7th Grade Outdoor Education Field Trip

Catalina Island September 11, 2017 - September 15, 2017

The primary focus of the trip is to create an outdoor educational experience that cannot be replicated in the classroom setting. This trip has been a long-standing tradition for our 7th graders in the San Marino Unified School District. This opportunity allows students to meet and foster friendships with their peer group. The activities and instructors at Catalina will provide the challenging critical thinking that students are accustomed to in San Marino Unified. Activities include the study of marine ecosystems through snorkeling, canoeing, nature hiking on the island, and dissecting squid. About Mountain and Sea Adventures in Catalina MSA is located at Emerald Bay Cove in Catalina, which is known to be the most beautiful cove on the island and is one of the top 10 snorkeling spots in the world. Crystal clear water hosts abundant sea life found nowhere else on the island. Students are guided through a hands-on educational experience. The plankton lab, fish aquariums, shark touch tanks, and invertebrate touch tanks are a few of the amenities that make this an unparalleled research and study center. MSA employs a staff of instructors and an onsite director for the duration of the students' experience on Catalina. Each research group of students will be supervised at all times by MSA staff. Additionally, HMS is taking site employees, both certificated and classified, including an administrator, for additional supervision. Prior to departure, all chaperones are required to attend a mandatory chaperone orientation and medical training session. Additionally, all students will attend a student orientation outlining expectations for behavior and daily operations. Students begin each day at 8:00AM and rotate between sessions within their research groups. Each evening will bring a nighttime activity that incorporates all students in attendance. The buses will depart from HMS for a ferry at San Pedro to Catalina. Students return on Friday via ferry and bus back to HMS. Cost Per Student Pursuant to California Education Code Section 35335, fees may be charged for outdoor science camp programs, so long as no pupil is denied the opportunity to participate because of nonpayment of the fee (Education Code section 35335). Furthermore, Education Code section 39807.5(b), (d), and (f) allows for fees to be imposed for an event deemed optional. Parent fees fund this trip. The cost per student is $675 (check made out to HMS) and includes but not limited to:

• All meals • Accommodations • Access to water sport equipment • MSA instructors • Transportation to and from Catalina

Parents who request assistance to pay the fee may contact Michelle Boecking, HMS Account Technician, to develop a payment plan or other option. Teachers at Huntington Middle School will provide regular instruction to students not attending this trip. This packet contains the following forms that must be completed for all attendees unless otherwise stated:

• Temporary Delegation of Parental Rights and Limited Power of Attorney for Consent to Medical Treatment form. • Behavior Contract • Medical Form • Administration of Medication Form (Complete this ONLY if your child must take medication at Catalina.) • Medication Policy (Read only) • Packing List for Catalina • MSA Medical and Release forms

To request tent-mate choices: https://goo.gl/9o8hOm PleaseturninthiscompletedpacketbyMay31,2017totheHMSoffice.

Principal’s Approval________________________________________ United Records Management 8/2016

San Marino Unified School District Temporary Delegation of Parental Rights and Limited Power of Attorney for Consent to Medical Treatment

Date: _____________________

School: _________________________________________________

Student's Name: ________________________________________ has permission to participate in the following field trip:

Destination/Nature of Activity: _______________________________________________________________ (Please be specific, e.g., Concert at UCLA.)

Special Instructions:_______________________________________________________________________________ (e.g., Bring sack lunch.)

