NDW Camping Excursion Handbook

The Camp Mids Camping Excursion
is a true camping experience for youth living in the Naval District
Washington (NDW) region. Youth enjoy three days of recreational
activities such as swimming, biking, kayaking, crabbing and
teambuilding and two nights of tent camping.
If you have additional questions or need clarification, please contact
the Youth Activities Center at your installation. We welcome your
comments and suggestions and look forward to your participation in
the Camp Mids Camping Excursion!
INTERACTIVE CONTENT
This document features interactive content. That means with a simple click or tap,
you will be able to navigate to a specific page, view additional content, send
emails, visit websites and fill-in forms all to help you better prepare for your child’s
Camp Mids Camping Excursion. Some features may be limited on some devices.
TABLE OF CONTENT*
WELCOME..........................................................................1
THINGS TO DO................................................................2
CAMP INFORMATION..................................................4
WHAT TO BRING............................................................6
SAMPLE AGENDA..........................................................7
FORMS................................................................................9
Code of Conduct
Permission Statements
Registration Form
Health Information
Riverside Beach Boat Rental Form
INSTALLATION MAP...................................................20
CONTACT INFORMATION.......................................21
*Click the CYP logo at the top of any page to return to the
Table of Content.
THINGS TO DO
Arcade
The Adventure Zone features an air-conditioned TV lounge with an arcade,
billiard tables and a ping pong table.
Beach
The beach offers 400 feet of river shoreline, sandy beaches, a designated
swimming area and kayak and paddleboat rentals. The beach is patrolled
daily from 10 a.m. - 8 p.m. and swimming is permitted in the designated
swimming area only when lifeguards are on duty. Picnic tables and lounge
chairs are available at the beach for your use.
Boating
Some of the wonders of the Chesapeake Bay are best enjoyed on the water checking out the
amazing aquatic life. Campers at Salomon’s Island will enjoy scheduled time to Canoe, Paddle
Boat and Kayak.
Fishing and crabbing
Sunset Pier offers the perfect place for fishing and crabbing.
Golf
Putt-putt course and driving range.
Group Games
Camp is a great place to display your physical skills and strategic mindset.
Campers often say that the group games are among their favorite things
about the Camping experience.
Meals and snacks
Meals are served throughout the camping excursion at various locations on Solomons Island.
Breakfast on Thursday and Friday is continental style so the campers may eat as they wake up.
Wednesday’s lunch is a box lunch grab-and-go style since campers will arrive at various times and
will be eager to explore Solomons Island. Thursday’s lunch the campers will cook out on the grill
and Wednesday and Thursdays dinners are held at Club 9. S’mores around the fire bring the night
to a close.
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S’mores Around the Camp Fire
What would camp be without a campfire and S’mores. Campers gather in the
evening with their new friends around the camp fire for some fellowship and
a S’more fest! Don’t be surprise if someone brings up an idea to have a
sing along or evening group game or two.
Special Guest(s) / Activities
Each year camp administrators work to provide campers something
extra special. In the past we have been rewarded by having a guest
artist, professional group game leaders and a Marine lead teambuilding
obstacle course.
Swimming
The Riverside Aquatics complex includes two 25-meter pools (5-feet depth or
less) and a diving pool with a 1.5 meter dive board and two water powered
slides. Swimmers 16 years of age and under are required to pass a swim test
before they use the dive pool or slide. Upon completion of the swim test, the
swimmer will be required to wear a wristband. There is a weight restriction
on the slide. Lifeguards are on duty during operation. Flotation devices
such as noodles, swim rings, arm bands, etc. are prohibited in all pools.
There will be a 10-minute swim break every hour in weather 90 degrees
or hotter.
Campers may purchase snacks at the Riverside Refreshment stand, which offers a
variety of drinks, candy, chips, ice cream, hot dogs and popcorn.
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CAMP INFORMATION
Lost and found
Lost and found items will be collected at the end of camp and brought back to the Pax River Youth
Center. If your camper has lost an item please contact your local youth center for assistance. We
are not responsible for lost or stolen items. Due to sanitation, items not claimed within the following
week will be disposed of.
Illness
Parents will be notified if a camper is suspected of illness. Parents will be required to pick up their
camper from Navy Recreation Center Solomon’s within two hours. Parents are obligated to inform
the youth center of their camper’s exposure to a contagious illness. Refunds will not be given if a
camper has fallen ill and has been sent home.
Medications
Campers requiring any medications to be administered by camp personnel require proper
documentation. All documentation must be completed prior to attending camp. The Medication
itself must be in original box with prescription on it including over the counter medications such as
Benadryl. All action plans require a medical professional to sign the documentation please allow
yourself time to complete this process before attending camp. No child will be accepted without
the proper documentation for medications or without the proper medication needed for emergency
situations for the safety of that child.
