C E N T R A L W O O D L A N D S 5 / 6David Simpson, Principal

400 Alta Dale SE. Ada, MI49301 Phone: 616.493.8790 Fax: 616.493.8795

We are excited to offer a trip to start off our year together with three days and two nights of team-building andleaming at Camp Henry. Students will experience different activities that will incorporate team building andworicing together. These activities include canoeing, survival skills, archery, scavenger hunts, a bog walk, and teamchallenges. This will be a great time to bond and celebrate our time together building lasting friendships that willextend into middle school. Camp Henry staff, sixth grade staff, and parents will accompany groups of students asthey go through each activity.

On Monday, October 17, students in Elsholz/Jasperse and May/Hanson will leave Central Woodlands on schoolbuses to Camp Henry, Newaygo, Michigan at 9:00 a.m. and retum to school during the school day on Wednesday,October 19 at 2:00 p.m. Students from Peneycad/Homrich, Tolly/Becker, and Maloney/Koenigsknecht will leaveCW on school buses to Camp Henry, Newaygo, Michigan at 9:00 a.m. on October 19 and will retum to schoolduring the school day on Friday, October 21 at 2:00 p.m. Please drop your child off at 8:15 on the moming ofdeparture and pick up your child at 2:00 p.m. on the aftemoon of their arrival back at CW to go home.

The total cost for the three days for each child will be $110.00. No student will be excluded based on an inabilityto pay. Should you need confidential financial assistance, please call Mr. Kessel at 616-493-8790, ext. 3906 for aplan to fit your needs before October 7th, 2016. Please retum the form below with your payment in cash or checkpayable to Central Woodlands by Friday, October 7,2016.

We are still in search of chaperones for our sixth grade camp experience. Ideally, we wouldappreciate a chaperone to participate and be available for a complete half week includingovernight; however, we will work to pair chaperones with others who are only available forspecific days or nights. There will be no cost for chaperones to attend camp. If interested, pleaseemail Ted Knudsen at tknudsen@fhps.net.

Thank you.

Cen t ra l Wood lands S ix th Grade S ta f f

Permission Slip for Camp Henry

Homeblock Teacher Name:

M y d i i l d , ( p l e a s e p r i n t ) , h a s p e r m i s s t o n t o t r a v e l b y F o r e s t H i l l s s c h o o l b u s t o C a m p H e n r yand participate in the sixth grade team building activities on October 17-19, 2016 or October 19-21, 2016.

I have enclosed $110.00 to cover my child's expense (checks payable to Central Woodlands)..

I have enclosed an additional $ to help other students with finandal assistance.

1 am requesting financial assistance for my child.

I am willing to chaperone an entire half week! My email is:

I am willing to chaperone but am only availableMy email Is:

Dear Sixth Grade Famil ies:

Parent/Guardian Signature D a t e

6**^ Grade Camp 2016C A M P H E N R Y

It is our hope that all sixth grade students will be available to participate in thisvaluable outdoor educational experience. The camping program promotes socialmaturity and individual self-reliance as students plan for and experience this two andhalf day group experience. They will work hard, play hard, and grow measurably -forming memories that will last a lifetime. Team building and school community will beemphasized.

This packet is vital for supplying you with needed information and necessary forms forsixth grade camp.

All five teams will be attending camp on the dates shown below. The camp fee (checkmade out to Central Woodlands), permission slip, health form and camp rules withparent/guardian and student signatures are to be turned in to your homeblock teacher.This must be done by October 7, 2016. The camp fee is $110.00.

Oct. 4: Parent Meeting @ CW (6:30 p.m) with Camp Henry Staff

Oct. 17-19: May-HansonElsholz-Jasperse

Oct. 19-21: Tolly-BeckerHomrich-PeneycadMaloney-Koenigsknecht

Camp fees and permission slips are due by4:00 p.m. on Friday, October 7th, 2016.

The money will cover the expense of food, cabins, transportation, materials and campactivities. While these fees are needed, we do not want to keep any child from enjoyingthis experience with his/her classmates.

Should you need confidential financial assistance, please call Mr, Kessel at616-493-8790, ext. 3906 for a plan to fit your needs before October 7th,2 0 1 6 .