Departure: Return: From __________________________________________ To____________________________________________

Name of Teacher: _______________________________ Grade: ____________

Transportation Waiver _____ Parent/Guardian Initial here Student authorized to use following mode of transportation: Bus____ Walk ______ Other: __________________________________________________________________

Health or special needs: Check as appropriate. _____ My student has no special health needs the staff should be aware of. _____ My student has a special need, and instructions are attached. Number of attached pages: ________. Medical Release _____ Parent/Guardian Initial here In the event of emergency illness or injury, I do hereby consent to whatever X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care and emergency transportation considered necessary in the best judgment of the attending physician, surgeon, or dentist and performed under the supervision of a member of the medical staff of the hospital or facility furnishing medical or dental services. I further understand that all medical expenses are fully my responsibility. (If no family insurance is available, please inquire about a School-Time Coverage Policy good for the current school year. See your site administration office.) Liability Statement _____ Parent/Guardian Initial hereI fully understand that participants are to abide by all rules and regulations governing conduct during the trip. If the Supervising Teacher deems a student’s behavior as uncorrectable, the parents will be informed and the student will be sent home at the expense of the parents. See SMUSD Administrative Regulation 5131 & 5131.1. As provided for in California Education Code Section 35330, I agree to waive all claims against the San Marino Unified School District (District) and hold-harmless the District, its officers, agents and employees, from any and all liability or claims, which may arise out of or in connection with my child's participation in this activity. This waiver shall not apply to any occurrences that may arise solely out of the negligence of the District, its employees or agents. _________________________________ ___________________________ Cell Phone: ( )_____________________________ Signature (Parent/Guardian) (Print Parent/Guardian Name)

Home Phone: ( ) ____________________________

Work Phone: ( ) _____________________________

Email address: _________________________________

___________________ ____________________________________________ ________________________________ Student Date Student Signature (Print Student Name)

Parent’s name (print clearly)

United Records Management 8/2016

BEHAVIOR CONTRACT

Participating in this off-campus trip will be one of the highlights of your school career. However, along with the opportunity of representing your school and your community, certain expectations will be required of you. Please read the following guidelines and expectations regarding your role as a student traveling with the

_________________________________________________________________ (school site) and (school organization)

Trip: ________________________________________________________________ (Destination) (date through date)

Medical Emergencies: A separate Medical Form must be executed by each student and their parents/guardians. In the event of any medical problem(s) on the multi-day field trip students must immediately contact__________________________________________

or one of the chaperones. (coordinator and/or designee)

Curfew Times: Curfew times will be listed or stated daily. All students are required to be in their rooms at the appointed curfew time for their safety and accountability. Walking around the hotel or leaving the hotel grounds is not allowed after the assigned curfew time. For any violations, appropriate consequences will be given including being sent home at the expense of the student’s parents/guardians.

Alcohol/Drugs/Tobacco/Etc.: Any student caught in possession of or using alcohol/illegal drugs/tobacco/weapons, etc. will be sent home immediately at the expense of the student’s parents/guardians. Even if a student is of the legal age to use tobacco or alcohol, it is a violation of school policy and is NOT permitted. THIS IS A KNOWN SCHOOL POLICY AND HAS BEEN DISCUSSED WITH THE STUDENTS BY________________________________________.THERE WILL BE NO FURTHER WARNING. (coordinator and/or designee)

School District Rules: ALL School District and school rules and policies, including policies pertaining to possession/use of alcohol and illegal drugs, are in effect throughout the length of the trip. The coordinator and/or designee must report all violations and students will receive appropriate disciplinary action (e.g., suspension, etc.). Possible consequences of violation of School District rules is suspension or expulsion.

Behavior: Reasonable, positive, and responsible behavior is expected at all times. Participating in mutli-day field trips can be very fun and exciting but also comes with great personal responsibility. You are responsible for your own behavior at all times. You are expected to be on time to all scheduled events, meeting times and departures. You are also expected to be responsible for carrying your own luggage, as well as helping with loading and unloading. Be respectful to directors, chaperones, tour guides and all property you come in contact with. All property damage caused by any student during the trip will be the responsibility of the student’s parents/guardians.

I have read and agree to abide with all of the above requirements and expectations.

