2016 Summer Camp Brochure FINAL - Tri

A LIFETIME
OF MEMORIES
TRI-COMMUNITY YMCA
2016 SUMMER DAY CAMPS
A: 43 Everett Street, Southbridge, MA 01550
1
P: 508-765-5466
W: Tricommunityymca.org
IMPACT FOR LIFE
OUR FOCUS IS ON YOUTH DEVELOPMENT
GENERAL INFORMATION
WELCOME CAMPERS!
We’re ready for the warm weather! Join the Tri-Community YMCA for our 54th camping season and enjoy the
new additions to our fun filled program!
CAMP DIRECTORS!
Danielle Krzemien, Youth & Teen Director – Camp Director of Camp Foskett & Overseeing Summer Fun Club
Jim Flynn, Assistant Camp Director – Camp Foskett
Claudette “Cloie” Eagleton, Co-Camp Director – Summer Fun Club
Denise “Dee” Larsen, Co-Camp Director – Summer Fun Club
REGISTER NOW!
Registrations can be processed at the Front Desk of the Tri-Community YMCA. Please remember: a nonrefundable/non-transferable 50% deposit per child/per session is required upon registration. All remaining
camp balances must be paid by June 1st for Sessions 1&2, by June 15th for Sessions 3-6 and by July 15th
for Sessions 7-10. Balances not paid by the due date will be subjected to a $10 late fee per child.
FINANCIAL ASSISTANCE!
The Tri-Community YMCA, as a charitable tax-exempt
organization, provides financial aid to those families
who qualify. Financial Assistance is awarded on a
sliding scale. Applications are available at our
NEW IN 2016!
Summer Fun Club:
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TABLE OF CONTENTS
General Information ..………………….…… 2
General Camp FAQ’s ………………………...3
Session Themes & Descriptions …..….. 4
Summer Fun Club ……………..……………... 5
Camp Foskett …………………………………. 6
Camp Foskett Transportation ………….. 7
Xtend The Summer Fun …………………... 8
Summer Camp Sleepover & CIT………… 9
Camp Rentals …………………………………. 10
Registration …………………………………... 11
Camper Information …………….. 12
Session Dates & Rates ……….. 13
Transportation ……………………. 14
Health Form ..…………………..…. 15
Open House ……………………………………. 16
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Distinct age groupings:
 Pioneers: Ages 5-7
 Discoverers: Ages 8-10
 Explorers: Ages 11-13
Improved daily schedule
Revamped traditional camp
Enhanced CIT leadership programming
New sign in/out procedures
Camp T-shirt included in registration cost
Camp Store
Camp Foskett:
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Enhanced Senior Camping program
Improved CIT leadership programming
Sports & Games Specialist
Arts & Crafts Specialist
Camp T-shirt included in registration cost
Improved daily schedule
All Tri-Community YMCA camps comply with regulations of the MA DPH and are licensed by the local Board of Health
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GENERAL
CAMP FAQ’S
EXTENDED CARE
Extended AM and PM care is available ONLY at
the YMCA at 43 Everett Street in Southbridge.
Busing is available to and from Camp Foskett in
the morning and afternoon to the YMCA. AM and
PM extended care hours are as follows:
 6:45 AM to 8:00 AM
5 visits for
$15
 5:00 PM to 6:00 PM
To participate in extended
10 visits for
$25
care purchase a punch card
20 visits for
$40
at the front desk.
CAMP STORE
At both Camp Foskett & Summer Fun Club the
camp store will run daily featuring camp t-shirts,
drawstring bags, and other camp apparel.
Additional pre-packaged snacks and drinks are
also available for purchase.
WHAT TO BRING
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Backpack
Swimsuit
Towel
Water Bottle
Play Clothes
Lunch & Snacks
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Sun Screen
Bug Spray
Rain Coat
Closed toed shoes only!
Money for Camp Store
Please LABEL everything you send to camp with
your child’s name. Things that are brought to
camp are the sole responsibility of the camper.
Camp staff cannot be held responsible for lost
or stolen items.
LUNCH
Pack a lunch daily. Drinks may be purchased upon request. Lunches should be labeled with
child’s first and last name.
