Welcome to the Project SHARE 2023 Summer Program at the Black Butte Schools!

1st Student Information

Weeks to Attend*

Which week(s) will your child attend the Black Butte Summer Program?

Grade starting in the 2023-2024 school year:required

Primary Language*

English Spanish Other

Current School of Enrollment During the 2022-2023 school year:required

First Namerequired

Last Namerequired

Date of Birthrequired

Gender*

Female Male

Home Phonerequired

Please answer the following questions so that we may care for your child to the best of our abilities:

Students Who Are English Learners (English is a 2nd Language)*

Yes No

Students Who Are Economically Challenged*

Yes No

Students With Disabilities*

Yes No

IEP*

Yes No

Total number of members in immediate household.required

Ethnicity*

Ethnicity: Check all that apply:

May Project SHARE photograph/record/use photos of my student, and use such images, at no compensation, for promotional, educational purposes; in unlimited print; on educational websites promoted by or for Project SHARE & partners?*

Yes No

In regard to sun sensitivities*

I am concerned about sun exposure and/or my student has known sun sensitivities. I have provided sunscreen with SPF15 or higher, does not contain DEET or other mosquito repellant, and my childs name is clearly written on the container No, I do not have concerns about sun exposure and/or my student has no known sun sensitivities.

Swimming Permissions*

Swimming will be offered during the Project SHARE summer program. All swimming activities are done under the supervision of a certified lifeguard. Please check all that apply.

I give permission for my child to swim under the supervision of a certified lifeguard. I do not give permission for my child to swim.

Life Jacket

Does your student need to wear a life jacket when swimming?

Yes No

WES (Whiskeytown Elementary School) Permissions:

Edible Plants*

As part of the activities at the WES sponsored events/camps, we give the children the choice of tasting some of the edible plants in the area, i.e., Manzanita berries, wild onions, and Douglas fir needles. Some parents have expressed that they are not comfortable with this. Please indicate your preference.

I DO want my child to participate in the activities of tasting wild, edible plants, if they want to. I DO NOT want my child to participate in the activities of tasting wild, edible plants.

Tie-Dye Day:*

We may tie-dye during summer camp. We will let you know beforehand. You may bring a white or light colored t-shirt from home to tie-dye.

I DO want my child to participate in tie-dye. I will provide a t-shirt from home. I DO NOT want my child to participate in tie-dye Tuesday.

Any special alerts/restrictions?*

Yes No

Have a behavior plan?*

Yes No

Any medications?*

Yes No

Any allergies?*

Yes No

Watch PG rated movies?*

Yes No

Please explain special alerts / restrictionsrequired

Please explain the behavior planrequired

Name of Medicine:required

Will they be required to take medication during after school hours?*

Yes No

Describe allergy and the symptoms.required

May your student walk home?*

Yes No

May your student ride the bus?*

Yes No

If documentation is required to be on file for allergies, medications, alerts / restrictions and/or behavior plan, it must be updated each year by the parent. An option at the end of the questionnaire is available for uploading.

If you prefer, please email to ProjectShareInfo@shastacoe.org. Please include the child's name and site within the body of the email.

2nd Student Information

Weeks to Attend*

Which week(s) will your child attend the Black Butte Summer Program?

Grade starting in the 2023-2024 school year:required

Primary Language:*

English Spanish Other

Current School of Enrollment During the 2022-2023 school year:required

First Namerequired

Last Namerequired

Date of Birth:required

Gender:*

Female Male

Home Phonerequired

Please answer the following questions so that we may care for your child to the best of our abilities:

Students Who Are English Learners (English is a 2nd Language)*

Yes No

Students Who Are Economically Challenged*

Yes No

Students With Disabilities*

Yes No

IEP*

Yes No

Total number of members in immediate household.required

Ethnicity*

Ethnicity: Check all that apply:

May Project SHARE photograph/record/use photos of my student, and use such images, at no compensation, for promotional, educational purposes; in unlimited print; on educational websites promoted by or for Project SHARE & partners?*

Yes No

In regard to sun sensitivities*

I am concerned about sun exposure and/or my student has known sun sensitivities. I have provided sunscreen with SPF15 or higher, does not contain DEET or other mosquito repellant, and my childs name is clearly written on the container. No, I do not have concerns about sun exposure and/or my student has no known sun sensitivities.

Swimming Permissions*

Swimming will be offered during the Project SHARE summer program. All swimming activities are done under the supervision of a certified lifeguard. Please check all that apply.

I give permission for my child to swim under the supervision of a certified lifeguard. I do not give permission for my child to swim.

Life Jacket

Does your student need a life jacket when swimming?

