
systemic Frankensteins of aesthetic terror. It is important to
know when mixing oil and water is a perfectly good idea. Using
exploratory techniques, collage, assemblage, a bag full of dry
and wet media, found materials and homemade pigments, we will
bring these creaking constructed/deconstructed monsters to life.
Bring on the mad laughter.
Creating with Clay
Use your imagination and take it to endless possibilities when you
create in 3D! You will use clay that will be fired and finished with
glazes, stains, and other experimental techniques. You will be
taught how to create real or fictional animals, masks, lanterns and
pottery that you can use. You will learn hand building techniques
and have a chance to throw clay on the wheel!
Dance Expressions
If you have a passion for movement and expression then this
is the perfect program for you! You will have the opportunity
to build your own choreography, as well as develop a modern
contemporary technique. We will also focus on improvisational
and contact movement through co-operative learning activities.
Explore, create, dance!
P.M.
Jam Speak – Songwriting and Musical Production
This program is a journey of discovery in the incredible world of
songwriting. You will learn how to create, arrange, perform and
record a song on professional recording equipment. Every day we
will learn about different styles of music and song writing.
Honouring your Experiences – A Playwright’s Journey
The best stories are the ones that come from our hearts, our
experiences, and our memories. Come explore your inner
playwright. Caution: You may like what you find.
Tell Me An Animation Story
Have you ever wanted to create your own animation film? Are
you interested in telling a unique story? Would you like to have
your creativity come alive? Then “Tell Me An Animation Story”
is for you! In this intense program you will be working in small
groups to tell a short story with the use of stop-motion animation.
You do not have to have any experience with photography or
animation as you will gain all the training that you need during
the Arts Camp week.
How to Draw Realistically
Want to improve your drawing skills? Do you want to be able to
draw more realistically? This is the class for you!
Drawing in 3D with 3Doodlers
Ever dreamed of drawing in 3D? In this workshop, students
will use the world’s first 3D printing pen to explore a variety of
different art forms, including relief and sculpture. The pen uses
a thin plastic thread that is heated and cooled, allowing the artist
to draw with plastic in 3D. You will be encouraged to explore the
medium to help you become inspired to create a completed piece
of art. (14+)
Send it to Print
Do bold colours blending together creating eye-popping pieces
of art interest you? Try this printmaking program with a multimedia flair. In this program you will carve blocks of wood,
etch plexiglass and dig at linoblocks to make beautiful prints
incorporating nature filled and inspiring subject matter. Finish
off your beautiful prints with other media styles to enhance and
express your own individuality.
Figure Painting Exploration
Looking to advance your figure drawing and painting skills? This
program will teach you how to paint the human figure. You will
learn fun tips, styles and tricks in painting the figure, starting
from gesture drawing to studying the human anatomy and being
exposed to various painting styles ranging from realism to abstract
expressionism. The purpose of this program is to encourage
students to explore various techniques, methods, and styles in
creating a figure and what a figure can express through simple
body composition. The final project will be a figure painting done
in acrylic with optional use of mixed media that demonstrates the
students’ full self-expression.
Dream Painting
Have you ever had a dream that is so vivid and real yet
completely bizarre? In this course you will be learning how to
take symbols from your dreams and fantasies and incorporate
them into a Surrealist style painting just like great Surrealist
painters like Salvador Dali. Make the impossible, possible!
Green Eggs and Hamlet: Shakespeare Like You Have Never
Seen or Heard It!
Come out and read, act, sing, and/or dance out Shakespeare in a
brand new way. Turn tragedy into musical/ spoken word/ choral
experience! This program will make you see life in a whole new
way. Look into the past to discover where the future lies…
Step It Up!
If you love to dance, this is the program for you! Step It Up is
an intensive dance program which focuses on the unique dance
style known as Stepping. With its roots in Africa, this style of
dance has been popularized in North American Hip Hop culture
and is featured in such movies as Stomp the Yard. You will learn
choreography from an experienced teacher and will have the
opportunity to create their own moves as they prepare for a high
energy dance performance at the end of camp.
SLAM! Poetry & Storytelling
Interested in performing for live audiences? Learn some
performance and writing techniques from a former Canadian
SLAM champion. This program will help you find and focus
on your own, unique voice and teach you how to capture an
audience’s imagination through performance and words. Topics
we will discuss include: comedic timing, metaphor, narrative
structure, memorization, and back flips. There will be many,
many back flips.
