Fill - Free fillable 2020 Summer Registration Packet! (City of Kingsburg) PDF form

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

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.

ample: 1. Administer Epi-pen 2. Administer 2 teaspoons of liquid Benadryl

3. Call 911 4. Call Parents/Guardians at ----------

1.____________________________________________________________

2.____________________________________________________________

3.____________________________________________________________

4.____________________________________________________________

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

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Child's Name____________________

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