Yes No

WES (Whiskeytown Environmental School) Permissions:

Edible Plants*

As part of the activities at the WES sponsored events/camps, we give the children the choice of tasting some of the edible plants in the area, i.e., Manzanita berries, wild onions, and Douglas fir needles. Some parents have expressed that they are not comfortable with this. Please indicate your preference.

I DO want my child to participate in the activities of tasting wild, edible plants, if they want to. I DO NOT want my child to participate in the activities of tasting wild, edible plants.

Tie-Dye Day:*

We may tie-dye during summer camp. We will let you know beforehand. You may bring a white or light colored t-shirt from home to tie-dye.

I DO want my child to participate in tie-dye. I will provide a t-shirt from home. I DO NOT want my child to participate in tie-dye Tuesday.

Any special alerts/restrictions?*

Yes No

Have a behavior plan?*

Yes No

Any medications?*

Yes No

Any allergies?*

Yes No

Watch PG rated movies?*

Yes No

Please explain special alerts / restrictionsrequired

Please explain the behavior planrequired

Name of medicine.required

Will they be required to take medication during after school hours?*

Yes No

Describe allergy and the symptoms.required

May your student walk home?*

Yes No

May your student ride the bus?*

Yes No

3rd Student Information

Weeks to Attend*

Which week(s) will your child attend the Black Butte Summer Program?

Grade starting in the 2023-2024 school year:required

Primary Language:*

English Spanish Other

Current School of Enrollment During the 2022-2023 school year:required

First Namerequired

Last Namerequired

Date of Birth:required

Gender:*

Female Male

Home Phonerequired

Please answer the following questions so that we may care for your child to the best of our abilities:

Students Who Are English Learners (English is a 2nd Language)*

Yes No

Students Who Are Economically Challenged*

Yes No

Students With Disabilities*

Yes No

IEP*

Yes No

Total number of members in immediate household.required

Ethnicity*

Ethnicity: Check all that apply:

May Project SHARE photograph/record/use photos of my student, and use such images, at no compensation, for promotional, educational purposes; in unlimited print; on educational websites promoted by or for Project SHARE & partners?*

Yes No

In regard to sun sensitivities*

I am concerned about sun exposure and/or my student has known sun sensitivities. I have provided sunscreen with SPF15 or higher, does not contain DEET or other mosquito repellant, and my childs name is clearly written on the container. No, I do not have concerns about sun exposure and/or my student has no known sun sensitivities.

Swimming Permissions*

Swimming will be offered during the Project SHARE summer program. All swimming activities are done under the supervision of a certified lifeguard. Please check all that apply.

I give permission for my child to swim under the supervision of a certified lifeguard. I do not give permission for my child to swim.

Life Jacket

Does your student need to wear a life jacket while swimming?

Yes No

WES (Whiskeytown Environmental Schools) Permissions:

Edible Plants*

As part of the activities at the WES sponsored events/camps, we give the children the choice of tasting some of the edible plants in the area, i.e., Manzanita berries, wild onions, and Douglas fir needles. Some parents have expressed that they are not comfortable with this. Please indicate your preference.

I DO want my child to participate in the activities of tasting wild, edible plants, if they want to. I DO NOT want my child to participate in the activities of tasting wild, edible plants.

Tie-Dye Day:*

We may tie-dye during summer camp. We will let you know beforehand. You may bring a white or light colored t-shirt from home to tie-dye.

I DO want my child to participate in tie-dye. I will provide a t-shirt from home. I DO NOT want my child to participate in tie-dye Tuesday.

Any special alerts/restrictions?*

Yes No

Have a behavior plan?*

Yes No

Any medication?*

Yes No

Any allergies?*

Yes No

Watch PG rated movies?*

Yes No

Please explain special alerts / restrictionsrequired

Please explain the behavior planrequired

Name of medicine:required

Will child be required to take medication during after school hours?*

Yes No

Describe allergy and the symptoms.required

May your student walk home?*

Yes No

May your student ride the bus?*

Yes No

Welcome to the Project SHARE 2023 Summer Program at the Black Butte Schools!

1st Student Information

2nd Student Information

3rd Student Information

In case of Emergency FIRST CONTACTS

Custodial Parent/Guardian:

Custodial Parent/Guardian:

Child may be picked up by:

Child may NOT be picked up by:

Medical/Miscellaneous Information

Welcome to the Project SHARE 2023 Summer Program at the Black Butte Schools!

1st Student Information

2nd Student Information

3rd Student Information

In case of Emergency *FIRST CONTACTS*

Custodial Parent/Guardian:

Custodial Parent/Guardian:

Child may be picked up by:

Child may NOT be picked up by:

Medical/Miscellaneous Information

In case of Emergency FIRST CONTACTS