Transportation to and from camp will be by Forest Hills school buses. Campers in thefirst group will meet at Central Woodlands at 8:15 AM, Monday in the parking lot todrop off their camp gear. Then they will go to their classroom. They will be returning onWednesday at 2:00 PM at CW, where they are expected to be picked up to go home.

The second group will meet at CW on Wednesday at 8:15 AM in the parking lot to dropoff their camp gear. Then they will go to their classroom. They will return to the schoolon Friday at 2:00 PM, when they are expected to be picked up to go home.

NOTE: Parents should plan to meet their children at approximately 2:00 pmon the day of their return in the back of the school. Students will bedismissed for the day at that time.

S P E C I F I C S F O R 2 0 1 6

6*^ Grade students in Eisholz/Jasperse and May/Hanson will attend

camp on 10/17 -10/19

6"^ Grade students in Peneycad/Homrich, Tolly/Becker, and

Maioney/Koenigsknecht will attend camp on 10/19 -10/21

COST: Camp - $110

Permission siips and fees are due no later than 10/07/16.

Make checks payable to Central Woodlands.

**Students who do not choose to attend camp will have a regular scheduleat school.

6th Grade Camp Packing ListCamp Henry is thrilled to be welcoming the 6th graders from Central Woodlands inOctober. We have had the privilege of serving campers, students, families, and guestsat Camp Henry since 1937. We believe that a camping experience at Camp Henry hasthe capacity to transform lives in many ways. With such a concentrated amount of time,a beautiful natural environment, intentional camp programs and activities, opportunitiesto try something new, and being surrounded by positive and encouraging staff members- the combination is perfect for enhancing and positively changing the lives of thestudents who come to Camp Henry.

Our expectation is that everyone who comes to Camp Henry - whether a summercamper in July or a student coming in the Fall with their school group - will have theopportunity to have a life changing experience in a loving, caring, authentic, andsupportive environment. Our staff members are truly awesome - energetic,knowledgeable, compassionate, fun-loving, dedicated, hard-working, and full of joy -and can hardly wait to welcome you to Camp Henry

Suggested Packing List

BeddingSleeping Bag (preferred)or shee ts /b lanke ts

Pi l low and case

Ba th room A r t i c l es

To w e l

Wa s h c l o t h

Soap/Shampoo

Toothbrush/paste

Optional Items

FlashlightC a m e r a

ClothingSweatsh i r t o r sweater

S h i r t s

Jeans or Long Pants

S h o r t s

Tennis shoes, boots, or hikings h o e s

Pajamas

R a i n c o a t / P o n c h o

Warmer coat (depending onweather forecast)

S o c k s & U n d e r w e a r

Leave the Following at Home: MoneyA/aluables, Electronics, Cell phone, iPod, Kindle

Safety is always our number one priority - and our staff work hard to ensure that eachchild will have a safe environment - both physically and emotionally - to learn, grow, andexplore.

Camp Henry is licensed by the State of Michigan and accredited by the American CampAssociation, meeting or exceeding best practices and policies in the camping industry.

www.camphenry.org

C E N T R A L W O O D L A N D S 5 / 6David Simpson, Principal

400 Alta Dale SE. Ada. Ml 49301 Phone: 616.493.8790 Fax: 616.493.8795

Sixth Grade Families,

Attached is the medical authorization form used at Forest Hills Public Schools. If your childreceives medicine at school and you have already completed one of these forms for the year,you may disregard this form unless you administer medication at home that we wili need togive at Camp Henry.

If your child receives medication at home that we will need to administer next week at CampHenry, please compiete this medication authorization form with your healthcare provider. Inorder for us to administer prescription or over the counter medications, this form must besigned by your physician.

You can then drop the medicine and this form off at school in a ziptoc bag with your chiid'sname on it either on October 13 and 14 between 8:00 am and 4:00 pm.

One form does need to be completed for each medication that we administer. In addition,medication must be in its original packaging.

You may fax the completed form to 616-493-8795 or email the completed medication form tosscott@fhps.net

Thanks !

CW 6th Grade Staff

Forest H i l ls Publ ic SchoolsGrand Rapids, Michigan

M E D I C A T I O N A U T H O R I Z A T I O N F O R M

r Central Woodlands 5/6I 400 Aita Dale SE, Ada. Mi 49301I PHONE (616)493-8790 FAX (616)493-8795I ATTN:L . — .

