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.
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