Personal items
Personal items such as toys, IPods, gaming systems, cell phones and money are allowed but
at your discretion. We are not responsible for storing these items and cannot guarantee a safe
storage location. This is an outdoor camp where there are NO charging facilities.
Camp site
When campers first arrive they will set up camp. Camp sites are identified by gender and
separated by counselors tents and camp fire.
4
Camp Information (continued)
Lights out
Lights out at camp means everyone is by the fire by 1100. Youth can hang by the fire or in their
tents for the remainder of the night.
Showering facilities
Bath house are located near the camp site and are available for use. In addition to toiletries it is
also recommended that campers bring their own towel and flip flops for showering in.
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WHAT TO BRING: PACKING LIST
Check the box next to the items you have packed and ready to go!
Required equipment and supplies
This is an outdoor camping experience where campers should be prepared for all types of weather. It is suggested to wear
lightweight, comfortable clothing for daytime activities and to bring layers for evening activities or inclement weather.
Tent
Basic linens (sleeping bag, sheet, pillow, blanket, towel and wash cloth)
Water bottle
Flashlight
Sunscreen
Duffel bag or suitcase
Shoes – two pairs and at least one pair gym shoes
Shirts, pants and shorts
Medications
(Please talk with your Summer Camp Director for more information regarding the dispensing of medications.)
Suggested equipment and supplies
Folding chair
Swimsuit(s)
Beach towels
Tarp for underneath tent
Hat(s)
Underwear, socks and pajamas
Toiletries (in plastic containers)
Bug spray
Raincoat or poncho with hood
Sunglasses
Shower shoes Camera (bring at your own risk)
Sweater(s) and/or sweatshirt(s) Money (for Riverside Refreshment stand
Battery Operated Fan and boat/kayak rentals)
For more information or questions regarding the packing list please contact your installation’s Summer Camp Director.
6
SAMPLE AGENDA
Monday/Tuesday Campers will use the beginning of the week to prepare, rent/pick up
equipment and pack for the camping trip.
Wednesday
11 a.m. - 1 p.m. Arrive at camp and set up
1 - 2 p.m.
Lunch at Club 9 (boxed grab-and-go lunch)
2 - 4 p.m.
Get Your Bearings: Staff and campers explore recreation areas including
The Adventure Zone, pool, beaches, fish/crab pier, putt-putt golf, golf
driving range, etc. Feel free to stop and play.
4 - 5 p.m.
Welcome and overview: Night Games registration
5 - 5:30 p.m.
Camp site to get ready for dinner
5:30 - 6:30 p.m.
Dinner at Club 9 (spaghetti, salad, bread, beverage and ice cream sundaes)
6:30 - 7 p.m.
Camp site to get ready for an evening of games lead by 4-H staff
7 - 8 p.m.
Teambuilding: Getting to Know You icebreaker activity led by 4-H staff
8 - 9 p.m.
Night Games led by Youth staff (campers must have registered in the afternoon)
1. Snow dodgeball
2. Water balloon toss/whiffle ball
3. Kickball team games
4. Volleyball team games
9 - 10 p.m.
Camp site for s’mores and snacks around the campfire
11 p.m.
Quiet: All campers in tents
Thursday
7 - 9 a.m.
7:30 - 9 a.m.
9 - 10 a.m.
10 - 11 a.m.
11 a.m. - Noon
Wake up and prep for day at camp site
Breakfast at camp site (muffins, juice and fresh fruit)
Group 1: Boating
Group 2: Teambuilding
Group 3: Adventure Zone, putt-putt and golf driving range
Group 1: Adventure Zone, putt-putt and golf driving range
Group 2: Boating
Group 3: Teambuilding
All groups: Pool or beach
7
Sample Agenda (continued)
Noon - 1 p.m. 1 - 2 p.m.
2 - 4:30 p.m.
4:30 - 5:30 p.m.
5:30 - 6:30 p.m.
6 - 7 p.m.
7 - 7:30 p.m. 7:30 - 9 p.m.
9 - 10 p.m.
11 p.m.
Lunch at beach (hamburgers and hot dogs, chips and beverage)
Group 1: Team Building
Group 2: Adventure Zone, putt-putt and golf driving range
Group 3: Choice of team sport (basketball, soccer, flag football, etc.), beach, pool
or dock visit (boating will occur after dinner)
All groups: Pool or beach
Camp site to get ready for dinner
Dinner at Club 9 (chicken or beef taco bar, fruit and beverage)
Groups 1 and 2: Choice of team sport (basketball, soccer, flag football, etc.), beach,
pool or dock visit
Group 3: Boating
Camp site to get ready for an evening of games lead by 4-H staff
Night Games led by Youth staff (campers must have registered Wednesday afternoon)
Camp site for s’mores and snacks around the campfire
Quiet: All campers in tents
Friday
7 - 9 a.m.