ADDRESSES
Summer Fun Club:
Tri-Community YMCA
43 Everett Street
Southbridge, MA 01550
Tel. 508-765-5466
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g
Camp Foskett:
Camp Foskett
189 Daniels Road
Charlton, MA 01507
Tel. 508-248-7541
MEDICAL REQUIREMENTS
A health form MUST be completed and returned
to the YMCA the Friday before attending Camp.
Health Forms REQUIRE a Doctor’s signature on
immunization history only. The rest of the form
may be completed and signed by a parent.
STAFFING / RATIOS
Hiring Requirements: The Tri-Community has a
comprehensive pre-employment screening procedure that includes a YMCA job application, a
minimum of 3 checked references, personal
interview with Camp Directors, CORI/SORI
checks, and a minimum age of 16 years old.
Staff Certifications: Current CPR, AED, & Basic
First Aid certifications required. Specialty staff
(i.e. lifeguards) maintain certifications specific to
their program area.
Staff Training: All staff are required to proficiently complete a rigorous and educational staff
training process. For more information on specific training please contact the Camp Director.
Staff to Camper Ratio:
 Ages 6 & up:
1:10 campers
 Ages 5 & under: 1:5 campers
SESSION DATES
AND THEMES
Session 1: June 20 - June 24 (SFC)
ALOHA SUMMER
Summer is upon us! Hula and luau with us as we
begin summer in this Hawaiian themed week!
Session 2: June 27- July 1 (SFC)
OUR CAMP IS 1 IN A MINION
The Tri-Community YMCA’s summer camps are
AMAZING! But guess what… so are MINIONS!
And the best part is, they’re coming together
throughout this week of camp!
Session 3: July 5 - July 8 (SFC)
MAD SCIENCE
Muahahaha - Icky sticky, ooey gooey slime, explosions, and other experiments galore. Be ready
to join our insane counselors. Gear up and bring
your craziest ideas to life!
(Note: The Tri-Community Y is closed on Monday, July 4th)
Session 4: July 11- July 15 (SFC & CF)
GAME ON
Take me out to the ball game! Touchdown! Slap,
shoot, score! This week is all about the sports.
Swimming, gymnastics, climbing, soccer, baseball,
flag football, and more. You name it, we’ll do it!
Session 5: July 18 - July 22 (SFC & CF)
SECRET SPY SCHOOL
Top Secret… Your secret mission, if you choose
to accept it, is to help save camp. All secret
agents must report to camp on Monday and be
ready to solve this mystery. This message will self
destruct in 10 seconds.
Session 6: July 25 - July 29 (SFC & CF)
AYE AYE CAPTAIN
Welcome aboard the SS YMCA! Fend off the
incoming pirates and keep our ship afloat, as we
sail through this week!
Session 7: August 1- August 5 (SFC & CF)
SHARK WEEK
Dunnah, dunnah, dunnah, dunnah - Shark attack!
AHHHH! Create fish food, swim with the fish,
and design your own ocean aquarium. Get ready
for this wild ride!
Session 8: August 8 - August 12 (SFC & CF)
LEGENDS OF THE
HIDDEN TEMPLE
Move through the ancient ruins and travel through
time all the way back to the temples and pyramids
from years ago. This week will be filled with action
packed activities sure to impress even the most
adventurous!
Session 9: August 15- Aug 19 (SFC & CF)
THE LAND OF OZ
Lions, tigers, and bears - OH MY! We’re off to
see the Wizard, the wonderful Wizard of Oz!
Follow the yellow brick road to the Emerald City!
Session 10: August 22 - August 26 (SFC)
XTEND THE SUMMER FUN
Every day is a different theme! Register for this
flexible day-by-day session where you choose the
days to come! For more information see page 6.
** SFC = Summer Fun Club / CF = Camp Foskett**
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SUMMER
FUN CLUB
RUNS SESSIONS 1-9: 6/20 - 8/19
Schedule includes daily swim
lessons, arts & crafts, rock
wall, sports & games, weekly
field trip, and more!
PIONEERS
DISCOVERERS
EXPLORERS
Ages 11-13
Ages 14-15
Leap into the fun of
camp with a focus on
socialization and play.
Pioneers will express
their creativity
throughout every
exciting camp activity.
Laugh, play, and
discover during a
summer filled with
excitement. Your
camper will build
meaningful
friendships through
activities and
experience all the
thrilling things camp
offers!
You will have a
fabulous time
exploring at camp this
summer! Your camper
will gain a sense of
empowerment and
begin to serve as a role
model for our younger
campers. Leave your
mark at Y Camp!
