& CLUB

Join in on the fun! Register online today! www.bloomfield.org/recreation

Two easy steps! 1. Submit payment online. Please make sure you receive a confirmation number when registering online. If you do not receive a confirmation number, you are NOT registered. 2. Return completed forms to athletics, recreation, and community services. Email: recreation@ bloomfield.org Fax: 248-341-6449. ID cards will be mailed to those who turn in emergency contact and liability forms prior to December 10, 2017. Cards must be picked up from the recreation office. Orientation meeting for families, skiers & snowboarders on Wednesday, December 6, 2017, 7:00 pm at Bloomfield Hills Middle School.

WELCOME TO THE BLOOMFIELD HILLS Orientation Meeting SCHOOLS SKI & SNOWBOARD CLUB! For families, skiers & snowboarders Wednesday, December 6, 2017, 7:00 pm Dear Skiers/Snowboarders: Bloomfield Hills Middle School

We are pleased that you have selected the Bloomfield Hills Athletics, Recreation and Community Services ski/snowboard program. More than 500 people ski/snowboard with us each year. We provide a staff of experienced SKILL PATCH SYSTEM skiers to assist you and we work closely with the instructors at Mt. Holly & Pine Knob to ensure that each trip is enjoyable. All Ski & Snowboard Club members will carry their ID card and have the proper patch sewn on the outside of their jackets. Wear your ability level patch on Our Ski & Snowboard Club program is designed to: your upper left arm. Your patch and ID punch must match. The patch indicates the level of / ability. Patches are earned in lessons taken at the ski area when they demonstrate specific skiing/snowboarding skills. * Teach as many people as possible to ski/snowboard. Club members are restricted to skiing/snowboarding only on the proper slopes * Develop in each person an appreciation of and the enjoyment of skiing/ for their ability level. snowboarding. * Develop skills for maximum enjoyment and reasonable safety. Lost blue, red, white, and black patches will be replaced only after regrading * Provide information on the importance of safety rules and procedures at the member’s expense. Skiers/Snowboarders who do not have a matching around the slopes. patch and ID punch will not be sold at a discount lift ticket.

We look forward to having you with us for this season of skiing/snowboarding. Please call our office at 248-433-0885 if you have any questions not answered MT. HOLLY PATCH SYSTEM in this handbook. Join our traditional program for ages 10-18 which includes supervised bus Mike Cowdrey transportation, two lessons, reduced lift prices, and ski area assistance. Director, Athletics, Recreation & Community Services No Patch Beginner Rope tows & Beginner Slopes Yellow Intermediate All Ropes & Grant’s Run SKI & SNOWBOARD CLUB RULES Brown Advanced Intermediate All Ropes, Woodward & Snowstream Blue Advanced All Lifts EXCEPT White Lightning, 1. Ride only the bus you are assigned to and from ski area. You may not Canyon & Thunderbolt return home by other means without parental permission in advance Red Expert All Lifts EXCEPT Thunderbolt of the trip. Do not leave the area with advising your bus leader and White Advanced Expert All Lifts signing out. Black Superior All Lifts 2. Your ID card must be carried during every Ski & Snowboard Club trip. A separate patch system will be used for snowboarders. 3. Your ski/snowboard school ability level patch must be worn on your left arm. Your ability patch must match your ID card.