9 - 11 a.m.
11 a.m. - Noon
Noon - 1 p.m.
2 - 4 p.m.
4 p.m.
Wake up and breakfast at camp site (muffins, juice and fresh fruit)
Clean up camp sites and check out
All groups: Pool or beach
Lunch at beach (hamburgers and hot dogs, chips and beverage)
Return home
Parents Pick Up
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9
NAVAL DISTRICT WASHINGTON
CHILD & YOUTH PROGRAM
CAMPING EXCURSION CODE OF CONDUCT
To ensure a successful and harmonious camping excursion we feel it necessary to state clearly our code of
conduct. I, the undersigned camper and parent/legal guardian have read the basic rules for participation at the
Naval District Washington Camp Mids Camping Excursion outlined below and agree to abide by the rules.
Campers will:
 Participate fully in the program.
 Be responsible for his/her own behavior and uphold standards for their peers.
 Follow all scheduled times, including quiet hours and wake-up.
 Will dress appropriately for a co-ed outdoor recreation experience.
Campers will not:
 Leave the camp premises without staff supervision and director permission.
 Disobey directives from camp staff or camp policies, rules and regulations.
 Be disrespectful or direct profanity, vulgar language, or obscene gestures towards other campers or
camp staff or wear offensively worded or graphic clothing.
 Play with matches, fire, or commit arson.
 Partake in the theft or the unauthorized removal of camp property, staff property or camper property.
 Fight, provoke fighting or commit physical abuse to others or themselves.
 Commit extortion, coercion or blackmail that force an individual to act through the use of force or threat
of force.
 Make derogatory statements that may substantially disrupt the camp program or insight violence.
 Engage in sexual harassment: any unwelcome sexual advance or conduct including lewd remarks,
touches, or request for sexual favors that have the effect of intimidating individuals or disrupting the
camp environment will not be tolerated.
 Sell, give, deliver, possess, use or be under the influence of drugs, alcohol or tobacco products. This
includes the misuse of prescription and over the counter medications.
 Haze other campers.
 Possess a weapon or dangerous instrument to be used as a weapon.
 Violate local, state or federal laws.
 Intentionally damage camp facilities including graffiti; you will be billed for damages.
 Hold the Naval District Washington Camp Mids Program staff responsible for the loss of money,
jewelry, or personal articles brought to camp.
CELL PHONES AND OTHER ELECTRONIC ITEMS ARE BRING AT YOUR OWN RISK! Please be
aware that Camp Staff will not be monitoring the use of this equipment; therefore, if a camper brings these
types of items parents/legal guardians should talk with their camper about appropriate usage. Please note that
cell phones and electronic items will be prohibited during certain activities and times throughout the camp day.
Failure to comply with these rules may result in but not be limited to a “time-out” from an activity, removal
from a program area, or expulsion from the camping. If expulsion occurs, parent/legal guardian will be notified
and expected to immediately come and pick up their camper from the Naval Recreation Center, Solomon’s
Island, Md. I understand that there are NO REFUNDS FOR EARLY DISMISSAL DUE TO
HOMESICKNESS, MISCONDUCT OR MEDICAL REASONS.
cont.
NAVAL DISTRICT WASHINGTON
CHILD & YOUTH PROGRAM
CAMPING EXCURSION CODE OF CONDUCT
CAMPING EXCURSION YOUTH REGISTRATION-AUGUST 8-12
Youth enjoy three days of recreational activities such as swimming, biking, kayaking, crabbing and teambuilding and two nights of
tent camping at the Navy Recreation Center Solomon’s located in Solomon’s Island, MD (Campers will use the beginning of the week
to prepare and pack for the camping trip with their local Youth Activities Center).
Name of Youth: ____________________________________________________________________________________
Birth Date: _________________________
Age:___________________
Grade: __________________
(2016/2017 School Year)
SELECT T-SHIRT SIZE
___YS (6-8) ___YM (8-10) ___YL (10-12) ___ YXL (12-14) ___ Adult S ___Adult M ___Adult L ___Adult XL ___Adult XXL
By signing, you recognize that I understand that I am committing to attend this camp and these rules of behavior
apply from the time I leave the installation youth program until I return from Naval Recreation Center,
Solomon’s Island, Maryland camp. This code of conduct serves as our permission form. By signing, I am
hereby giving permission for the named camper to attend the Naval District Washington Camp Mids and to
participate in all activities, subject to the authority of the camp staff.