As our eldest
campers, your
camper will serve as
a role model and
gain invaluable
leadership training
throughout the
summer!
$130 Members
$180 Non-Members
(price per session)
$130 Members
$180 Non-Members
(price per session)
$100 Members
and Non-Members
(price per session)
Ages 5-7
Must be entering
Kindergarten to participate.
$130 Members
$180 Non-Members
(price per session)
Ages 8-10
Summer Fun Club takes place at the
Tri-Community YMCA at 43 Everett
Street in Southbridge, MA. No
transportation is provided. Program
runs from 8:00am-5:00pm,
Monday through Friday. Extended
Care is available (See page 3 or the
parent handbook for more general
camp information).
CIT’S
For more information
see page 9.
Summer Fun Club
Field Trips:
Session 1:
Ocean Beach State Park
Session 2:
SkyZone
Session 3:
Museum Of Science
Session 4:
Baseball Game
Session 5:
Laser Tag
Session 6:
U.S.S. Constitution and
Castle Island
Session 7:
Douglas Water Slides
Session 8:
East Point Beach
Session 9:
Zoo
Session 10: **See Page 8**
(Note: Trips are subject to change)
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CAMP
FOSKETT
RUNS SESSIONS 4-9: 7/11 - 8/19
SCAMPER
CAMP
DAY
CAMP
Schedule includes daily swim
lessons, arts & crafts, project
adventure, sports & games,
archery, biking, hiking, & more!
**Activities available based on age / development**
SENIOR
CAMP
CIT’S
(Counselor in Training)
Ages 3-5
Ages 5-12
Ages 12-14
Ages 14-15
This 3-day program
(Mon-Wed-Fri)
designed for PreSchoolers will have
them swimming, doing
arts and crafts, and
hands-on activities
with a focus on
socialization.
Hands on learning,
outdoor fun, and
plenty of memories.
These campers will
focus on exploration
during their full day of
activities. These
campers will focus
on character
development.
An advanced
program for these
campers tackling
special project
focused on service
as well as mountain
biking and hiking!
These campers take
a weekly field trip!
(See page 5 for field trips)
As our eldest campers,
this age group will
take a different
approach to daily
activities throughout
the camp day. Your
camper will serve as a
role model and gain
invaluable leadership
training throughout
the summer!
$130 Members
$180 Non-Members
(price per session)
$145 Members
$195 Non-Members
(price per session)
It is the policy of the
Tri-Community YMCA that staff
do not participate in toileting.
1/2 day (9am-1pm)
$65 Members
$90 Non-Members
(price per session)
$100 Members
and Non-Members
(price per session)
Camp Foskett operates at 189 Daniels Road in
Charlton, MA. Program runs from
9:00am-3:30pm, Monday through Friday.
Extended Care is held at the YMCA, located at
43 Everett Street, with transportation available
(but is not offered for Scamper Campers).
See page 3, or the Parent Handbook
for more general camp information.
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CAMP
FOSKETT
TRANSPORTATION
PICK-UP & DROP-OFF
PROCEDURES
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**Bus Transportation NOT provided for Scamper Camp**
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A local bus company is contracted to transport campers to
and from Camp Foskett with the same standards required
by the Board of Education. Transportation is provided from
pre-determined stops selected for their convenience and
safety. The YMCA provides a ‘bus monitor’ who is
responsible for the personal safety, attendance and behavior of the campers. Bus routes are designed to accommodate the maximum number of campers while trying to limit
the length of time a child spends riding the bus. Times
given are approximate and a 5-10 minute variance either
way is reasonable.
Camp Foskett will only release campers to adults listed on
the registration under “Authorized Pick Up”. All adults must
provide a photo State I.D. at the time of pick up. If you do
not meet your child per the schedule, your child will be
transported to the Y and be supervised by camp staff.
Children will not be left unsupervised at bus stops.
BUS #1
HOLLAND - STURBRIDGE
A.
B. St. Anne’s Church Driveway, Rte 148
C.
D. YMCA
A.M. / P.M.
7:50 / 4
8:00 /
8:15 /
8:30 /
BUS #2
SOUTHBRIDGE - WEBSTER - DUDLEY
A.M. / P.M.
A.
B.
C.
D.
E.
F.
