Day Camp Registration Form Stokes County

Day Camp Registration Form
Stokes County
FOR OFFICE USE ONLY
______ Day Camp Registration Form
______ Codeword
______ Youth Programs Policy Form signed
______ Behavior Expectations & Discipline Policy Form signed
______ Orders for Medication signed (must be completed even for sunscreen)
______ Copy of Child Immunization Record
______ Registration Fee
______ Weekly Deposit
______ Subsidy Voucher: If applicable. Three copies per child must be provided by parent. Vouchers are good for one camp location only.
______ Financial Assistance Forms: If applicable. Must be filled out completely with income information attached.
______ Complete Camp Registration Form:
______ Remind parents to register for all sessions needed to reserve a spot for their child(ren).
*Please make sure all selections/lines are completed before accepting registration packet.
Our Mission: Helping people reach their God-given potential in Spirit, Mind & Body.
A UnitedWay Agency
2009 Day Camp Registration Form
Date of Registration: ___ /___ /20___
o My child is a YMCA member.
In 2008–2009 my child is in ________ grade.
Child’s Information (Please print legibly)
Codeword ____________________
T-shirt size _________ _________
(Initials)
Child’s name (first/middle/last) __________________________________________________ Name called ____________________
Address ________________________________________________ City _______________________ Zip _____________________
o Male o Female Birth date __________ Age (as of registration date) __________
Check all that apply to your child, or check “None” for those that don’t apply:
o Allergies (type) _______________________________________________________ o None
o ADD o ADHD o None
o Special circumstances (see back page and provide additional information if necessary) o None
Family Information (check parent to contact for payment and other questions)
o Mother/guardian’s name __________________________________ Employer ___________________________________________
Home address ___________________________________________________ City _____________________ Zip ______________
Home # __________________ Work # _________________ ext. ____ Mobile # _________________ Pager # _________________
Email address ______________________________________________________________________________________________
o Father/guardian’s name _______________________________________ Employer _______________________________________
Home address ___________________________________________________ City ____________________ Zip ______________
Home # __________________ Work # _________________ ext. ____ Mobile # _________________ Pager # _________________
Email address ______________________________________________________________________________________________
Emergency Information
In case of emergency, please contact the following first: o Mother/guardian o Father/guardian
Child’s doctor _____________________________________________________ Doctor’s phone ______________________________
Hospital preference ____________________________________________________________________________________________
Insurance company ___________________________________________________ Policy # _________________________________
If mother, father, or guardian cannot be reached, call:
Name _______________________________________________ Relationship to child ______________________________________
Home # _______________ Work # _______________ ext. ____ Mobile # ______________________ Pager # ___________________
Name _______________________________________________ Relationship to child ______________________________________
Home # _______________ Work # _______________ ext. ____ Mobile # ______________________ Pager # ___________________
I hereby acknowledge that the YMCA will assume that either parent of the child may pick up the child at any time during the program
unless there is sufficient court documentation on file at the Brach that indicates otherwise.
I hereby authorize the Branch to allow the following individual(s) to pick up my child (photo id will be required):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Persons not authorized to visit or pick up my child: (Court documentation must be attached)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
2009 Summer Camp Registration Form
Child’s Name_______________________________________
Use this form to register for appropriate camp by placing a check in the appropriate box/session. A non-refundable deposit of $15 ($50 at Camp Hanes) is required to register all campers for each weekly traditional/teen camp
session. ($5 deposit if on YMCA Financial Assistance or Child Care Subsidy Voucher is used).
3
Check Box For Each Camp
You Wish To Attend
One-Time
Registration
Fee
Fee Per Session
Session 1 Session 2 Session3 Session 4 Session 5 Session 6 Session 7 Session 8 Session 9 Session 10
June 15 June 22 June 29 July 6
July 13 July 20 July 27 August 3 August 10 August 17
Traditional Camps
Stokes Family YMCA
$40 $120 Member
$150 Non-member
$19 Member
$39 Non-member
$19 Member
$39 Non-member
$160 Member
$180 Non-member
$150 Non-member
$120 Non-member
$49 Non-member
$29 Member
$49 Non-member
Water Academy w/ Day Camp
Water Sports School w/ Day Camp
YMCA Camp Hanes
(Call 983-3131 to register)
$50 Teen Day Camp
Teen Camp
$40 $120 Member
Sports Camp
Camp Play Ball
$80 Member
Aquatics
Water Academy
$29 Member
Water Sports School
2009 Day Camp Programs Policy
Child’s Name_______________________________________
Please read each of the following policies and sign below to indicate your understanding of these policies.