4. Observe school rules & display courteous conduct to all members of the LESSONS

club. The ski area operates a Ski School. Two prepaid lesson tickets are given to 5. No smoking, alcoholic beverages or other drugs are permitted. members as requested on the way to the ski area. Lesson announcements are 6. Ski/snowboard only on the slopes for which you have been made by the Ski School. Each member is responsible for the appropriate skill tested/qualified. lesson; supervisors and aides will assist. Tests and grading for skill 7. Ski/Snowboard under control at all times. improvement must be taken during a lesson. Mt. Holly and Pine Knob Ski 8. Do not take cuts in the tow or lift lines. Schools will distribute ability level patches and punch your ID card. Failure to 9. Return to the bus on time: listen for departure announcements at 8:30 wear the correct patch could result in suspension from the Club. Lessons start p.m. (Friday) and 2:45 p.m. (Saturday/Sunday) and keep track of the on the hour at the Ski School sign in front of the lodge. time. 10. You must be picked up within 15 minutes of your return to school. ABILITY GRADING Parents: a charge of $5 per quarter hour (after 9:45 p.m. on Fri or 4:15 All skiers and snowboarders will be tested by ski and snowboard school p.m. on Sat & Sun) will be assessed for late pick up. personnel and graded according to their ability. This will be done in a lesson 11. If you miss a Ski & Snowboard Club trip, there is no makeup, additional at the appropriate level during the first trip. After passing an ability level, pick trip or refund. Memberships are not transferable and no substitutions up your patch and have your ID punched at the Ski School. To ensure our are permitted. member’s safety, failure to have a matching patch and ID punch may result in retesting to purchase a lift ticket. VIOLATIONS OF SKI/SNOWBOARD CLUB RULES If you bring last year’s ID card along with last year’s ability patch to the Ski MAY RESULT IN THE FOLLOWING: School desk, retesting will not be necessary. A patch alone, however, is not sufficient. 1. Surrender of your Ski & Snowboard Club card at the time of the incident. REGISTRATION 2. A verbal warning or detention in the lodge. Online Registration begins on Saturday, October 14, 2017, at midnight. 3. A request for conference with the bus supervisor upon return to the Liability and Emergency forms must be completed and returned prior to school or at a later date. January 4, 2018. Membership in the Bloomfield Hills Ski & Snowboard club is 4. Suspension from the Ski & Snowboard Club for one or more trips open to all. Registration deadline is Sunday, December 3, 2017. After the without monetary refund. Parents will be notified. deadline, late registrations are possible, space permitting, with a $50 late fee. 5. Exclusion from Ski & Snowboard Club for the rest of the season without This normally is not a problem until the week of the trip. Superstars is limited monetary refund. Parents will be notified. to 60 people.

CANCELLATION When snow/weather conditions interfere with a regularly scheduled trip, the Club Coordinator will announce a cancellation as soon as possible. Such EMERGENCY INFORMATION & PROCEDURES cancellations are rescheduled at a later date, if possible. To determine if a ski trip has been cancelled, visit our webpage at www.bloomfield.org/recreation TO CONTACT A CHILD AT THE SKI AREA or call our office at 248-433-0885 after 7 a.m. morning of the trip, press 3 for Call the Mt. Holly ski area at 248-634-8269 or Pine Knob at 248-625-0800 and cancellations/announcements. We do not cancel for cold temps until the wind page the child or club supervisor. chill reaches -20 degrees or lower. If weather conditions prevent the completion of 6 trips, we are unable to refund payment. Dates missed due to TO PICK UP A CHILD AT THE SKI AREA weather will be scheduled the next available weekend. There will be no Page his/her supervisor or an alternate supervisor and notify him/her of the refunds for rescheduled dates, regardless of previous commitments and circumstances. Do not remove your child without notifying an adult ski & appointments. No exceptions! Snowboard Club sponsor. You will also be asked to complete a Student Release form.

SKI CLUB PROGRAMS IF A PARENT WILL NOT BE HOME WHILE CHILD IS SKIING Please give his/her supervisor the phone number where a parent can be Bloomfield Hills Athletics, Recreation & Community Services offers programs reached. for every level of ability. Select the one that is right for you and Register early online at www.bloomfield.org/recreation. IN CASE OF ACCIDENT OR INJURY

The Ski Patrol will administer first aid in the presence of a club sponsor. The SUPERSTARS bus supervisor will notify the parents by phone and together they will Children 5-9 will enjoy this Saturday or Sunday morning instructional program. determine if the parents should drive to the ski area and pick up the child. Transportation, professional instruction and supervision is included. Children will be grouped by skill level. Hot chocolate and a snack provided. Please do FOR FOLLOW UP INFORMATION ON ACCIDENTS & INJURIES not send a lunch. We cannot purchase food for the children. Please supply Please call the club coordinator or the Athletics, Recreation and Community child’s height, weight and show size to rent ski equipment. Register early: Services office at 248-433-0885. enrollment is limited to 60 members on Saturday and 30 members on Sunday.

Saturday program for ages 5-7 and Sunday program for ages 5-9. DIRECTIONS TO SKI AREAS:

Mt. Holly: Drive north on I-75 to the Dixie Highway exit. Exit and drive north NOVICE SKIERS (right) on Dixie Highway approximately 10 miles. The ski area is on the left High school age counselors will supervise this learn-to-ski activity for 8 & 9 side of the road. The Ski Patrol house is in the A-frame building to the right of year olds. Instruction will be provided by professional ski instructors and skiing the lodge. will be in small groups. Time will be allotted for free skiing. Fee includes transportation, supervision and six lessons. Pine Knob: Drive north on I-75 to Sashabaw Road exit. When you exit, turn

right and enter off Sashabaw Road. NOVICE SNOWBOARDERS

High school age counselors will supervise this learn-to-snowboard activity for 8 and 9 year olds. Instruction will be provided by professional snowboard instructors and snowboarding will be in small groups. Time will be allotted for free snowboarding. Fee includes transportation, supervision and six lessons. IMPORTANT REMINDERS