Bud’s Country Store
KFC
North Village Entrance
Shotokan Karate Academy Parking Lot
7:50 /
8:00 /
8:15 /
8:30 /
8:39 / 4:44
8:45 / 4:50
BUS #3
BROOKFIELD - SPENCER - CHARLTON
A.M. / P.M.
A. Old Lashaway School (Brookfield)
B. Spencer Big Y
C.
D. Charlton Library
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8:10 /
8:15 /
8:20 /
8:40 /
All visitors MUST check in at the Camp
Foskett Administrative Office located on
189 Daniels Road.
Early pick up & late drop off: If you are
picking up or dropping off your camper
outside of the scheduled times, you must do
so at the Camp Foskett Administrative
Office Building located on 189 Daniels Rd.
Regular pick up & drop off: If you are
planning to opt out of using the Camp
Foskett bus transportation, you may pick up
or drop off your camper at the office (the
brown building) through Camp Foskett’s
main entrance.
DIRECTIONS:
From Southbridge:
Go past Big Y on East Main St. Turn left and go
over bridge onto Saundersdale Road. Turn left
at the stop sign. Go to the next stop sign. Turn
right and go up Dresser Hill Road. At the next
stop sign, continue straight across intersection
onto Schoolhouse Road. Take the second right
onto Daniels Rd. Camp Foskett is 1.7 miles on
Daniels Road on the left.
From Sturbridge:
From Route 20, once into Charlton, turn right
onto Masonic Hill Road. Continue up the road
until you get to a stop sign, turn right onto
Route 31, Main St in Charlton. Go through the
center of Charlton. Take a left onto Muggett Hill
Road. Go past Bay Path High School. Take the
first right after Bay Path onto Bond Road. Go to
the end of Bond Rd. Bear left as the road
quickly forks. Continue straight across onto
Daniels Road. Camp Foskett is 1.7 miles down
Daniels Road on the left-hand side.
From Webster/Dudley:
From Main Street, Route 197 in Dudley. Turn at
Dudley Fire Station onto Mason Road. Turn left
at first stop sign and go past Shepherd Hill High
School. Turn right at the next stop sign onto
Ramshorn Road. Follow Ramshorn Road approx.
2.2 miles. Turn right onto Barrett Road. Camp
Foskett is .7 miles down Barrett Road on the
right-hand side.
XTEND THE
SUMMER FUN
This unique week will feature
day-by-day registration.
Daily themes, unique activities
based on the theme of each
day, and so much more!
Program at 43 Everett Street.
RUNS SESSION 10: 8/22 - 8/26
Ages 5-15
(Must be entering Kindergarten to participate)
MONDAY
TUESDAY
Theme:
Theme:
WEDNESDAY THURSDAY
Theme:
Theme:
The League Of
Superheroes
Decades
Of Fun
It’s A
Thingamajig
Medieval
Madness
Special Event:
Police & Fire
Dept. visit
Special Event:
Sock Hop
Special Event:
Painting Class
Special Event:
Indoor Archery
$26 Members
$36 Non-Members
$26 Members
$36 Non-Members
$26 Members
$36 Non-Members
$26 Members
$36 Non-Members
“After just one
week, I noticed
both of my children
not only excited to
share the day’s
activities, but the
excitement around
trying new things
and wanting to do
better the next
time.”
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FRIDAY
Theme:
One Fish, Two
Fish, Red Fish,
Blue Fish
Special Event:
SURPRISE!
$26 Members
$36 Non-Members
SUMMER CAMP
SLEEPOVER
THEME:
ANIMAL PLANET
AUGUST 19 - 20
From 6:00 PM until 9:00 AM
The Tri-Community YMCA Sleepover is on!
Complete the summer with a sleepover at the
YMCA if your camper participated in at least one
week of Summer Fun Club or Camp Foskett.
If your child is at Camp Foskett or Summer Fun
Club during Session 9, they may stay until camp
ends at 6:00pm and then transition into the
sleepover. If not, arrive at 6:00pm, drop off your
child, and allow them to reconnect with old
friends and camp counselors that evening.
C.I.T.
TRIP
Counselor In Training
WHAT TO BRING:
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Sleeping Bag & Pillow
Pajamas
Swim Suit / Towel
Toiletries
Favorite Stuffed Animal
SPECIAL TRIP FOR CIT’s
(Both Summer Fun Club & Camp Foskett)
Wednesday, August 10th
SIX FLAGS
NEW ENGLAND
New England's biggest, most popular
CIT - Counselor In Training
This program is designed for teens
ages 14 and 15 to help them enhance
their leadership skills through handson work with young people, character
development activities, and skill
development workshops. CIT’s are an
invaluable resource to the camp
community and is great preparation
to apply as staff in future summers.