Campers Name (please print):_____________________________________________
Campers Signature: __________________________________
Date: __________________
AND
Parent/ Legal Guardian’s Name (please print):_______________________________________
Parent/ Legal Guardian’s Signature: ________________________________
Clear Form
Date: __________________
Navy Child and Youth Programs Registration Form
Start Date (MM/DD/YY):
Child’s Name (Last, First, Middle):
Sex:
Birthdate (MM/DD/YY):
Name of Child’s School (if applicable):
Registering for:
CDC
CDH
24/7 Center
Child’s School Grade Level (if applicable):
SAC
YP
YSF
Sponsor’s Name (Last, First, Middle):
Type of Care:
Rank/Rate:
Home Address (include City and Zip Code):
Home Phone (include area code):
Lives on base
Branch:
Cell Phone (include area code):
Single Parent
Dual Military
FT Working Spouse/Partner
Spouse’s/Partner’s Name (Last, First, Middle):
Spouse’s/Partner’s Work Phone:
Full-Time
Part-Time
Part-Day Enrichment
Hourly Care
Status:
Lives off base
Duty Station/Place of Employment (include address, city, and zip code):
Family
Type:
Requiring Directive OPNAVINST 1700.9
Age:
ACT
RET
RES
Email Address:
Work Phone:
PT Working Spouse/Partner
Student Spouse/Partner
Unemployed Spouse/Partner
Spouse’s/Partner’s Cell Phone:
Before School
After School
Before & After School
Camp
CIV
CTR
COM CIV
PCS Date (if known)
(MM/DD/YY):
If Spouse/Partner is Military:
Branch:
Rank/Rate:
Spouse’s/Partner’s Place of Employment or School:
Spouse’s/Partner’s Email Address:
Child has sibling enrolled in another CY program:
Yes
No
If “yes,” child’s name and program (if more than one child is enrolled, list all children and their programs):
Emergency Notification Contacts (may also pick up the child in non-emergency situations)
(at least 2 local emergency contacts other than the child’s parent(s) or legal guardians required; provide as many phone numbers as possible)
Name
Relationship to Child
Cell Phone
Home Phone
Work Phone
Non-emergency Authorized Release/Pick Up Contacts
(will not be contacted for emergencies, but is authorized to pick the child up in non-emergency situations; provide as many phone numbers as possible)
Name
Relationship to Child
Cell Phone
Home Phone
Work Phone
Consent for Ambulance for Emergency Care
I hereby give my consent for an authorized Navy CYP Professional to call an ambulance for my child, __________________________, in case of a
medical or dental emergency. I understand that every effort will be made to contact me or my emergency contacts in the event of an emergency prior to
such action. Treatment may take place at any medical facility. Any expense incurred will be borne by me.
Name of Child’s Medical Insurance Co.:
______________________________
Policy/Grp. # (not needed for Active Duty):
____________________________
Name of Policy Holder:
__________________
Name of Child’s Physician
_____________________
Sponsor’s Consent for Ambulance for Emergency Care and Date: _______________
__________________________________________________
Sponsor’s Signature and Date
(Signature indicates the sponsor has provided true and accurate information to the
best of his/her knowledge)
____________________________________________
CYP Representative Signature and Date
(Signature indicates the CYP Professional has reviewed the registration form and verified
the family’s eligibility and priority type)
AUTHORITY: P.L. 101-89, Sec, 1507, “ Military Child Care Act of 1989”; Title 5 U.S.C. 301 Department Regulations; E.O. 9397; and OPNAVINST 1700.9 “ Child and Youth Programs.”
PURPOSE: To provide Child and Youth Programs (CYP) with authorization for medical treatment in emergency situations; identify children and sponsors; record required immunizations; and record known allergies and
special instructions.
ROUTINE USES: Information may be furnished to military or civilian doctors or hospitals in the course of obtaining medical attention for children. The SSN is necessary so that the Child and Youth Programs can
identify the individual and his/her records. Information furnished may be disclosed to any DoD component, and upon request, to other federal, state and local governmental agencies in the pursuit of their official duties
relating to proper child care. Finally, the information may be disclosed to law enforcement activities for the purpose of litigation.
VOLUNTARY DISCLOSURE: Furnishing the information is voluntary; however, failure to provide the requested information could result in denial of a child’s admission to the CYP.
CNICCYP 1700/04 (Rev 07-15)
For Official Use
Only –Form
Privacy Sensitive
Clear
Page 1 of 2
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Navy Child and Youth Programs Registration Form
Instructions for Completing the Navy Child and Youth Programs Registration Form
For all programs:
1.
A separate registration from shall be completed for each child being registered.
2.
The parent shall complete all the information about the family and/or child.
3.
For the “Status” blocks, check any category that apply to the status of sponsoring parent and/or military spouse, if applicable (ACT
- Active Duty, RET - Retired, RES - Reservist, CIV - DoD Civilian, CTR - DoD Contractor, COM CIV - Community Civilian).