YORK REGION DISTRICT SCHOOL BOARD – ARTS CAMP 2015
PROGRAM DESCRIPTIONS
WORKSHOPS – 1 HOUR CLASSES
Hike & Sketch
Explore beautiful Camp White Pine and capture the magic of Arts
Camp through a series of landscape sketches.
Steppin’ Out
You will learn some simple choreography and have the
opportunity to create your own Step Dance moves in a fun and
creative setting.
Creative Mindfulness Meditation
Using a scientific approach to meditation, learn how to open your
mind to daily creativity.
My Own Lens
In this workshop you will create your own personal vision board,
create a concept for your personal vision or view of the world,
implement a design strategy and creative elements to arrive at
your own personal vision.
On Broadway!
Love to sing, dance and act? Join us to learn some of the most
popular broadway hits.
Tom Thomson Club
Learn various visual art techniques and capture your
surroundings while exploring nature in this workshop that pays
tribute to the Group of Seven.
Mountain Biking and Other Sports
Enjoy biking and sports? If so, this workshop is perfect for you!
Coed Booyah Bellydance
This workshop gets you moving to traditional and fusion bellydance
music. With coin belts and finger cymbals you will learn how to
bellydance and feel fabulous!
Sketch Comedy
You funny? Then take this class. Learn to be funnier. Have fun
making funny with your friends.
Face Art
Let your face be the canvas! Learn how to design and create a
variety of different looks using special effects and face painting
techniques.
Paddle Your Canoe
Learn how to paddle and control a canoe as you take excursions
out onto the beautiful Lake Placid. Play canoe games as you
practice your new paddling skills! By the end of the week you will
feel comfortable and confident in a canoe.
Counsellor Circle (Required for Counsellors)
The role of the Arts Camp Counsellor is vital to the success of
camp. This program will offer you the opportunity to further
develop your leadership skills, receive support, problem-solve,
and work with other counselors to build a strong and vibrant
camp community.
Study Hall
If you need a quiet hour each day at camp to work on
assignments or prepare for exams, study hall will provide you
with time and space to do so.
Arts Camp 2015 - Camper Application
May 23 - May 30, 2015
PLEASE PRESS FIRMLY AND PRINT NEATLY
MAXIMUM OF 250 CAMPERS
Name:School:
Sex: Male ❑ Female ❑
Home Phone:
Cell Phone:
Parent/Guardian
Address: Email Address:
Town: Postal Code:
Parent/Guardian
Date of Birth: Age as of May 23, 2015: Designated School - Sept. 2015:
(yr)
(m)
(d)
Present School: Grade:
Have you attended Arts Camp in the past? If yes, in which years (please circle): Yes
No
20102011201220132014
You may request one student to share a cabin with (we will attempt to accommodate this request if possible.)
Please indicate their name, grade and school here:
We accept the conditions set forth and agree to abide by all camp regulations and
to co-operate with the Directors and staff.
Signature of Parent/GuardianSignature of Applicant
Print Parent/Guardian NameSignature of Teacher Reference
Signature of PrincipalDate
(Teacher reference and Principal’s signature indicates student has earned the opportunity to attend.)
Please Note:
If you are applying as a Counsellor or C.I.T. please refer to the Counsellor/C.I.T. information form located on the following
page. This MUST BE COMPLETED ALONG with the camper application
FEES PAYABLE
PROGRAM SELECTIONS
Please number choices in order of preference,
1st, 2nd, 3rd for EACH PROGRAM.
CAMP FEES
CAMPER FEE$500.00
C.I.T. FEE$400.00
COUNSELLOR FEE
(no charge for transportation)
CIT LEADERSHIP
TRANSPORTATION
Arts Camp is held at Camp White Pine in Haliburton, ON
1. NO transportation required 2. Transportation to and from camp required 3. Transportation to camp required 4. Transportation from camp required N/C
$50.00
$25.00
$25.00
GLASS WITH CLASS
MAKE A MUSIC VIDEO
PLAYMAKING FOR SOC. JUSTICE
W&W OF WATERCOLOUR
CLOTHING (please circle appropriate size)
PRINTMAKING
CHARCOAL, CHALK, AND FACES
MIXED MEDIA
CREATIVE WITH CLAY
DANCE EXPRESSIONS
T-SHIRT
S
M
L
XL
XXL $15.00
SWEATSHIRT
S
M
L
XL
XXL $25.00
TOTAL AMOUNT DUE WITH REGISTRATION FORM
ALL APPLICATIONS MUST BE RETURNED BY February 18, 2015
ARTS CAMP
EDUCATION CENTRE NEWMARKET –
CENTRE FOR LEADERSHIP AND LEARNING
Attn: Lori Tant
300 Harry Walker Parkway South
Newmarket, ON
L3Y 8E2
Phone: (905) 727-0022
TO: VOCAL AND SOUNDSCAPE
SOUND OF THE DRUM
$300.00
2.5 HR. P.M. PROGRAM
2.5 HR. A.M. PROGRAM
JAM SPEAK
HONOURING YOUR
EXPERIENCES
ANIMATION STORY
DRAW REALISTICALLY
DRAWING WITH 3DOODLERS
SEND IT TO PRINT
FIGURE PAINTING
DREAM PAINTING
GREEN EGGS AND HAMLET
STEP IT UP!
