Channel Islands YMCA Sleepaway Camp 2016 Registration Packet

FROM THE
MOUNTAINS TO
THE SEA
Channel Islands YMCA Sleepaway Camp 2016
Registration Packet
YMCA CAMP FOX:
School Age Camp
Teen Camp
YALP (Youth and Leadership Program)
YMCA SEQUOIA LAKE CAMP:
Youth Camp
Teen Camp
CIT (Counselor in Training)
CHANNEL ISLANDS YMCA
serving Santa Barbara and Ventura counties
CHANNEL ISLANDS YMCA SLEEPAWAY CAMP
(One packet is required per camper)
Campers Name: __________________________________________Camp Name: _______________________________Grade (Fall ’16):_____________
YMCA Branch Registered Through: __________________________________________________________________
T Shirt Size (please circle): Youth M
Youth L Adult S
Adult M
Adult L
Adult XL
Adult XXL
I was referred by another camper: ____Yes ____ No If yes, by whom:_______________________________________________________
Are you involved in the Rags/Leathers Program: Yes
No
If yes, please list Rag or Leather level:_________________________________________________________________________
CAMP SESSION/DATES
FACILITY/
PROGRAM MEMBER
COMMUNITY FEE
$625
$665
$625
$665
$625
$665
CAMP FOX
SCHOOL AGE CAMP:
June 19-25
(Entering Grades 3-6)
TEEN CAMP
June 19-25
(Entering Grades 6-9)
YALP CAMP
Youth and Leadership Program
June 19-25
(Entering Grades 9-12)
$100 deposit due at time of registration. Balance due by 5/29/2016. Parent and Camper Rally on 6/8/2016 at 6:00pm
CAMP SEQUOIA
YOUTH CAMP
JULY 17-22
$595
$635
$595
$635
$595
$635
(Entering Grades 3-7)
TEEN CAMP
JULY 17-22
(Entering Grades 8-12)
CIT CAMP
Counselor In Training
JULY 17-22
(Entering Grade 12)
$50 deposit due at time of registration. Balance due 7/6/2016. Early Bird rates for Sequoia Student Camps.
Fee adjustment made at the time of registration. Expires 4/30/2016 Parent Rally 7/6/2016 at 6:30pm
*To receive the Early Bird Rate for Camp Sequoia, I understand that I must register by April 30, 2016
*I understand that final payments for all camps are due as indicated above. Failure to complete payment on time will
result in loss of registration and deposit.
*I understand that a $50 deposit/child is due upon registration for Camp Sequoia and a $100 deposit/child for Camp Fox.
*Scholarships are available upon completion of the Open Doors application and proof of income. All scholarships are
based on income, and availability of scholarship funds. Scholarships are processed on a first come first serve basis.
___________________________________________________________________
Parent Signature
__________________________________
Date
EMERGENCY/HEALTH INFORMATION HISTORY FORM
General Information (Please print)
Child’s Name: ______________________________________________Age __________ M______F_____ Grade in Sept 2016___________
Address: ___________________________________________________City ____________________________________Zip _______________________
Home Phone: _________________________________ School: ______________________________ Birthday: _____/______/_____
Adult #1 Name:___________________________________________________________ Birthday: ________/_________/__________
Work Phone:_____________________________________ Cell Phone __________________________________________
E-Mail Address:______________________________________________________________________________________________________
Adult #2 Name:___________________________________________________________ Birthday: _________/_________/__________
Work Phone_____________________________________ Cell Phone :________________________________________
E-Mail Address:_____________________________________________________________________________________________________
Child lives with __________________________________________________ Relationship _____________________________________
Thank you for agreeing to receive our periodic email communications. We never share or sell email addresses
Please attach copies of any legal documentation regarding non-custodial parents
Health Information
Has your child had any serious or severe illnesses or accidents in the last 3 years?
Yes
No
If yes, explain ________________________________________________________________________________________________________________
Does the child take any medication during the day?
Yes
No
If yes, Medication Release Form is required* Please list medications: ___________________________________________
Food Allergies?
Yes
No If yes, explain: ______________________________________________________________________
Environmental Allergies?
Yes
No
If yes, explain: ___________________________________________________________
Medication Allergies?