4.
After completing the form, the parent(s) must sign and date all required signature blocks. This is the sponsor’s verification that all
information is correct and validates the agreement to allow transport for medical or other emergencies.
5.
If information becomes outdated during the year (before the next year’s annual registration), the family may cross out the incorrect
or outdated information and write in ink the new updated information. The parent(s) must initial and date any updated information
on the form.
6.
Annually, a new form shall be completed, signed, and dated.
7.
All “outdated” registration forms shall be kept on file for one additional year (e.g., the 2014 registration form must not be purged
until the end of 2015).
8.
A CYP Professional (e.g., Operations Clerk, Director, CDH Provider, etc.) shall sign and date in the CYP Professional signature
boxes as witness to the parent’s signature and date.
9.
The original Navy CYP Registration Form (CNICCYP 1700/15) shall be kept in the Emergency Registration Binder. This binder
shall be maintained in an easily accessible location and shall be taken outside with the day’s sign-in sheet during an evacuation drill
or in the event of an emergency.
10. A duplicate of each child’s Navy CYP Registration form, with local emergency contact names/numbers must be taken on each field
trip.
11. Medical insurance policy numbers are not required for parents who are active duty. Social security numbers are used to identify the
member for medical and insurance purposes and should not be collected.
For Child Development Homes (CDH)
1.
CDH Providers shall maintain the original Navy CYP Registration Form for each child in the home. Form shall be kept in an easily
accessible location for emergency contact or evacuation purposes.
2.
The CDH office shall maintain an alphabetized binder with a current copy of each child’s Navy CYP Registration Form for each
child enrolled in the CDH program. Forms shall be kept in an easily accessible location for emergency contact of evacuation
purposes.
CNICCYP 1700/04 (Rev 07-15)
For Official Use Only – Privacy Sensitive
Page 2 of 2
2
NAVY CHILD AND YOUTH PROGRAM
PERMISSION STATEMENTS 1700/43
Start Date (MM/DD/YY):
Requiring Directive OPNAVINST 1700.9
 Male  Female
Child’s Name (Last, First, Middle):
Birthdate (MM/DD/YY):
Age:
Sponsor’s Name (Last, First, Middle):
SPONSOR ACKNOWLEDGEMENTS, PERMISSIONS, AND RELEASES
Field Trip/Transportation Acknowledgement: I acknowledge that field trips are an important part of the CYP in that they enhance
my child’s experience with the CYP. CDC and CDH field trips may include walking in the immediate CYP and CD home surroundings
(infants may be transported in a buggy/stroller) or on the military installation. Some preschool trips may require bus or other vehicle
transportation, either in a CYP vehicle or a chartered vehicle or bus. YP field trips may include transportation via a CYP-operated or
chartered vehicle or bus to and from schools and field trip locations in the surrounding areas. The YP may also offer excursions
within walking distance of the CYP facility and military installation.
Sponsor’s Initials and Date of Acknowledgement:
Topical Non-Prescription Product Application Permission: I understand there might be occasions when my child may need a topical
non-prescription product—for his/her own health, safety, and comfort—such as diaper cream, sunscreen, insect repellent, etc. I
understand that I must provide these types of topical products and I grant permission for CYP Professionals to apply such products
to my child when needed to prevent diaper rash, sunburn, bug bites, etc. If I choose topically applied products with which the CYP is
not familiar, a Materials Safety Data Sheet will be required for each product.
Sponsor’s Permission and Date:
Sponsor Denied Permission and Date:
Media Release: I grant permission for my child to be included in the use of the following formats for the purpose of education and
publicity of the CYP community without further permission from me—photographs, video, and audio recordings used in the CYP
facility and media such as social media (e.g., Facebook, Twitter), military installation website, CNIC CYP website, etc. I have listed
below any exceptions to this release (e.g., “Pictures of my child may be posted in center, but may not be posted or published
anywhere outside of the center.” Or, “My child may have his picture taken, but I do not want him to be videotaped.”)
Exceptions (list any exceptions to the media release; if none, enter “None”):
Sponsor’s Release and Date:
Sponsor Denied Release and Date:
Acknowledgement of Receipt of the Navy CYP Parent Handbook: I have received and understand the policies contained in the Navy
CYP Parent Handbook.
Sponsor’s Initials and Date:
Acknowledgement of Revocation or Invocation of Any of the Above Permissions or Releases: I understand that I may revoke or
invoke any of the above permissions or releases in writing at any time. If I choose to revoke or invoke a permission or release, it is
my responsibility to provide written notification to the CYP requesting the revocation or invocation.