SLAM! POETRY
1 HR. WORKSHOPS
HIKE & SKETCH
STEPPIN' OUT
CREATIVE MINDFULNESS MEDIATION
MY OWN LENS
ON BROADWAY!
TOM THOMSON CLUB
MOUNTAIN BIKING AND OTHER SPORTS
COED BOOYAH BELLYDANCE
SKETCH COMEDY
FACE ART
PADDLE YOUR CANOE
COUNSELLOR CIRCLE
(REQ. FOR COUNSELLORS)
STUDY HALL
We will try to
accommodate
one of your
preferences
however, there
will be no
guarantees.
“Personal Information is collected pursuant to the Education Act, as amended, and will be used to process your application for Arts Camp Camper Application.
Please contact Arts Camp Co-Director Marion Ahrens at 905-479-4795 or Co-Director Kim Smith at 905-313-8693 for information about this form.”
Arts Camp 2015 Leadership Program
Counsellor/ C.I.T. Application
PLEASE PRINT NEATLY
Last Name:First Name:
School:Grade:
(this school year)
Gender:
Male ❑
Female ❑ Age: (as of May 23, 2015)
Have you attended Arts Camp in the past?
If yes, please provide a brief description of the experience you had:
Yes ❑
No ❑
Yes ❑
No ❑
Have you been a Camp Counsellor or C.I.T. at YRDSB Arts Camp or any other camp?
If yes, please provide a brief description of the experience and any other details.
Yes ❑
No ❑
Have you participated in the Arts Camp Counsellor-in-Training (C.I.T.) program?
If yes, please provide a brief description of the experience you had:
Which position are you applying for?
❑ Counsellor-in-Training (C.I.T.)
❑ Counsellor
With which grade group would you be most effective as a leader?
❑ 7/8
❑ 9/10
❑ 11/12
1. Being a Counsellor or C.I.T. is a unique and rewarding job. What relevant skills and/or experiences can you bring to this position?
(Please include three skills and/or experiences.)
2. Submit a current resume that highlights work or volunteer experiences and/or skills that you believe will support you in your role as
Counselor or C.I.T. (e.g., problem solving, conflict resolution, collaboration, working as a member of a team, creativity, sense of play, empathy, organization, flexibility, etcetera).
Counsellor Applicants:
By signing & submitting this complete application and dependent upon meeting eligibility requirements, I understand
that I will be invited to attend a mandatory group interview session that will include a short personal interview and
other group activities. Following the interview session, decisions regarding counsellor positions will be made by Arts
Camp staff and applicants will be notified via email. Be sure to provide a current and legible email address below.
C.I.T. Applicants:
By signing & submitting this complete application and dependent upon meeting eligibility requirements and Arts
Camp staff approval, I understand that I will be accepted into the C.I.T. program. All C.I.T. applicants will be notified
of their acceptance into the program via email. Be sure to provide a current and legible email address below.
Important Dates - Attendance Expected for Counsellor/C.I.T. Candidates:
Mandatory Group Interview for Counsellor candidates: April 16th from 4:00 - 9:00 pm
Mandatory Counsellor/C.I.T. Meeting: May 5th from 4:00 - 8:00 pm
Arts Camp Family Night: Tuesday, May 12th @6:30 pm
Applicant's Signature: Date:
Email address: (PLEASE print clearly)
“Personal Information is collected pursuant to the Education Act, as amended, and will be used to process your application for Arts Camp Camper Application.
Please contact Arts Camp Co-Director Marion Ahrens at 905-479-4795 or Co-Director Kim Smith at 905-313-8693 for information about this form.”