Yes
No
If yes, explain:____________________________________________________________
Special needs or fears?
Yes
No If yes, explain:___________________________________________________________
Physician: ______________________________________________________ Phone: ____________________________________________________
Dentist : ________________________________________________________ Phone: ____________________________________________________
Insurance Co: ___________________________________________________________ Group #: __________________________________________
*Medication Release Form can be found at the Welcome Center
Emergency Contacts/ Authorized Pick-Up (In addition to Parents)
Name: ____________________________________________ Phone: _______________________________ Relationship: ____________________
Name: ____________________________________________ Phone: _______________________________ Relationship: ____________________
Name: ____________________________________________ Phone: _______________________________ Relationship: ____________________
Name: ____________________________________________ Phone: _______________________________ Relationship: ____________________
I hereby give permission to Channel Islands YMCA and it’s employees and volunteers to release
any and all of the above health history to any medical personnel rendering emergency medical
aid or treatment to my child.
Parent's or Legal Guardian’s Signature: _________________________________________________ Date: _________________________
3
Walking Fieldtrip permission, Consent to Treatment and Release, Child’s Health
Statement, Photographic Release, and Insurance Disclaimer
Child’s Name (Please Print) ____________________________________________________________________________
PERMISSION FOR FIELDTRIPS, WALKING FIELDTRIPS, WALKING EXCURSIONS, AND USE OF
PUBLIC PARK FACILITIES
I hereby give consent to the Channel Islands YMCA and its designated leaders to take the above
named child on walking trips in the neighborhood, public park facilities, special excursions to places
of interest in YMCA vans, buses, commercial vehicles, public transportation, or rented vans or buses,
with the understanding that such trips are under supervision of authorized personnel of the YMCA
and that all possible precautions are taken to insure the health and safety of my child.
Initial ___________
CONSENT FOR EMERGENCY MEDICAL TREATMENT
As the parent [ ], domestic partner [ ], or authorized representative [ ], I hereby give consent to
Channel Islands YMCA to obtain all emergency medical or dental care prescribed by a duly licensed
physician (M.D) Osteopath (D.O.) or Dentist (D.D.S.) for the child named above. This care may be given
under whatever conditions are necessary to preserve the life, limb or well being of a child named
above.
Initial ___________
CHILD’S HEALTH STATEMENT
I, the undersigned parent/legal guardian, understand that at a YMCA Camp Program and Child Care
Program, physical activity is a regular part of the program. To the best of my knowledge, my child is
in excellent physical health and needs no restrictions (except what is listed on the Emergency/Health
Information Form) from strenuous physical activity. If I have any questions regarding my child’s
health, I understand that it is my obligation to seek professional medical advice and to inform the
Channel Islands YMCA of any restrictions on my child’s activities.
Initial ___________
PHOTOGRAPHIC RELEASE
In exchange for good and valuable consideration, the adequacy of which is hereby acknowledged, I
hereby give Channel Islands YMCA, its volunteers, employees and any other person and entity acting
with its permission the right to take, copyright, use, and publish any photographs or video of the
above named child for the purpose of any YMCA advertising, promotion, or other purpose consistent
with the YMCA mission.
I agree that any such photograph or video is the property of the Channel Islands YMCA, and I hereby
waive all rights thereto. I further waive any right to inspect or approve any printed or electronic
material that may be used in conjunction with the photographs or video, or to approve the use to
which the photographs or video may be applied.
Initial ___________
INSURANCE DISCLAIMER
The Channel Islands YMCA does not carry health or accident insurance on its members or
participants. All expenses incurred in the treatment of illness, injuries or accidents will be the
responsibility of the participant’s parents or guardians.
Initial ___________
5
PARTICIPANT SWIM ABILITY ASSESSMENT FOR MINOR :
The YMCA program may include aquatic activities at a pool, beach or other location with water. Your
initial below authorizes your child to participate in swimming activities.
Please check the box below with the description that most closely fits the participant.
Type I: Does not know how to swim or is uncomfortable or nervous around water. Cannot put their
face in the water, hold their breath, right themselves or float.
Type 2: Can hold their breath, fully submerge their head under water, right themselves, float
unsupported for five (5) seconds, flutter kick and can turn over from front and back. Is
uncomfortable in water over their head and is unable to propel themselves beyond ten (10) yards.