Sponsor’s Acknowledgement of Permission/Release Revocation or Invocation and Date:
Hold Harmless Release: I agree to release and hold harmless the United States, its officers, its agents, and its instrumentalities,
against any claims, demands, actions, debts, liabilities, judgments, costs, or attorney’s fees arising out of, claimed on account of, or
in any manner predicated upon his/her participation in any Navy MWR/CYP activity, use of facilities and/or equipment including any
loss or damage to property, any injury or death of any person, in any manner, caused or contributed to by the United States, its
officers, its agents, or its instrumentalities.
Sponsor’s Hold Harmless Release and Date:
AUTHORITY: P.L. 101-89, Sec, 1507, “Military Child Care Act of 1989”; Title 5 U.S.C. 301 Department Regulations; E.O. 9397; and OPNAVINST 1700.9 “Child and Youth Programs.”
PURPOSE: To provide Child and Youth Programs (CYP) with authorization for medical treatment in emergency situations; identify children and sponsors; record required immunizations; and record known allergies and
special instructions.
ROUTINE USES: Information may be furnished to military or civilian doctors or hospitals in the course of obtaining medical attention for children. The SSN is necessary so that the Child and Youth Programs can identify the
individual and his/her records. Information furnished may be disclosed to any DoD component, and upon request, to other federal, state and local governmental agencies in the pursuit of their official duties relating to
proper child care. Finally, the information may be disclosed to law enforcement activities for the purpose of litigation.
VOLUNTARY DISCLOSURE: Furnishing the information is voluntary; however, failure to provide the requested information could result in denial of a child’s admission to the CYP.
CNICCYP 1700/43 May 2015
FOR OFFICIAL USE ONLY – Privacy Sensitive
Clear Form
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NAVY CHILD AND YOUTH PROGRAM
PERMISSION STATEMENTS 1700/43
INSTRUCTION PAGE
For all programs:
1.
Separate permission statements shall be completed for each child being registered.
2.
The parent shall complete all the information about the family and/or child.
3.
The parent(s) must initial and date all permissions, releases, and acknowledgements. This is the sponsor’s confirmation that
he/she agrees with the statements.
4.
Annually, a new permission statement form shall be completed, initialed, and dated.
5.
All “outdated” permission statements shall be kept on file for one additional year (e.g., the 2014 form must not be purged until
the end of 2015).
6.
The original Navy CYP Permission Statements Form (CNICCYP 1700/15) shall be kept in the child’s administration file.
CNICCYP 1700/43 May 2015
FOR OFFICIAL USE ONLY – Privacy Sensitive
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NAVY CHILD AND YOUTH PROGRAM
HEALTH INFORMATION FORM 1700/52
Child’s Name (Last, First, Middle):
Sex:
Birthdate (MM/DD/YY):
Age:
Sponsor’s Name (Last, First, Middle):
SPONSOR ACKNOWLEDGEMENTS, PERMISSIONS, AND RELEASES
PART A: IDENTIFICATION OF CHILD/YOUTH MEDICAL AND/OR DIETARY NEEDS
(Some of these questions may require additional documentation. Please refer to the instructions on Page 2.)
1.
Does your child have any food allergies?  Yes  No If yes, please list these foods.
2.
Does your child suffer from other allergies or allergic reactions (e.g., seasonal hay fever, bee stings, hives, rashes, etc.)?  Yes  No
If yes, please list the allergies/allergic reactions.
3.
Is your child allergic to any medication(s)?  Yes  No If yes, please list the medication(s).
4.
If you answered “yes” to any of the above questions, please describe the reaction that your child experiences.
5.
Does your child take medication?  Yes  No If yes, please list the medication(s) and how often your child takes the
medication.
6.
Will your child need to take medication while in care at the CYP?  Yes  No If “yes,” please list the medication your child
will need to take while in care at the CYP.
7.
Does your child require in Epi-pen?  Yes  No If yes, please describe when your child might need an Epi-pen.
8.
Does your child have any food intolerances that require food substitutions (e.g., lactose intolerant)?  Yes  No
If “yes,” please describe:
9.
Does your child have asthma (Reactive Airway Disease)?  Yes  No
10. Does your child have any medical needs that require assistance while in care?  Yes  No
If “yes,” please check all that apply below.
 Blindness/visual problems
 Hearing problems
 Physical disability
 Diabetes
 Heart Problems
 Epilepsy
 Kidney problems
 Other chronic medical needs
(describe below in #11)
11. If you checked “other chronic medical needs” in #10 above, please briefly describe your child’s chronic medical needs.
12. Briefly describe any type of assistance your child will need while in care. If your child will not require any type of assistance
while in care, indicate “None.”