YORK REGION DISTRICT SCHOOL BOARD – ARTS CAMP 2015
Health Certificate
(Must be signed by Parent or Guardian)
TO BE COMPLETED BY PARENT
Name of Camper:
Age:
Date of Birth: Year _____
Month _____ Day _____
Name of Parent/Guardian:
Address:Email Address:
City: Postal Code:
Phone:(Home) (Cell.) Mother: (Cell.) Father:
Parents or designates must be available for contact and possible pick-up at the Camp White Pine all week.
Submission of Health Card Numbers is NOT a requirement for acceptance to camp. Students requiring medical
attention will be taken to a health care provider in Haliburton and parents will be notified. Students may bring their
own health care information with them to camp.
1. MEDICAL HISTORY
CIRCLE ANY OF THE FOLLOWING CONDITIONS YOUR CHILD CURRENTLY HAS OR HAS PREVIOUSLY HAD.
CHICKEN POX
MEASLES RHEUMATIC FEVER MUMPS ASTHMA / HAY FEVER
APPENDICITISDIABETES
EAR ACHESEPILEPSY
LACTOSE INTOLERANCE
ANY OTHER SPECIAL CONDITIONS (PLEASE PROVIDE DETAILS):
2. IMMUNIZATION
Indicate the MOST RECENT date when the following vaccines and toxins were last given.
This should ensure current protection.
Diphtheria:MMR:
Tetanus:Polio:
FYI-Diphtheria/Tetanus/Polio booster should be given every 10 years
3. ALLERGIES
Circle any of the following substances which have caused an allergic reaction in the past.
Penicillin
Shellfish
ASA
Grass
Sulpha-Based Drugs Codeine
Mold
Dust
Peanuts
Trees
Bee/Wasp/Hornet Stings
Food (provide List)
Others:
Describe the reaction:
Has an anti-anaphylaxis kit been prescribed for this child?
YES ❑NO
❑
ROUTINE ALLERGY INJECTIONS WILL NOT BE ADMINISTERED AT CAMP.
4. OTHER
State any physical or emotional abnormalities or other information which might be of use to the
Camp Nurse.
“Personal Information is collected pursuant to the Education Act, as amended, and will be used to process your application for Arts Camp Camper Application.
Please contact Arts Camp Co-Director Marion Ahrens at 905-479-4795 or Co-Director Kim Smith at 905-313-8693 for information about this form.”
5. MEDICATIONS
All medications will be administered in accordance with the York Region District School Board Procedure
P662, dated July 1986. Forms P662-02, Administration of Medication, and P662-03,
Self-Administration and Storage of Medication must be completed. These forms are available in the
Student Handbook which will be distributed at Family Information Night.
6. MEDICAL RELEASE
1) I understand that the services of a registered nurse, will be available at York Region
District School Board Arts Camp 2015.
2) Each camper must be covered by provincial or equivalent health insurance. I hereby assume full
responsibility for any extra expenses required for the treatment of the above named camper that are not
covered by the Ontario Health Insurance or equivalent Health Insurance.
3) I HEREBY AUTHORIZE the nurse to administer adrenaline (Epinephrine) in a
life-threatening situation as well as the following non-prescription medications; Acetaminophen,
Ibuprofen, Dimenhydrinate, Bradasol, Chlorpheniramine Maleate, Pepto-Bismol, Kaopectate, Calamine
Lotion, Decongestant, Benadryl and a general purpose antiseptic cream. I also agree to the provision of
first aid measures including the use of bandaids, minor dressing supplies, tensors and slings to my child
while attending the York Region Arts Camp from to May 23 to May 30, 2015 in accordance
with procedures.
4) To the best of my knowledge my child is in good health. I will notify the camp if my child is
exposed to infectious disease during the three weeks prior to arriving at camp. In the case of
medical emergency, I understand every effort will be made to contact the parents or guardian. In the
event I cannot be reached, I hereby give permission to the physician selected by the Camp Director to
hospitalize, secure proper treatment, order injection, anesthesia or surgery for my child as named above.
Name of Student: _______________________________ Date of Birth:_____________________________
Signature of Parent/Guardian/Camper (if over 18):
Date:
Name of Family Physician:
Family Physician’s Address:
Family Physician’s Phone:
Comments:
NURSE USE ONLY:
DATE
TIME
C/O
TREATMENT
“Personal Information is collected pursuant to the Education Act, as amended, and will be used to process your application for Arts Camp Camper Application.