Student

G r a d e T e a c h e r / C l a s s r o o m

TO BE COMPLETED BY THE HEALTH CARE PROVIDER OR AUTHORIZED PRESCRIBER

Name of medication:

Reason for medication (optional):

Method of administrat ion:

□ Tablet/Capsule □ Liquid □ Inhaler □ Injection □ Nebulizer □ Other

Instructions (schedule and dose to be given at school): Time(s):Dose:

Start date of medication: □ Date form received Other dates

Stop date of medication: □ End of school year Other date/duration

□ For episodic/emergency events only

Restrictions and/or important side effects: □ None anticipated □ Yes

If yes, please describe:

Special storage requirements: □ None □ Refrigerate □ OtherThis student is both capable and responsible for self-administering this medication:■ □ No Q Yes - supervised Q Yes - unsupervised

This student may carry this medication on him/her: □ Yes □ No

Signature of Health Care Provider

Pr in ted name o f Hea l th Care Prov ider

TO B E C O M P L E T E D B Y PA R E N T / G U A R D I A N

I request that receive the above medication at school according to standard school pol icy.

I r e q u e s t t h a t b e a l l o w e d t o s e l f - a d m i n i s t e r t h e a b o v e m e d i c a t i o n a t s c h o o l a c c o r d i n g t o t h eschool policy.

Date of birth

P h o n e :

F a x :

Signature Relationship D a t e

Fores t H i l l s Pub l i c Schoo lsGrand Rapids, Michigan

A D M I N I S T E R I N G M E D I C A T I O N T O S T U D E N T S

The guidelines for administering student medication have been developed to promote a safeand drug-free educational environment while providing for the medical needs of students.

A D M I N I S T R AT I O N O F M E D I C AT I O N :• A Medication Authorization Form must be completed by the student's health care

provider and parent/guardian before anv medication Is administered by school personnelor, when permitted, self-admlnlstered by the student.

• A student's parent/guardian may administer medication to his/her child at schoolprovided arrangements have been made with the principal or designee.

• Administration of medication by Injection or ultrasonic Nebulizer will be Individuallyplanned with the student's parent/guardian, school nurse, health care provider andprincipal.

• School personnel are not permitted to honor Independent requests from a parent/legalguardian to administer medication other than as specified on the medicationa u t h o r i z a t i o n .

• All medications administered by school personnel must be delivered to school by theparent/guardian or other authorized adult. In the current original container with anunaltered prescription label attached.

• Any change In medication, dosage, or directions will require the completion of a newM e d i c a t i o n A u t h o r i z a t i o n F o r m .

• All signatures. Including health care provider, parent/guardian, must be original andh a n d w r i t t e n .

• Faxed Medication Authorization Forms requiring a health care provider's signature mustbe sent directly to the school from the health care provider's office.

SELF-ADMINISTRATION OF MEDICATION BY STUDENTS:• Elementary Students - Grades K-6

The only medications that can be carried and self-admlnlstered by elementary studentsare metered-dose Inhalers and emergency Injectable medications. If authorized In writingby both the student's health care provider and parent/legal guardian.

• M i d d l e S c h o o l S t u d e n t s - G r a d e s 7 - 8

Prescription medication may not be self-admlnlstered by middle school students with theexception of metered-dose Inhalers, and emergency Injectable medication. If authorizedIn writing by both the student's health care provider and parent/guardian.Over-the-counter medication may be carried and self-admlnlstered by middle schoolstudents If authorized In writing by the student's parent/guardian. All medication must beIn the original container that contains no more than one day's dosage.

• High School Students - Grades 9-12Prescription medication may be carried and self-admlnlstered by high school students Ifauthorized In writing by both the student's health care provider and parent/guardian.Over-the-counter medication may be carried and self-admlnlstered by high schoolstudents If authorized In writing by the student's parent/guardian. All medication must beIn the original container that contains no more than one day's dosage.

Any questions or concerns regarding the administration of medication should be directed tothe school nurse, at 493-8870, who will determine appropriate action.

4

CAMPHENRY General Release Form

u n d e r 1 8

School/Group Name

Participant Name

A d d r e s s

J Date(s) attending Camp Henry

J Male or Female (circle one) Birthdate.

J P h o n e N u m b e r .

City, St. Zip J E - m a i l

Parent/Legal Guardian. J Emergency Phone.