Waivers/Permissions:
I permit my child to participate in activities the YMCA conducts outside
the fenced-in play areas at YMCA facilities.
Field Trips – I permit my child to leave the YMCA on authorized trips
under the supervision of the YMCA staff. I may review a written schedule
of activities to be conducted off the YMCA premises.
Photography - I permit the YMCA to use images of my child as a YMCA
program participant in internal and external promotional material. This
includes any printed material, broadcast and print advertising, promotional
videos and the YMCA website which are produced or published by the
YMCA. I also permit the YMCA and/or the media to use images of my
child in broadcast and print media news coverage of the YMCA. I understand that my child’s name is not published.
Payment Policies
I understand policies concerning payment, cancellation and refunds. I may
not register my child for a new program until outstanding balances due on
past programs are paid.
Insufficient Funds – If my bank returns a draft or check due to insufficient
funds, immediate payment is required to keep my child’s account up to date.
I understand that I will be charged $25 for each returned check or draft.
I will need to send cash, money order or a certified check for the draft or
check within 10 business days after I receive a notification letter from Metro
Financial Services. Personal checks will not be accepted. Payment in full is
required before my child can continue to participate in YMCA programs.
If I have two returned drafts or checks within a six-month period, I
will no longer have the bank draft privilege and will be required to
pay program fees in full, in advance.
Cancellations: Non-attendance, without written cancellation, does not
relieve me of the responsibility to pay for the program. I will refer to the
registration receipt for details on specific program cancellation policies.
Bank draft participants – I understand that I must cancel, in writing,
prior to the date of bank draft in order to stop payment.
Refunds – I understand that non-attendance does not entitle me to a refund.
I understand that no refunds or adjustments are granted for illness, vacation
or when YMCA programs are cancelled due to inclement weather. All
refunds or program credits given for other reasons are issued on a prorated
basis. I understand that the YMCA reserves the right to apply any credit
due to other outstanding balances. Refunds are issued within 30 days of
cancellation. Program payment is not transferable from one YMCA
program to another nor from one YMCA branch to another.
Accident Insurance – Participants are responsible for their own accident
insurance when using the YMCA and when participating in YMCA programs
off-site.
Medication – The YMCA does not normally administer any medication and
will do so only when directed in writing by the child’s parent or guardian.
However, in the event of an emergency in which the parent cannot be
contacted, Emergency Medical Staff and the YMCA may take appropriate
action in the best interest of the child.
Immunization Records – Current copies of each child’s immunization
records must accompany this form.
Blood Borne Pathogen Exposure – I understand that, while my child is
in the care of the YMCA, if a child is exposed to a body fluid on broken skin
or mucous membrane (e.g. splashing in mouth or eye), from another child,
the YMCA will contact the parents of both children. They will explain what
has occurred, and then provide the name of the attending physician of the
source child to the parents of the exposed child. If a staff member has a blood
or body fluid exposure from a child, the YMCA will provide the name and
telephone number of the child’s attending physician to the staff member.
I have read and agree with the statement and specifically authorize the
YMCA to release the name and telephone number of my child’s physician,
and a description of the event to the parent or guardian of any child who is
exposed to blood or body fluid or any staff member who experiences such
an exposure from my child.
Program Policies
Babysitting Policy – The YMCA strives to employ the very best staff
possible in all of our programs. During staff time-off or after they are no
longer employed with us, these persons are private citizens and no longer
subject to our employment rules and procedures. The YMCA cannot and
does not endorse or recommend its present or former staff members as
babysitters to any parent or guardian of any child in any of our programs.
Any babysitting arrangements with present or former staff of the YMCA is
separate and independent from any YMCA program and must be based on
the independent investigation, responsibility and judgment of the parent or
guardian. I agree that the YMCA shall not be responsible and will be held
harmless from any claims or liability in connection with such babysitting
activities.
Pickup Policy – I hereby acknowledge that the YMCA will assume that
either parent of the child may pick up the child at any time during the program unless there is sufficient court documentation on file at the Branch that
indicates otherwise. A pickup card is always required to pick up your child.
Inclement weather – Please refer to local media sources or, if available,
www.ymcanwnc.org for program closings related to inclement weather.
Lost Items – I understand that the YMCA is not responsible for any
personal items lost or stolen at our programs.
Medical Treatment Policies
I have read and understand all the policies stated above.
Parent/guardian signature __________________________________________________ Date _____________________
2009 Behavior Expectations and Discipline Policy
Child’s Name_______________________________________
It is important that staff maintain good order and discipline in all programs. Top objectives in all YMCA programs are safety and a positive
atmosphere for learning and developing social skills. The YMCA makes every effort to help children understand clear definitions of acceptable
and unacceptable behavior.