Type 3: Comfortable in deep water, can demonstrate basic swimming stroke techniques with
controlled breathing, can propel themselves twenty five (25) meters and tread water for two
minutes.
Type 4: Comfortable in deep water, can demonstrate advanced swimming stroke techniques with
controlled breathing, can continuously propel themselves for a minimum of 100 meters, tread water
for four (4) minutes and swim fifteen (15) meters under water.
Initial: __________
PERMISSION FOR AUTHORIZING USE OF SUNSCREEN:
I understand that providers now must have written permission from parents authorizing use of sunscreen and
identifying the Sunscreen Brand and Sun Protection Factor (SPF) to be used on children. The Channel Islands YMCA
is trying to avoid the possibility of an allergic reaction.
I hereby give consent to the Channel Islands YMCA and its designated leaders to apply sunscreen, which I have
provided for my child during the YMCA program. The staff may use the brand provided by the Channel Islands
YMCA in the event my child does not have their own sunscreen.
Sunscreen provided by parent: (brand)
__________________________________ SPF: ___________________
I understand that I am required to provide my sunscreen for my child and I authorize the YMCA Staff to
directly apply the sunscreen to my child.
Initial: __________
CODE OF CONDUCT FOR ALL PARTICIPANTS:
By Submitting this application, you, for yourself or on behalf of your minor child, agree to abide by the policies and
conditions of the Channel Islands YMCA Association "Code of Conduct.” The “Code of Conduct” can be found at the
front service center of your local YMCA.
Initial: __________
MANDATED REPORTING:
I understand that the YMCA staff is mandated by state law to report any suspected cases of child abuse or neglect
to the appropriate authorities for investigation.
Initial: __________
I HAVE READ AND AGREE TO THE ABOVE INFORMATION:
_________________________________________________________________
Parent or Legal Guardian’s Signature
__________________________________________________________________
Printed Name
_________________
Date
6
September 2009
Supplemental Medication Packet
If you have more than ONE bottle of medication please bring your medications (that are in pill or tablet form) preseparated into pill planners/separators to the morning check in for camp. It is your responsibility to make sure
that this is done accurately. For liquids, birth control pills, injections etc., we realize that you will need to bring
them in original containers. Prescription medication must be dispensed according with physician’s current orders. It
must be prescribed for the child who is to receive the medication.
IMPORTANT: You will also be required to bring along the original bottles/containers with the detailed,
printed, prescription information. In addition, please verify that at least one days worth of medication is
in included in the bottle or container for reference purposes by the nurse and to serve as a backup.
Those with no prescribed medication must still have a Medication Sheet on file. Please fill out the top portion and
write in No Meds in the first Medication Name box. Please be aware that the nurse on duty must see every camper
regardless of their medical or medication issues. Please feel free to make copies of this form as necessary.
For all of campers, the Channel Islands YMCA requires that all medication either be pre-packaged in daily pill
dispensers or in bubble packs according to the time and date of each scheduled dispensation time and marked with
the Camper’s name. Contact your pharmacist to see if the pharmacist can pre-package your medication for you. Also,
ask the pharmacist for a current medication sheet, they will be able to print this off at no charge. The
guardian/parent/ caregiver is responsible for making sure this is completely accurate. An extra day’s supply of
medication, in the original prescription bottles, must be brought to camp in case of an emergency. With the change of
routine, added stress, change of diet, etc., all PRN’s (medication as needed – seizure medication, epi-pens, pain
medications, asthma inhalers, etc.) medications that the camper takes must be brought to camp also. All medications
will be turned in during the camper’s appointed check in time.
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Medication Release
___________________________________
___________________________________
______________________
_________
Camper’s First Name
Last Name
DOB
Age
Reason for camper needing medication:_____________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
I give my permission to the Channel Islands YMCA and its designated leaders to dispense medication
to my son/daughter _______________________________________(child name).