SUPERVISED SKIING RETURN ANNOUNCEMENTS Experienced skiers ages 8-9 who can use the lifts will be supervised by high Announcements at the ski area will be made over all public address systems. school age counselors. Professional instructors will provide lessons for all However, be aware of the time as the 3:00 p.m. or 8:45 p.m. departure time ability levels above yellow. Time will be allotted for free skiing. Fee includes approaches. Skiers/Snowboarders are responsible for knowing the departure transportation, supervision and six lessons. time and should keep track of time so they do not miss the bus. Those with rental equipment should allow adequate time to return the equipment. LEARN TO SKI Beginner level instruction for age 10 and above and will be combined with LOST ID CARDS AND/OR PATCHES progressively reduced supervision. Fee includes transportation, supervision Ski & Snowboard Club members who lose their ID card must come to the and six lessons. Athletics, Recreation & Community Services office to have it replaced before the next trip. There is a $5 charge. SKI CLUB Join our traditional program for ages 10-18 which includes supervised bus Skill or ability patches may be replaced by purchasing an additional one from transportation, two lessons, reduced lift process and ski area assistance. the Ski School, but retesting will be necessary for blue, red, white and black patches. Ability level patches are awarded by the Ski School. SNOWBOARD CLUB For students 10-18 years of age! This club combines supervised bus PROTECTION OF SKI/SNOWBOARD EQUIPMENT transportation, two lessons, reduced lift prices and ski area assistance. All skiers and snowboarders should protect their equipment from theft while Snowboarding is now permitted on all slopes. will not be skiing/ snowboarding. Lock it securely or use the free ski/snowboard corral allowed in any other club. when leaving equipment outside the lodge.

HILL MASTERS SKI TEAM PROTECTION FROM COLD WEATHER This team is for 10-14 year olds who want to improve their skiing and gain All skiers/snowboarders should have and use face masks, goggles and glove racing experience in anticipation of high school ski racing. The team will be liners during extreme weather conditions. led through a two-hour training exercise each week. This year’s team will compete against other ski teams. LOST & FOUND If you lose ski/snowboard clothing or equipment, check with your Ski & SKI/SNOWBOARD CLUB FOR DEAF & HARD OF HEARING Snowboard Club supervisor. Next, call Athletics, Recreation & Community Interpreters and signing volunteers will be available to assist the participants, Services at 248-433-0885, followed by the bus company and the ski area. ages 10-14. Two ski/snowboard lessons are included. Must follow the Pine Knob Patch program.

TRIP INFORMATION

Trips begin January 12th, 13th and 14th & End on February 16th, 17th & 18th Make ups for cancelled trips will be scheduled based on available dates and slope conditions.