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theme park featuring dozens of thrill
rides, shows, and activities!
COST: $50
CAMP
RENTALS
CAMP FOSKETT
We have been providing experiences for families and
community groups of the tri-community and beyond for
over 60 years. In the spring, summer and fall we are
always delighted to open Camp Foskett to the
surrounding community to be used as a group retreat
or getaway.
With a maximum capacity of 400, we hope
that Camp Foskett can offer a wonderful
place for whatever it is you are looking for:
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Our Facilities:
 Situated on 114 acres of woodlands & wide open fields
 Pristine and private waterfront beach access to the
beautiful South Charlton Reservoir.
 Pavilion, modern toilet facilities, bath house, changing
rooms, and large athletic fields.
 Playground equipment, rope course, archery, boating,
swimming, fishing, hiking and more!
RATES:
$400 Family Rental
$600 Corporate Rental
Non-profit (call for pricing)
A non-fundable $150 deposit is
required to hold date.
Contact Danielle Krzemien
[email protected]
for details.
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Youth leadership programs, school /
college dances and celebrations.
Family retreats, special events,
birthdays & reunions.
Small business team building programs,
group meetings & presentations.
Weddings, private events, sports
events, graduations, training programs
and more!
HOW TO
REGISTER
How to Register:
Fill out all 4 sides of the Registration Packet
completely, using one form per child (additional
copies are available at the YMCA). Place an “X” in
the white box that indicates which camp(s) and
week(s) your child is applying for. Please note
that not all camps run for a full day. Check
descriptions for details. Drop off the complete
package, including application and payment for
each session you have registered for at the
YMCA!
YMCA Membership:
As a member of the Tri-Community YMCA, your
child will receive the lowest camp rates available.
Please note: Only memberships which are paid
through September 2016 qualify for the YMCA
Member Camp rate. Payment plan or summer
memberships do not qualify for the discounted
rate. If your Family or Youth Membership expires
prior to September, only those weeks preceding
the expiration date qualify for the discount. This
may mean renewing in advance to qualify for additional weeks. A twelve-month youth membership
is only $100.00. Family and adult memberships
are also available.
Cancellation:
In the event Camp Foskett or Summer Fun Club
cannot operate due to severe weather, these
radio stations: WTAG (AM 580) and WSRS (FM
96.1) will air the announcement. If Camp
Foskett or Summer Fun Club is closed early due
severe weather, every attempt will be made to
contact parents by phone, as well as announce
the early closing on the radio, the TriCommunity Y’s website (tricommunityymca.org)
& Facebook page. If we are unable to contact a
parent, your child will be transported to the
YMCA at 43 Everett Street in Southbridge and
supervised by camp staff.
Refunds and Transfers:
If you need to change your summer camp plans,
you can transfer your child to another session
at no charge, provided that space is available.
Refunds will only be considered with a doctor’s
note. 50% of the camp fees are nonrefundable.
Refunds and transfers must be approved by the
Camp Director. Refunds will not be given in the
event of early dismissal for misconduct.