The YMCA does not condone and will not permit:
1. Corporal punishment
2. Ridiculing, threatening, using an inappropriate loud voice
3. Leaving children unsupervised
4. Use of profanity
A child’s behavior is expected to be consistent with the following:
1. Use appropriate language at all times.
2. Cooperate with staff and follow directions.
3. Respect other children and staff, equipment and facilities,
and yourself.
4. Maintain a positive attitude.
5. Stay in program areas – running away is not acceptable.
The Discipline Policy
1. If a child is unable to comply with the behavior expectations,
a conference will be held by the program director with the child. The parent(s)/guardian will be notified in writing.
2. If after the above meeting the child is still unable to comply
with the behavior expectations, the program director will set up
a conference with the parent(s)/guardian. A behavior contract will be established and signed by the child (if appropriate),
parent(s)/guardian and the program director.
3. If the child’s behavior continues to be disruptive and/or unsafe,
the child will be subject to suspension or dismissal.
4. Failure of the parent(s)/guardian to attend conference(s) and
cooperate will subject the child to suspension or dismissal.
Behaviors which may result in immediate dismissal include but
are not limited to:
1. Any action that could threaten or pose a direct threat to the
physical/emotional safety of the child, other children or staff
2. Fighting
3. Possession of a weapon of any kind
4. Vandalism or destruction of YMCA property or property
of others
5. Sexual misconduct
6. Possession of or use of alcohol or controlled substances
unless under the prescription of a doctor
7. Running away
8. Biting
Special Circumstances
Parents or guardians are required to inform the YMCA in writing, prior to a child’s acceptance in a YMCA program, of any special
circumstances which may affect the child’s ability to participate fully and within the guidelines of acceptable behavior, including but
not limited to any serious behavioral problems or special circumstances regarding psychological, medical or physical conditions.
Upon being informed of such circumstances, the branch director (or his or her designee, i.e., senior program director, youth director)
may require a conference with the parent(s)/guardian to discuss issues created by these circumstances.
I understand and acknowledge that: (i) it is the responsibility of the parent(s)/guardian to make full disclosure to the YMCA of any
special circumstances which may affect the ability of my child/ward to participate, as described above; (ii) it is the responsibility of the
parent(s)/guardian to inform the YMCA of any requested accommodation believed by the parent(s)/guardian to be necessary and readily
achievable for such participation; and (iii) full disclosure of any special circumstances is material to the YMCA’s evaluation of the
child’s/ward’s ability to participate and the YMCA’s consideration of any requested accommodation.
Please initial, indicating that you have read and understand the above:
_________________________________________________________
Parent/legal guardian Date
I have read, understand, and agree with the policies as stated in this document and have discussed the expectations of behavior with my child/ward.
___________________________________________________________________________________________
Parent/legal guardian signature Date
Orders for Medication
To be completed by parent/guardian:
If it is absolutely necessary for the child named below to take medication during camp or child care hours, or in the event your child
has a medical condition of which the Branch should be aware, please complete the information requested, sign and return this form
to the Branch.
Child’s Name___________________________________________________________ Age (as of registration date) ______________
Day Camp/Child Care Program__________________________________________________________________________________
Name(s) of Parent(s)/Guardian(s):
Mother’s Name______________________________________________________________________________________________
Home Phone_________________________________________ Work Phone_______________________________________
Father’s Name______________________________________________________________________________________________
Home Phone_________________________________________ Work Phone_______________________________________
Medication:
Medication Prescribed________________________________________________________________________________________
Dosage_______________________________________ Times(s) to Administer_________________________________________
Possible Side Effects/Special Instructions_______________________________________________________________________
______________________________________________________________________________________________________
Medication Prescribed: Sunscreen_____________________________________________________________________________
Dosage_______________________________________ Times(s) to Administer_________________________________________
Possible Side Effects/Special Instructions_______________________________________________________________________
______________________________________________________________________________________________________
Medical Condition(s): Please list below any allergies (do not include allergies to medications), asthmatic conditions or the like which
may require the Branch to administer the child’s medicine.
Condition
Symptoms
Medication/Dosage
Special Instructions
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
________________________________________________________ ___________________________________________________
(Parent/Guardian Signature and Date)
(Print Parent/Guardian Name)
Medicine
Dosage
Time(s) Given
Caregiver’s Initials
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
Please Read: No medication (including Tylenol, sunscreen, etc.) may be dispensed/applied without written authorization from
parent/guardian. Prescription drugs may only be dispensed from their original container.