CLUB AGES DAY TIME DEPART SITE BUS SKI HILL COST COURSE # Superstars 5-7 Sat 9:00 AM – 1:00 PM BHHS Bus #1 Pine Knob $390 7132-18A01 Superstars 5-7 Sat 9:00 AM – 1:00 PM BHHS Bus #2 Pine Knob $390 7132-18A02 Superstars 5-9 Sun 8:30 AM – 12:30 PM BHHS Bus 1 Pine Knob $390 7132-18A03 Novice Ski 8-9 Sat 8:30 AM – 4:00 PM BHHS Bus #1 Pine Knob $390 7133-18A01 Novice Snowboard 8-9 Sat 8:30 AM – 4:00 PM BHHS Bus #1 Pine Knob $390 7134-18A01 Supervised Ski 8-9 Sat 8:30 AM – 4:00 PM BHHS Bus #1 Mt. Holly $330 7135-18A01 Supervised Ski 8-9 Sat 8:30 AM – 4:00 PM BHHS Bus #2 Mt. Holly $330 7135-18A02 Learn to Ski 10-18 Sat 8:30 AM – 4:00 PM BHHS Bus #1 Pine Knob $330 7136-18A01 Ski 10-18 Fri 4:30 PM – 9:30 PM IA ** Bus #1 Mt. Holly $225 7130-18A01 Ski 10-18 Fri 4:30 PM – 9:30 PM BHHS Bus #1 Mt. Holly $225 7130-18A02 Ski 10-18 Sat 8:30 AM – 4:00 PM BHHS Bus #1 Mt. Holly $255 7130-18A03 Ski 10-18 Sat 8:30 AM – 4:00 PM BHHS Bus #2 Mt. Holly $255 7130-18A04 Ski 10-18 Sun 8:30 AM – 4:00 PM BHHS Bus #1 Pine Knob $255 7130-18A05 Snowboard 10-18 Fri 4:30 PM – 9:30 PM IA ** Bus #1 Mt. Holly $245 7131-18A01 Snowboard 10-18 Fri 4:30 PM – 9:30 PM BHHS Bus #1 Mt. Holly $245 7131-18A02 Snowboard 10-18 Sat 8:30 AM – 4:00 PM BHHS Bus #1 Mt. Holly $270 7131-18A03 Snowboard 10-18 Sat 8:30 AM – 400 PM BHHS Bus #2 Mt. Holly $270 7131-18A04 Snowboard 10-18 Sun 4:30 PM – 9:30 PM BHHS Bus #1 Pine Knob $270 7131-18A05 Hill Masters Ski Team 10-14 Sat 8:30 AM – 4:00 PM BHHS Bus #1 Mt. Holly $390 7137-18A01 Deaf & Hard of Hearing Ski 10-14 Sat 8:30 AM – 4:00 PM BHHS Bus #1 Mt. Holly $310 7130DHH-18A01 Deaf & Hard of Hearing 10-14 Sat 8:30 AM – 4:00 PM BHHS Bus #1 Mt. Holly $325 7130DHH-18A02 Snowboard * INTERNATIONAL ACADEMY DEPARTURE SITE FOR IA STUDENTS ONLY. ** NON RESIDENTS: ADD $5 PER PERSON

TRANSPORTATION

It is very important that friends who wish to ride on the same bus register online at the same time. ADDITIONAL FEES PER TRIP Buses are chartered by Athletics, Recreation, and Community Services. Skiers Fees for 2018 (Prices set by Mt. Holly & Pine Knob and are subject to change.) and snowboarders must ride their assigned bus to and from the ski area.

Exceptions must be made in advance by parents with the supervisor. Service: Friday Saturday/Sunday

Youth Lift Ticket $19 $21 A Ski & Snowboard Club supervisor is assigned to each bus. They check each member on the bus by looking at the Ski & Snowboard Club ID card. They sell Youth Equipment Rental $19 $21 lift tickets and equipment rental tickets, distribute lesson tickets, and maintain Snowboard Rental $19 $21 order. Parents of elementary age skiers/snowboarders must be sure that their Ski School Lesson $9 children have their ID card for each trip. Snowboard Lesson $9 Helmets $9

REFUND POLICY Please have a check for the exact amount for each trip. Make checks payable to Mt. Holly or Pine Knob for rental and lift ticket. Make checks payable to A full refund will be given less $7 service fee if you withdraw from the club by BHS for lessons. 4:00 p.m. on December 15, 2017. Additional money for food, snacks, and extra lessons should be provided for NO REFUNDS AFTER DECEMBER 15 each trip.

Club fees will not be prorated for appointments or previous commitments

Ski & Snowboard Club

Liability Form

Athletics, Recreation & Community Services

CompleteComplete and Return the LiabilityLiability FormForm and and Emergency Emergency Information Information Record Record By by January January 5, 5 , 201 8