CNICCYP 1700/52 May 2015
FOR OFFICIAL USE ONLY – Privacy Sensitive
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NAVY CHILD AND YOUTH PROGRAM
HEALTH INFORMATION FORM 1700/52
PART B: OTHER NEEDS REQUIRING ASSISTANCE WHILE IN CARE
13. Check any of the following needs that your child may need assistance with while in care:
 Communication (e.g., speech/language delay)
 Behavior (e.g., oppositional defiant disorder)
 Learning and attention (e.g., attention-deficit hyperactivity disorder)
 Social/emotional (e.g., anxiety disorder)
 Developmental (e.g. autism spectrum disorder)
14. If you checked any boxes in #13, briefly describe the type of assistance your child will need while in care.
PART C: EARLY INTERVENTION AND SPECIAL EDUCATION
15. Is your child receiving services through an Individualized Family Service Plan (IFSP) or Individualized Education Plan (IEP)?
 Yes  No
PART D: EXCEPTIONAL FAMILY MEMBER PROGRAM (EFMP) ENROLLMENT
16. Is your child enrolled in the EFMP?  Yes  No
I acknowledge that all the above information is true and accurate. I understand that I must immediately report any changes in my
child’s health or other needs to the CYP so that the staff can keep my child safe and healthy and provide the best possible care.
Changes to my child’s health information may require additional medical documentation and meeting with the Navy CYP Inclusion
Action Team (IAT).
Sponsor’s Signature and Date (Signature indicates the sponsor has provided true and accurate information to the best of his/her knowledge)
CYP Professional’s Signature and Date (Signature indicates the CYP Professional has reviewed the information provided on this form and will alert the CYP Director
immediately to ensure any necessary accommodations are made for the child)
This form must be reviewed by the parent(s) each year during the annual registration process. If there are no changes to be made,
the parent(s) may simply initial and date the form. If there are changes to be made, a new form must be completed.
Sponsor’s Initials and Date:
Sponsor’s Initials and Date:
Sponsor’s Initials and Date:
Sponsor’s Initials and Date:
________
__________
_________
_________
AUTHORITY: P.L. 101-89, Sec, 1507, “Military Child Care Act of 1989”; Title 5 U.S.C. 301 Department Regulations; E.O. 9397; and OPNAVINST 1700.9 “Child and Youth Programs.”
PURPOSE: To provide Child and Youth Programs (CYP) with information about your child's overall health and needs that may affect his/her care at the CYP.
ROUTINE USES: Information may be furnished to military or civilian doctors or hospitals in the course of obtaining medical attention for children. The information may also be shared with members of the command
Inclusion Action Team (IAT) for the purpose of identifying any accommodations your child may need.
VOLUNTARY DISCLOSURE: Furnishing the information is voluntary; however, failure to provide the requested information could result in denial of a child’s admission to the CYP.
CNICCYP 1700/52 May 2015
FOR OFFICIAL USE ONLY – Privacy Sensitive
Clear Form
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NAVY CHILD AND YOUTH PROGRAM
HEALTH INFORMATION FORM 1700/52
INSTRUCTION PAGE
1.
Answer “yes” if your child has any food allergies. Please list any food allergies (see definitions at the bottom of the page) which require food
substitutions. An Identified Needs Intake package containing a CYP Emergency Action Plan (EAP), (or a current EAP from your child’s physician
may be used), and a CYP Medical Statement to Request Special Meals and/or Food Substitutions form completed by the child’s physician is also
required.
2.
Answer “yes” if your child has any other allergies or allergic reactions, then list the allergies/allergic reactions. An Identified Needs Intake package
containing a CYP Emergency Action Plan (EAP), (or a current EAP from your child’s physician may be used) will be required (completed and signed
by your child’s physician).
3.
Answer “yes” if your child is allergic to any medication(s), then list the medications. An Identified Needs Intake package containing a CYP
Emergency Action Plan (EAP) (or a current EAP from your child’s physician may be used) will be required (completed and signed by your child’s
physician).
4.
If you answered “yes” to Questions 1, 2, or 3, please describe the allergic reactions your child may have if exposed to the allergen.
5.
If your child takes any medications, list the medications your child takes and how often he/she takes the medication(s).
6.
If your child will require medication while in care at the CYP, answer “yes,” then list the medication. If you answer “yes, “an Identified Needs
Intake package containing a CYP Emergency Action Plan (EAP), (or a current EAP from your child’s physician may be used) and a Medication
Administration Form completed by the child’s physician is required.
7.
Answer “yes” if your child needs an Epi-pen, and if CYP staff will need to use it for the child. Describe the type of situation when an Epi-pen might
be needed. If you answer “yes, “an Identified Needs Intake package containing a CYP Emergency Action Plan (EAP), (or a current EAP from your
child’s physician may be used), and a Medication Administration Form completed by the child’s physician is required.
8.