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CAMPER
INFO. FORMS
FOR OFFICE USE ONLY
Date Received:
Front Desk Initials
All Documents Attached
Yes
or
No
Date Info Entered:
Child’s Information:
Last Name: ____________________________________________ First Name: _____________________________________________ MI: __________________
Gender:  Female  Male  N/A
Date of Birth: ________________________
Age by 6/20/16: _____________
Nickname: ____________________________________________________________ Grade Entering Fall 2016: ______________________________________
Address: _______________________________________________ City: ____________________________________ State: __________ Zip: _________________
Primary Phone: ____________________________________  YMCA Member  Non-Member Exp. Date: _______________________
Emergency Name & Phone (if different from Home No.) ____________________________________________________________________________
T-Shirt Size: YS _____ YM _____ YL _____ Adult SM _____ Adult MD _____ Adult LG _____ Adult XL _____ Adult XXL _____
Parent(s) /Guardian(s) Information:
Parent/Guardian: _________________________________________________________ Relationship: ________________________________________________
Address: _______________________________________________ City: ____________________________________ State: __________ Zip: _________________
Primary Phone #: _______________________________________ Email:
Place of Employment: _______________________________________________ Work Phone: __________________________________________________
Parent/Guardian: _________________________________________________________ Relationship: ________________________________________________
Address: _______________________________________________ City: ____________________________________ State: __________ Zip: _________________
Primary Phone #: _______________________________________ Email:
Place of Employment: _______________________________________________ Work Phone: _________________________________________________
Person or agency having legal custody: ______________________________________________________________________________________________
Address if different from above: _______________________________________________________________________________________________________
 I receive financial assistance from another agency/org (proof of assistance must be presented with application)
 I receive financial assistance from the YMCA (proof of assistance must be presented with application)
Name of Organization ___________________________________ Contact __________________________________Phone ____________________________
Camp Waiver: In consideration for services rendered by the Tri-Community YMCA and acceptance of the undersigned in programs provided by the
Tri- Community YMCA, I hereby release for myself, my child, my heir, executors and administrators, any and all right and claim for damage I may
have against the Tri-Community YMCA, their agents, representatives or assignees, for any and all injuries suffered by me, my child or family. I also
understand that Health and Accident Coverage are not provided by the Tri-Community YMCA and that it is my responsibility to obtain the same.
The Tri-Community YMCA is founded on Christian principles and prohibits inappropriate behavior and conduct. This includes, but is not limited to
profanity or abusive language or attire, smoking, use of alcohol or drugs, the removal of the YMCA property and criminal conduct of any type.
Such inappropriate behavior or conduct is unacceptable and the YMCA consequently retains the right to deny membership to its applicants and to
revoke a membership of any current member or participant at its sole discretion. I understand that my membership is non-refundable, nor transferable to other people.
The following is mandatory, please initial:
_______ I understand that no part of the camp fee is refunded in the event of early dismissal for misconduct.
The following are optional, please check all that apply:
 I give permission for my child to participate in all of the activities described in the brochure for his/her age group.
 I give my permission to the YMCA to use my child’s picture in the YMCA publicity and media promotions.
Parent/Guardian Signature _____________________________________________________________ Date __________________________________________
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SESSION DATES & RATES
Place an “X” in the white box that indicates which session (s) you are enrolling your child.
Shaded area denotes the camp week is unavailable.
SESSION 1 SESSION 2 SESSION 3 SESSION 4 SESSION 5 SESSION 6 SESSION 7 SESSION 8 SESSION 9 SESSION 10
M - Member
Jun 20-24 Jun 27-Jul 1
*Jul 5-8
Jul 11-15
Jul 18-22
Jul 25-29
Aug 1-5
Aug 8-11
Aug 15-19
Aug 22-26
M NM M NM M NM M NM M NM M NM M NM M NM M NM M NM
NM - Non member
SUMMER FUN CLUB
Day Campers
(Age 5-13)
$130 $180 $130 $180 $104 $144 $130 $180 $130 $180 $130 $180 $130 $180 $130 $180 $130 $180
CIT (Age 14-15)
$100 $100 $100 $100
$80
$80
$100 $100 $100 $100 $100 $100 $100 $100 $100 $100 $100 $100
CAMP FOSKETT
Scamper
(Age 3-5)
$65
Traditional
(Age 5-12)