H e a l t h I n s u r a n c e J Policy Number.I recognize that adventure courses/climbing can be a strenuous endeavor requiring my child/ward to be in good physical condition. I hereby certify that my child/ward does not suffer from any physical infirmities or illnesses which would affect the ability to engage in adventureactivities and that if my child/ward is now under treatment for any of the follovring, I will circle the proper headingfs) and discuss them with theCamp Henry instructor prior to my child/ ward engaging in the activities;

Cardiac or Pulmonary Condition/DiseaseFainting SpellsHearing Loss or ImpairmentBack or Neck InjuryAny Orthopedic ProblemsRecent InjuriesO t h e r

Circle Appropriate HeadingsMigrainesD i a b e t e sS h o r t n e s s o f B r e a t h

Emotional ly ImpairedA s t h m aA D H D

High Blood PressureKidney Related Diseasesbeaming DisabledAnxiety/DepressionInsect AllergiesI n s o m n i a

Food Allergies

• I understand that during my child's participation in this adventurecourse or activity my child may be exposed to psychologically andphysically stressful and challenging situatiorrs. I recognize thatcertain hazards and dangers are inherent in camp events andprograms and particularly, but not limited to: swimming, boating, lowropes, high ropes courses, team courses, tower climbing, traversingwall climbing, canoeing, fishing, hiking, night hiking and campfires.• I understand, too, that although the program has taken precautionsto provide proper organization, supervision, irxstruction, andequipment for each activity it is impossible for the program toguarantee absolute safety. Also, I understand that my child sharesresponsibility for his/her safety and I have instructed my child in theimportance of knowing and abiding by the camp rules, regulationsand procedures for the safety of the camp participants. Further, Iwaive any claim that may arise against Camp Henry and/or itsemployees as a result of participation in the program, except for thosewhich are the direct result of the gross negligence of Camp Henry orits employees, staff or volunteers.• I have accepted responsibility for verifying my child's personalhealth and medical history on top of this sheet and my child has nophysical or psychological problems that would prohibit or limit mychild's participation in this program. Any medicines, prescriptionor non-prescription, will be dispersed by authorized school/grouppersonnel .• In sicfning this form, I give permission to Camp Henry to use

photographs, videotapes, and any other media, including my child/ward to be used in camp publicity; for my child/ward to betransported for approved out-of-camp activities; for the release ofmedical information in case of illness; and I agree to assume allfinancial responsibility for any medical attention needed by my child/ward and otherwise not covered by my insurance or Medicaidc o v e r a g e .• And I/we acknowledge that there can be no absolute guarantee

of safety against risk and unforeseen injury, as detailed above, andconsent to the participation of the above named participant in theadventure program. I also authorize the treatment of my child/wardby licensed medical personnel in the event of any emergency. Thisauthority is granted only after a reasonable effort has been made tor e a c h m e .

. CAMP HENRY EQUINE UABIUTY RELEASE: P lease read the

following agreement and liability release for horseback riding and orhorse related activity at Camp Henry before signing: WARNING; Underthe Michigan equine activity liability act, an equine professional is notliable for an injury to or the death of a participant in an equine activityresulting from an inherent risk of the equine activity.As a guest at Camp Henry, 1, the undersigned, recognize that CampHenry is located in a rustic setting with natural and artificial hazards(including surface and subsurface conditions). The undersigned alsounderstands that it is the propensity of an equine to behave in waysthat may result in injury, loss, or death. Equines can act unpredictablyto sounds, sudden movements, unfamiliar objects, persons, or otheranimals. It is also understood by the undersigned that there could bea collision with another equine, animal, person, or an object whileriding on Camp Henry premises.The undersigned will be given basic riding instruction prior to riding,yet there is a potential for the participant to act or fail to act in amanner that could contribute to injury, loss, or death. I understandthat by mounting a horse and by taking the reins that the rider is inprimary control of the horse. The rider's safety largely depends onhis/her ability to carry out simple instructions and hisAier ability toremain balanced aboard the moving equine.I/We, the undersigned, have read and do understand and agree to theforegoing agreement, warnings, waiver, and the assumption of risk.We assume the risk of injury from the above danger, and waiveliability, if any, of Camp Henry/Westminster Presbyterian Church ofGrand Rapids, MI and its staff and volunteers.

Parent/Legal Guardian Signature (REQUIRED) Part icipant Signature