Student’s name (print clearly) Student’s Signature Date

Parent’s Signature Date

SanMarinoUnifiedSchoolDistrictAdministrationofMedicationForm

PartI:ORDERFORADMINISTRATIONOFMEDICATIONDURINGTHESCHOOLDAY/FIELDTRIPSInaccordancewithCaliforniaEducationCodesection49423,thisformmustbecompletedbyauthorizedCalifornia

healthcareproviderandbeonfileforanystudentwhorequiresmedication(s)duringtheregularschoolday.

Student:LastName FirstName MiddleInitial DOB:month/day/year

626299-7064

Grade SchoolName SchoolPhoneNumber SchoolFaxNumber

RobertJudge626299-7000x1385

DistrictNurse:NameandPhoneNumber

TOBECOMPLETEDBYANAUTHORIZEDCALIFORNIAHEALTHCAREPROVIDER:(Californialicensedphysicians,surgeons,dentists,optometrists,podiatrists,nursepractitioners,nursemidwives,

andphysicianassistants–CaliforniaCodeofRegulations,Title5,section601[a])

A.Natureofconditionrequiringmedicationduringtheregularschoolday:

NameofMedication

MethodofAdministration

Dosage Amount Timetobegiven Frequency

B.Discontinuemedicationon(date):

C.Studentisauthorizedtocarry,andisabletoself-administer,prescriptionforasthmaordiabetes

(authorizedlicensedhealthcareproviderinitials: ).

D.Studentisauthorizedtocarry,andisabletoself-administer,auto-injectableepinephrineindependently

(authorizedlicensedhealthcareproviderinitials: ).

626299-7000HuntingtonMiddleSchool

AuthorizedHealthcareProviderName(print) Signature Date

_

LicenseNumber PhoneNumber FaxNumber

SEENEXTPAGEFORADDITIONALREQUIRMENTS

ParentalAuthorizationIauthorizetheschoolnurseorotherlicensedhealthcareprovider(RN,LVN)designatedbytheresponsible

administrator,toadministerthemedicationasdirectedbytheauthorizedhealthcareprovider.Iunderstandthat

theschoolnursehasmypermissiontocommunicatewiththeprescribinglicensedhealthcareprovideronthe

mattersrelatedtothismedication.

Parent/GuardianName(print) Signature CellNumber Date

RobertJudge 9/18/17

ReviewedbySchoolNurse(print) Signature Date

PartII:ORDERFORDELEGATIONOFADMINISTRATIONOFMEDICATIONDURINGTHESCHOOLDAY/FIELDTRIP

WHENBEINGADMINISTEREDBYANUNLICENSEDVOLUNTEERSCHOOLEMPLOYEE:TheprescribingCaliforniaauthorizedlicensedhealthcareproviderisdelegatingtheadministrationofthemedicationorderedabovetothe

identifiedunlicensedvolunteerschoolemployeewhohasagreedtoadministerthemedication.Thelicensedhealthcareproviderdelegatingtoadesignated,trainedunlicensedvolunteerschoolemployeewillcompletethedelegationauthorizationsectionbelow.

Ivoluntarilyagreetoadministerthemedicationasdirectedbythedelegatingauthorizedhealthcareprovider.I

understandthatImaycommunicatewiththeauthorizeddelegatinghealthcareprovideronmattersrelatedtothe

medication.MysignaturebelowaffirmsthatIhavesuccessfullycompletedtrainingtoadministerthemedication.I

understandthatImayrevokemyagreementtoadministerthemedicationatanytime,foranyreason,andwillnot

bepenalizedbymyemployerforsuchrevocation.

AlanaFauré626429-29219/18/17

VolunteerSchoolEmployeeName Signature CellNumber Date

DelegatingHealthcareProviderName Signature Date

Iauthorizetheunlicensedvolunteerschoolemployeeidentifiedinthissectiontoadministerthemedicationas

directedbythedelegatinghealthcareprovideronmattersrelatedtothismedication.

Parent/GuardianName Signature CellNumber Date

RobertJudge

9/18/17

DistrictNurse Signature Date