EMAIL: Recreation@bloomfield.org FAX: 248-341-6449

Student Name OFFICE USE ONLY Y N

Primary Phone # Email Address

th th / th th Program Selection (Check One) Trips Begin January 12th, th13 th& 14 th Trips End February 16thth, 1th7 & 18 (Check One) Trips Begin January 9 , 10 & 11 Trips End February 13 , 14 & Club Ages Day Time Departure Site Bus Ski Hill Cost Course # Club Ages Day Time Departure Site Bus Ski Hill Cost Course o Super Stars 5–7 Sat 9:00 AM–1:00 PM BHHS Bus #1 Pine Knob $390 7132-18A01 Super Stars 5–7 Sat 9:00 AM–1:00 PM BHHS Bus #1 Pine Knob $350 o Super Stars 5–7 Sat 9:00 AM–1:00 PM BHHS Bus #2 Pine Knob $390 7132-18A02 Super Stars 5–7 Sat 9:00 AM–1:00 PM BHHS Bus #2 Pine Knob $350 o Super Stars 5–9 Sun 8:30 AM– 12:30 PM BHHS Bus #1 Pine Knob $390 7132-18A03 Super Stars 5–9 Sun 8:30 AM–12:30 PM BHHS Bus #1 Pine Knob $350 o Novice Ski 8–9 Sat 8:30 AM–4:00 PM BHHS Bus #1 Pine Knob $390 7133-18A01 Novice Ski 8–9 Sat 8:30 AM–4:00 PM BHHS Bus #1 Pine Knob $290 o Novice Snowboard 8–9 Sat 8:30 AM–4:00 PM BHHS Bus #1 Pine Knob $360 7134-18A01 Novice Snowboard 8–9 Sat 8:30 AM–4:00 PM BHHS Bus #1 Pine Knob $350 8–9 Sat 8:30 AM–4:00 PM BHHS Bus #1 Mt. Holly $330 7135-18A01 o SupervisedSupervised Ski Ski 8–9 Sat 8:30 AM–4:00 PM BHHS Bus #1 Mt. Holly $290 o SupervisedSupervised Ski Ski 8–9 Sat Sat 8:308:30 AM AM––4:004:00 PMPM BHHSBHHS BusBus #2 Mt.Mt. Holly Holly $290$330 7135-18A02 o Learn to Ski 10–18 Sat 8:30 AM–4:00 PM BHHS Bus #1 Pine Knob $330 7136-18A01 Learn to Ski 10–18 Sat 8:30 AM–4:00 PM BHHS Bus #1 Pine Knob $290 o SkiSki 1010–18 FriFri 4:304:30 PMPM––9:309:30 PM IA*IA* BusBus #1 Mt.Mt. Holly Holly $195$2 2 5 7130-18A01 o SkiSki 1010–18 FriFri 4:304:30 PMPM––9:309:30 PM BHHSBHHS BusBus #1 Mt.Mt. Holly Holly $195$2 2 5 7130-18A02 o SkiSki 1010––1818 Sat Sat 8:30 8:30 AM AM––4:004:00 PMPM BHHS BHHS Bus Bus #1 #1 Mt. Holly $222$25 5 7130-18A03 o SkiSki 1010––1818 Sat Sat 8:30 8:30 AM AM––4:004:00 PMPM BHHS BHHS Bus Bus #2 #2 Mt. Holly $222$25 5 7130-18A04

o SkiSki 1010––1818 Sun Sun 8:30 8:30 AM AM––4:004:00 PMPM BHHS BHHS Bus Bus #1 #1 PinePine Knob $222$25 5 7130-18A05 o SnowboardSnowboard 1010––1818 Fri Fri 4:30 4:30 PM PM––9:309:30 PMPM IA* IA* Bus Bus #1 #1 Mt. Holly $215$24 5 7131-18A01 o SnowboardSnowboard 1010––1818 Fri Fri 4:30 4:30 PM PM––9:309:30 PMPM BHHS BHHS Bus Bus #1 #1 Mt. Holly $215$24 5 7131-18A02 o SnowboardSnowboard 1010––1818 Sat Sat 8:30 8:30 AM AM––4:004:00 PMPM BHHS BHHS Bus Bus #1 #1 Mt. Holly $232$270 7131-18A03

o SnowboardSnowboard 1010––1818 Sat Sat 8:30 8:30 AM AM––4:004:00 PMPM BHHS BHHS Bus Bus #2 #2 Mt. Holly $232$270 7131-18A04 o SnowboardSnowboard 1010––1818 Sun Sun 8:30 8:30 AM AM––4:004:00 PMPM BHHS BHHS Bus Bus #1 #1 Pine Knob $232$270 7131-18A05 o HillsHills Masters Masters Ski Ski Team Team 1010––14 Sat Sat 8:30 8:30 AM AM––4:004:00 PM BHHSBHHS BusBus #1 Mt.Mt. Holly Holly $346$390 7137-18A01 Deaf & Hard of Hearing Ski 10–14 Sat 8:30 AM–4:00 PM BHHS Bus #1 Mt. Holly $275 o Deaf & Hard of Hearing Ski 10–14 Sat 8:30 AM–4:00 PM BHHS Bus #1 Mt. Holly $310 7130DHH-18A01 Deaf & Hard of Hearing Snowboard 10–14 Sat 8:30 AM–4:00 PM BHHS Bus #1 Mt. Holly $285 o Deaf & Hard of Hearing Snowboard 10–14 Sat 8:30 AM–4:00 PM BHHS Bus #1 Mt. Holly $325 7130DHH-18A02 ACADEMY DEPARTURE SITE FOR IA STUDENTS ONLY. NON RESIDENTS: ADD $5 PER *INTERNATIONAL ACADEMY DEPARTURE SITE FOR IA STUDENTS ONLY NON RESIDENTS: ADD $5 PER PERSON