Please contact Arts Camp Co-Director Marion Ahrens at 905-479-4795 or Co-Director Kim Smith at 905-313-8693 for information about this form.”
YORK REGION DISTRICT SCHOOL BOARD – ARTS CAMP 2015
INFORMED CONSENT AGREEMENT
As a condition of participation in field trips lasting overnight or longer, this form must be completed by the
Parent/Guardian of each student participant.
Name of Student:
School:
Destination:
Dates of Arts Camp:
The York Region District School Board does not provide any accidental death, disability, dismemberment or
medical expenses insurance on behalf of the students participating in this activity. It is strongly recommended
that you subscribe to student accident insurance or arrange private coverage.
ACKNOWLEDGEMENT
I/We understand that Arts Camp activities (as listed on the application form) involve various
elements of risk and that each person has a different capacity for participating in these activities.
Accidents and injury may occur while participating in these activities. These accidents can occur
without any fault on the part of the student, the school board, its employees or agents of the facility
where the activities are taking place.
I/We hereby agree and promise that our child, ward or self is able to participate and understands that the
CHOICE to participate brings with it the ASSUMPTION OF THOSE RISKS AND RESULTS which are
part of these activities.
I/We agree that the YORK REGION DISTRICT SCHOOL BOARD or its employees, servants or agents
shall not be liable for any injury to my person or loss or damage to my personal property arising from, or
in any way resulting form, my participation in these activities, UNLESS such injury, loss or damage is
caused by the SOLE NEGLIGENCE of the Board or its employees, servants or agents while acting within
the scope of their duties.
I/We declare having read and understand the above INFORMED CONSENT AGREEMENT in its entirety
and hereby consent to participate acknowledging all of the foregoing.
Signature of Parent/Guardian/Camper (if over 18):
Address:
Telephone No.:
Date:
Personal information is collected under the authority of the Education Act and will be used
for the purposes of student safety for the duration of Arts Camp at Camp White Pine and
pertaining to transportation to and from the camp. Successful applications will be retained
for 1 year. Unsuccessful applications will be returned to the student with any and all monies
BEFORE May 25, 2015. If you require further information about this form you can contact the
camp director.
YORK REGION DISTRICT SCHOOL BOARD – ARTS CAMP 2015
MINOR MEDICAL EMERGENCY PROCEDURES
ALLERGIC REACTIONS
For minor signs and symptoms of allergic rhinitis, itchy skin, minor urticaria, or other minor
allergy related symptoms:
1. Chlorpheniramine Maleate 4mg. po. May repeat q4h prn times two.
For severe allergic reactions with probable impending anaphylactic shock
(edema, choking, wheezing, loss of airway):
1. Adrenalin 1:1000 solution: 0.01 cc per kilo s.c. Monitor vitals closely and transport to
hospital ASAP.
MINOR THERMAL BURNS
First or second degree burns to 10% or less of BSA:
1. Cold water soaks for 10-15 minutes.
2. Apply a lightweight sterile dressing of gauze and cling to completely cover the burn area.
3. Leave any blisters that develop intact.
4. Monitor for signs and symptoms of infection.
5. Change dressing prn.
DIARRHEA
1. Kaopectate – 2 tbsp. po after each loose B.M. to a maximum of four doses.
2. Encourage clear fluids until symptoms pass.
OR
1. Pepto-Bismol 15 ml po. May repeat q2h prn to a maximum of four doses.
2. Encourage clear fluids until symptoms pass.
GASTRIC UPSET/INDIGESTION
1. Pepto-Bismol 15 ml po. May repeat q2h prn to a maximum of four doses.
NAUSEA/VOMITING
1. Gravol suspension 30-45 mg po. May repeat q4h prn times two
OR
2. Gravol 50 mg tablets 1 po. May repeat q4h times two.
SPRAINS AND STRAINS
For minor sprains and strains: rest, ice, compression, elevation. Refer any questionable
or suspicious injuries to a physician for further evaluation and/or treatment.
MILD PAIN OR FEVER
1. Acetaminophen plain 325-650 mg po. May repeat times two q4h prn.
2. Encourage oral fluids for patients with fevers.
SORE THROAT
1. Warm saline gargles q2-4h prn.
2. Bradasol lozenges 1 q2-3h prn.
3. Refer to a physician for further assessment if signs and symptoms of acute infection
are observed.