Answer “yes” if your child has any food intolerances (see definitions at the bottom of the page) that require food substitutions. If “yes” is entered,
provide a short description of the child’s food intolerance (e.g., lactose intolerant, gluten intolerant). If you answer “yes,” your child’s physician
must complete a CYP Medical Statement to Request Special Meals and/or Food Substitutions Form before any food substitutions can be made
for your child.
9.
If your child has asthma (reactive airway disease), answer “yes.” If the answer is “yes,” an Identified Needs Intake package containing a CYP
Emergency Action Plan (EAP) (or a current EAP from your child’s physician may be used) and a Medication Administration Form completed by the
child’s physician is required.
10. If your child has medical needs that require assistance while in care, answer “yes.” If the answer is “yes,” check all of the boxes that apply. If you
answer “yes” to this question, an Identified Needs Intake package containing a CYP Emergency Action Plan (EAP) (or a current EAP from your
child’s physician may be used) and a Medication Administration Form (if your child will need medication while in care) completed by the child’s
physician is required.
11. If “Other chronic medical needs” is checked in Question #10, provide a brief description.
12. Provide a short description of any type of assistance your child will need.
13. Check any of the boxes applicable for any other types of assistance your child may need while in care.
14. Provide a brief explanation of any support your child will need while in care to address the areas answered in Question #13 (or indicate “None”).
15. Answer “yes” if your child is receiving services through an IFSP or IEP. If the answer is “yes,” you should provide a copy of your child’s IFSP/IEP so
that we can best support his/her needs.
16. Answer “yes” if your child is enrolled in the EFMP. If the answer is “yes,” you may wish to provide the EFMP Enrollment Letter for your child’s file.
Definitions:
Food Allergy—When a child has a food allergy, his/her body responds to food as if it were a threat. The body’s immune system response can be
mild or, in rare cases, associated with a severe and life-threatening reaction called anaphylaxis. Allergic reactions are highly unpredictable. The
severity of one attack does not predict the severity of the next attack. The only way to prevent a life-threatening reaction is strict avoidance of the
allergen.
Food Intolerance—When a child has a food intolerance, it is a reaction of the digestive system and is not dangerous. Although a child may
experience gas, bloating, abdominal pain and/or diarrhea, the reactions will pass and the child is not in danger. Children with food intolerances
likely do not have prescribed medications for their condition and do not need an EAP. Some common food intolerances are lactose and gluten.
CNICCYP 1700/52 May 2015
FOR OFFICIAL USE ONLY – Privacy Sensitive
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Morale, Welfare and Recreation Department
NAVY RECREATION CENTER SOLOMONS
RIVERSIDE BEACH BOAT RENTAL FORM
Date:______________________
Please Circle:
ACTIVE DUTY
Time:_________________________
RETIRED
RESEVERSIT
DOD
DEPENDENT
Sponsor’s Name:_________________________________________________________
Boat Users Name:_________________________________________________________
Mailing Address:___________________________________________________________
City:______________________
State:______________
Home Phone:_________________
Zip:__________
Work Phone: _______________________
Duty Station:_____________________________
Date of Stay:_____________________________
Lodging Site:__________________________
Please Circle: PADDLE BOAT
LIFEJACKET
Rental Duration:
KAYAK
½ Hour
1 Hour
Full Day
I hereby certify that I will not hold the U.S. Navy, U.S. Government or the MWR Department Fund responsible in the event
of accident or injury. I understand and assume full responsibility for the well being and safety of myself (or) my child
while I (or) he/she engage in this activity I understand that I am responsible for all equipment that I have rented. I
understand and assume full responsibility for the well being and safety of myself and guests while engaged in this activity.
I understand that I am to stay within the perimeters that have been shown to me by the Aquatic Team. I understand that
a personal flotation device (PFD) is to be worn at all times while on the watercraft.
I understand that there are no refunds for any unused time. I agree not to loan, rent or lease this equipment to any other
person and that only rented equipment will be accepted for return. I also agree to return all equipment in the same
condition as I received it and understand and agree that there will be a charge assessed to me to repair any equipment
returned damaged. I agree to reimburse the Navy Recreation Center Solomons for any lost, damaged or destroyed
equipment under this agreement.
Signature: _______________________________________ Date:_____________________
Clear Form
NRC SOLOMONS INSTALLATION MAP
20
Navy Recreation Center Administrative Office
(410) 326-6836
Navy Recreation Center Solomons
P.O. Box 147
13855 Solomons Island Road
Solomons, MD 20688
Joint Base Anacostia-Bolling
Bldg. 4485 • (202) 767-4003
NSF Indian Head
Bldg. 441 • (301) 743-5456
NSF Dahlgren
Bldg. 470 • (540) 653-8009
NSA Annapolis
Bldg. 354 • (410) 293-9396
NAS Patuxent River
Bldg. 1597 • (301) 342-1694