PAYMENT INFORMATION (Check One)

o PAID ONLINE CONFIRMATION #: o AM EX o VISA o MASTERCARD o DISCOVER

o CASH AmEx/Visa/MC/Discover # Exp Date Security Code • CHECK #: Make checks payable to Bloomfield Hills Schools Date Name on Card (PRINT)

LIABILITY WAIVER II acknowledgeacknowledge thatthat thethe BloomfieldBloomfield Hills Hills Board Board of of Education Education and and Athletics, Athletics, Recreation, Recreation, and and Community Community Services Services cannot cannot assume assume liability liability for forinjuries injuries en routeroute to and from thethe skiski areaarea oror duringduring the the ski/snowboard ski/snowboard activity activit ,y and and thereby, thereb , ygive, give my my permission permission for for my my child child to participateto participate in the in theBloomfield Bloomfield Hills Hills Ski& Snowboard & Snowboard Club Club trips tripsto Mt. to HollyMt. Holly or Pine or Pine Knob. o I have read thethe SkiSki && SnowboardSnowboard Club Club 2014 2017-2015-201 8 Handbook o I understand thethe REFUNDREFUND POLICYPOLICY for for the the Ski Ski & & Snowboard Snowboard Club A full refund will be given less a $7 service fee is you withdraw from the club no later than December 12th. No refund after December A full refund will be given less a $7 service fee if you withdraw from the club no later than December 15th. No refund after December 15th.

o I agree toto pay a chargecharge ofof $5$5 per per quarter quarter hour hour if if my my child child is is picked picked up up late. Fees will begin toto incurincur afterafter 9:45 9:45 p.m. p.m. on on Friday Friday and and 4:15 4:15 p.m. p.m. on on Saturday Saturday and and Sunda Sunday. Superstarsy. Superstars will will begin begin after after 1:15 1:15 p.m. p.m. on Saturdayon Saturday and and12:45 12:45 p.m. p.m.on on Sunda y.

— Online By Phone — Signature of the Parent Date

E M E R G E N C Y

Athletics, Recreation INFORMATION RECORD & Community Services

Last Name First Name Middle Name 0 Male

0 Female Address City Zip Code

Birthdate School Grade

Father’s Full Name Mother’s Full Name

Legal Guardian’s Full Name Residing With: 0 Parents 0 Father 0 Guardian 0 Mother

EMERGENCY CONTACT PHONE NUMBERS (Minimum Three Contacts – Number each item in order of desired action) Please include area code with phone number Contact Mother at Home ( ) Contact Mother’s Cell Phone ( ) Contact Mother at Place of Employment ( )

Contact Father at Home ( ) Contact Father’s Cell Phone ( ) Contact Father at Place of Employment ( ) Contact Relative – Name: ( ) ( ) Contact Neighbor – Name: Family Doctor’s Name Hospital of your choice in the event that injury needs immediate attention and no one can be located.

Family Doctor’s Phone Number

0 I agree to pay any and all charges which may become necessary during any emergency treatment and or pay any and all hospital charges if my child must be taken to the hospital should Bloomfield Hills Schools Athletics, Recreation, and Community Services program staff be unable to locate me by telephone at the time of said emergency.

Signature of the Parent Date

GENERAL INFORMATION Please fill out completely and accurately. Hospitalization Company Policy Number

Are there any known allergies/chronic health problems that would affect your child’s progress in a classroom situation? (Please check all the apply) 0 Hearing 0 Cerebral Palsy 0 Diabetes 0 Asthma 0 Vision 0 Epilepsy 0 Allergies 0 None 0 Speech 0 Hemophilia 0 Bee Stings (Epi-Pen) 0 Other

Is your child on any prescription medication that we should be aware of? Please explain.

If the medication needs to be taken during school hours, please complete the prescription medication form that can be obtained from the office.

Tetanus Toxoid Booster Up-To-Date (Check One): 0 Yes 0 No

ADDITIONAL COMMENTS

NOTE: If there is any change in the information on this form, which occurs during the school year, please contact Bloomfield Hills Schools Athletics, Recreation, 12 and Community S—ervices Five at once.Easy Ways Phone, Fax, Mail, In Person, Online —