As the legal guardian/parent/caregiver of the camp participant, I hereby agree to assume the
risks associated with improperly packaged and marked medication. In consideration for the
acceptance by Channel Islands YMCA of the Participant in the camp and related camp activities, the
undersigned do hereby release, forever discharge and waive any claims, causes of action, demands,
debts, lawsuits and liabilities which may arise against CIYMCA and its officers, directors, employees,
agents and representatives, and other camp related persons acting with permission of CIYMCA
(collectively its "Agents"), directly or indirectly, for injury to Participant's person, during his/her
involvement with or activities at camp and in particular related to claims for personal injury or death
resulting from the Participant being administered medication that was improperly packaged or
marked (collectively a "Loss"); and the undersigned further do agree and covenant to indemnify and
hold harmless, and not to sue, ESN and their Agents from and against any Loss on account of any
action which may be brought against any of them by the undersigned, or any person on behalf of the
undersigned or the Participant for the purpose of enforcing or collecting any Loss.
_____________________________________________________
Parent or Guardian Authorized Signature
_____________________________________
Date
_____________________________________________________
Parent or Guardian Printed Name
________________________________________
Parent Guardian Phone Number
8
Camper Name:
Medication Name
Branch:
Dosage
Morning
Afternoon
Evening
Night/Bedtime
__________________________________________________________________________
Parent or Guardian Authorized Signature
Date
9
CHANNEL ISLANDS YMCA
Branches:
Camarillo – Lompoc – Montecito -Santa Barbara
Stuart C. Gildred – Ventura - Youth and Family Services
PARENT STATEMENT OF UNDERSTANDING
The following information is important for the safety and protection of your child. Please read the
information, sign this form and return it to the YMCA.
I understand that YMCA staff are not allowed to babysit or transport children at any time outside of
the YMCA program. Immediate disciplinary action will be taken by the YMCA toward staff and
volunteers if a violation is discovered.
I understand that I am not to leave my child at the YMCA or program site unless a YMCA staff or
volunteer is there to receive and supervise my child.
I understand that my child will not be allowed to leave the program with an unauthorized person.
Any person authorized to pick up my child must either be listed with the YMCA or other
arrangements must be made by calling the YMCA office to inform them of a change.
I understand that should a person arrive to pick up my child who appears to be under the influence
of drugs or alcohol, for the child's safety, staff may have no recourse but to contact the police.
Please do not put staff in a position where they have to make this judgment call.
I understand that the YMCA is mandated, by state law, to report any suspected cases of child abuse
or neglect to the appropriate authorities for investigation.
______________________________________________________
Parent or Legal Guardian’s Signature
___________________
Date
10
CHANNEL ISLANDS YMCA
LETTER TO MY COUNSELOR
CAMPERS NAME: __________________________________________________________________ NICK NAME: ________________________________________________________
This letter will be given to your child’s counselor and used to help us provide the best possible experience for your child. If
the Health Care Staff should be aware of these needs please include them on the Health History Form.
Please take time to write this letter. The more we know about your child before he or she arrives at camp, the better we can
prepare for their experience. We know you are busy and have a lot to do, especially in preparation for camp. Please make this
a priority. Find some time to sit with your child and talk about their upcoming camp experience. He or she can even help you
write this letter. Once completed, mail it to us at the address listed on this form.
Please complete entire letter.
Dear Counselor,
This will be _________________________________’ s _____ year at an overnight camp and _______year at Sequoia Lake OR Camp Fox.
I want them to go to camp because
____________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________
While at camp, I hope that my child will ________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________
My child is looking forward to ____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________
Is worried about ______________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________
most unhappy when __________________________________________________________________________________________________________________________________________
is enthusiastic about ________________________________________________________________________________________________________________________________________
is be afraid of ________________________________________________________________________________________________________________________________________
is allergic to ___________________________________________________________________________________________________________________________________________________
likes to eat _____________________________________________________________________________________________________________________________________________________
does not like to eat __________________________________________________________________________________________________________________________________________
My camper is ________________________ at personal hygiene (brushing teeth, changing dirty clothes, hand washing, etc.), and is
________________________ at taking care of personal belongings.
My child gets along with other children who __________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________
My child has the following responsibilities at home _________________________________________________________________________________________________
_______________________________________________________________________________________________________
Please pay special attention to ___________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________
Thank you for taking care of my child while at camp. I know my child will have a great time. Be safe and have fun...
Sincerely,
_________________________________________________________________________________________________________
Parent/Guardian’s Signature
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