$130 $180 $130 $180 $130 $180 $130 $180 $130 $180 $130 $180
Senior
(Age 13-14)
$145 $195 $145 $195 $145 $195 $145 $195 $145 $195 $145 $195
CIT (Age 14-15)
$100 $100 $100 $100 $100 $100 $100 $100 $100 $100 $100 $100
$90
$65
$90
$65
$90
$65
$90
$65
$90
$65
$90
SUMMER CAMP SLEEPOVER
August 19 - 20
$25
CIT TRIP TO SIX FLAGS NEW ENGLAND
August-16
$50
XTEND THE SUMMER FUN
Mon, Aug 22
$26
$36
Tues, Aug 23
$26
$36
Wed, Aug 24
$26
$36
Thurs, Aug 25
$26
$36
Fri, Aug 26
$26
$36
*Note: The Tri-Community Y is closed on Monday, July 4th
TOTAL FEES DUE: $ ________________
PAYMENT INFORMATION
Payment Type (check):
 Cash / Check
 Scholarship
 Credit Card
 VISA
 AMEX
 MC
 DISCOVER
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Check Total $ _______________________
Cash Total $ __________________________
Credit Card Total $ ____________________
Scholarship Total $ _____________________
Credit Card # _________________________________________________ Exp. Date ___________
Name as it appears on Credit Card ____________________________________________________
Signature ______________________________________________________ Date ______________
TRANSPORTATION &
AUTHORIZED PERSONS
Last Name:
First Name:
DOB:
ARRIVAL TRANSPORTION (Select one)
DEPARTURE TRANSPORTION (Select one)
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


Parent will drop off at Camp Foskett
Parent will drop off at YMCA for SFC
AM Extended Care @ YMCA
Program bus for all Camp Foskett programs,
except Scamper Camp
Bus # _______ Letter Stop _______
Parent will pick up at Camp Foskett
Parent will pick up at YMCA for SFC
PM Extended Care @ YMCA
Program bus for all Camp Foskett programs,
except Scamper Camp
Bus # _______ Letter Stop _______
See Page 7 for more information on drop-off and pick-ups locations
I give permission for my child to be released from the program at the end of the day as stated above and /or give
permission to the following people to receive my child at the end of the day. Please note: Appropriate paperwork such as custody papers, must be attached if the custodial parent requests not to release the child to the
other parent.
_________________________________
Address:
_________________________________
Address:
Any other transportation requests must be stated in writing and maintained in the child’s file, or the above plan
must be implemented. This permission is valid for one year from the date of signature.
Signature
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Date
HEALTH INFORMATION FORM
Last Name: _____________________________________________ First Name: ______________________________________________ DOB: _________________
Emergency Contact ____________________________________________________ Ph# _______________________ Relationship: _____________________
Family Physician _________________________________________ Address: _______________________________________ Ph# __________________________
Medical Insurance Co ______________________________________ Policy# ___________________________ Subscriber ____________________________
IMMUNIZATION HISTORY
MEDICAL HISTORY
(CHECK ALL THAT APPLY)















Chicken Pox
Convulsions
Ear Infections
German Measles
Asthma
Heart Disease
Measles
Mumps
Rheumatic Fever
Poliomyelitis
Tonsillitis
ADD/ADHD
PDD
ODD
Other















All immunizations up-to-date?
Birth Defects
Diabetes
Encephalitis
Bi-polar
Hernia
Kidney Disease
Meningitis
Autism/Asperger's
Scarlet Fever
Depression
Anxiety
OCD
Strep Throat
Whooping Cough
Bee/Hornet Allergy
 YES  NO
Physician’s Signature
MONTH
YEAR
DPT / TD
Mumps, measles, rubella* (MMR)
Polio* (IPV)
Pneumococcal (PCV)
Hepatitis B
Hepatitis A
Varicella (chicken pox)
Meningococcal meningitis (MCV4)
SPECIFIC MEDICAL, BEHAVIORAL OR DEVELOPMENTAL NEEDS
Dietary Modifications/Allergy
Chronic/Recurring Illness
Current Medications (medication authorization may be required)
Operations/Serious Injury
Physical Disability
Developmental Delays
Behavioral Disorder
List any activities from which your child should be exempted for health reasons:
PARENT AUTHORIZATION:
This Health History is correct so far as I know, and the person herein described has permission to engage in all
prescribed activities, except as noted by me and the examining physician. In the event I cannot be reached in an
EMERGENCY, I hereby give permission to the physician selected by the Director to hospitalize, secure proper
treatment for and to order injection, anesthesia or surgery for my child as named above.
Signature ______________________________________________________________________________________ Date ______________________________________
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TRI-COMMUNITY YMCA
43 Everett Street
Southbridge, MA 01550
www.tricommunityYMCA.org
Like “Tri Community YMCA” on Facebook!
OPEN HOUSE DATES:
SUMMER FUN CLUB - Sat. March 19th
At the Tri-Community YMCA from 10am-2pm
CAMP FOSKETT - Sunday, June 5th
At Camp Foskett in Charlton from 1-4pm
Visit and Take A Tour
of the Facilities!
Meet our camp staff, enjoy some fun
activities, register for camp and only pay
a $20 deposit during these two “Open
House” days. AND be entered into a
raffle to win a FREE week of Camp!
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