summer day camp registration packet

CAMP IS Y
Summer Day Camp
Lake Community YMCA
May 31- August 19, 2016
WHEN
Grades 1-8
The completed registration
packet and payment for the first
week must be received before
your child may attend. ALL
OUTSTANDING BALANCES MUST
BE PAID IN FULL before your
child can be registered for
Summer Day Camp.
Please return this completed
packet to the Lake Community
YMCA as soon as possible and
allow three days to process.
Monday-Friday
630AM-630PM
JR DAY CAMP
Entering grades 1-2
WHERE
Lake Community YMCA
DAY CAMP
Entering grades 3-5
WHAT
Swimming
Field Trips (Now on Wednesdays!)
Outdoor Play
Crafts
AND MUCH MORE!
MEMBER
Part Time $100
Full Time $120
NON- MEMBER
Part Time $120
Full Time $140
Fill out and return the following pages:
- Child Information
- ODJFS Health Enrollment forms
- Schedule and Tuition Agreement
-Field Trip Permission
-Behavior Expectations and Discipline Policies
-Sunscreen & Purell Forms
*Special Care Plans & Medication Distribution forms are required for
children with allergies or special medical conditions.
**Camp Staff are CPR, First Aid, Communicable Disease & Child Abuse
Awareness Certified
**Morning and Afternoon Snack and lunch milk included
CAMP MID
Entering grades 6-8
MEMBER
Part Time $105
Full Time $125
NON- MEMBER
Part Time $125
Full Time $145
WEEK
THEME
TRIP
GOLD RUSH
QUAIL HOLLOW & PUMP IT UP
#2 June 6-10
AGE OF INVENTION
CLEVELAND ZOO
#3 June 13-17
ALL THAT JAZZ
NORTH CANTON SKATE CENTER
& PRICE PARK
#4 June 20-24
9-5
MASSILLON REC CENTER
ROCKIN ROBIN
GREAT LAKES SCIENCE CENTER
DISCO DAYZ
PIZZA HUT & BRIAN’S PARK
#7 July 11-15
HAMMER TIME
CLEARWATER PARK
#8 July 18-22
YOU’VE GOT MAIL
HOT POTS &
HUSTON BRUMBAUGH NATURE CENTER
#9 July 25-29
Y2K
CINEMARK MOVIES 10 & PRICE PARK
#10 Aug. 1-5
IN SYNC
DOVER PARK & POOL
#11 Aug. 8-12
TO INFINITY & BEYOND
BOETTLER PARK
#12 Aug. 15-19
GET READY TO PARTY
UHRICHSVILLE WATERPARK
#1 May 30-June 3
#5 June 27-July 1
#6 July 4-8
THINGS TO KNOW:
 APPLY
·
SUNSCREEN EVERY DAY BEFORE ARRIVAL.
The Y will provide generic sunscreen for application throughout the day.
·
MORNING SNACK BEGINS AT 8:30 AND ENDS AT 8:50 EACH MORNING.
·
PACK YOUR LUNCH EACH DAY IN A REUSABLE LUNCH BOX
· The state requires that the children have the following items in their packed lunches: a
carbohydrate (bread, crackers, pretzels), a protein (meat, peanut butter, cheese), a fruit and a
vegetable or two fruits.
· You will be charged $1.00 per item if we have to substitute any items.
· No candy or pop
· You will be charged $3 for each missing lunch.
·
BRING YOUR SWIMSUIT AND TOWEL EACH DAY
·
BRING AN EXTRA SET OF CLOTHES EACH DAY. (We will get messy from time to time.)
·
BRING A REUSABLE WATER BOTTLE WITH NAME ON IT
·
WEAR SHOES AND SOCKS EVERYDAY (no sandals or crocks)
·
CHILDREN MUST WEAR THEIR CAMP SHIRTS ON TRIP DAYS AND PARK DAYS
·
LEAVE ALL ELECTRONICS, CELL PHONES, TOYS AND MONEY AT HOME
·
PUT YOUR NAME ON EVERYTHING THAT COMES TO THE CENTER
YMCA of CENTRAL STARK COUNTY
SUMMER DAY CAMP REGISTRATION 2016
CHILD’S INFORMATION
Child’s Name (first/last) ______________________________________________________________ Home Phone # ________________________
Address ______________________________________________________________________________________________________________________________
City_________________________________________________________________________ State ____________ ZIP _________________________________
Male
Female Birth date _______/_______/_______ Age __________ Grade (School year 2016/2017) ________________
Membership Status (Please circle one):
Member
Non-Member
1st Parent ____________________________________________________Birthdate __________________Contact Phone # ___________________
2nd Parent __________________________________________________Birthdate __________________Contact Phone # ___________________
Parent Email ________________________________________________________________________________________________________________________
Marital Status:
Married
Separated
Divorced
Single
Custody/Contact restrictions (Equal access to the center and child will be granted to each parent in the absence of a Court
order, which must be provided to the YMCA, specifying otherwise).
___________________________________________________________________________________________
Please list the persons permitted to pick-up your child.
___________________________________ Phone # _______________ Relationship ____________________
___________________________________ Phone # _______________ Relationship ____________________
___________________________________ Phone # _______________ Relationship ____________________
___________________________________ Phone # _______________ Relationship ____________________
___________________________________ Phone # _______________ Relationship ____________________
T-Shirt Size (circle one):
Child’s Camp:
XS (2-4)
S (6-8)
Jr Day Camp (Grades 1-2)
M (10-12)
L (14-16)
Day Camp (Grades 3-5)
AS
AM
AL
Camp Mid (Grades 6-8)
1st week’s payment:__________
LakeLouisville
Community
AreaYMCA
YMCA
YMCA of Central Stark County
Schedule and Tuition Agreement Summer 2016
Child’s Name _________________________________________________
Start Date _______________________________________
Are you responsible for entire tuition payment? ____________ (If “no” please explain)
_______________________________________________________________________________________________________________________________________
Are you receiving assistance through Ohio Jobs and Family Services?
YES
NO
Copay? ________________
Please circle your tuition schedule:
Y Member
Non-Member
Y Member
Non-Member
1-3 days
1-3 days
4-5 days
4-5 days
JR Day Camp & Day Camp
$100
$120
$120
$140
Camp Mid
$105
$125
$125
$145
Please put an “X” on each week that your child will attend camp.
If he/she will be attending part-time, please circle the days of the week that he/she will be in attendance.
Program
1
2
3
4
5
6
5/30-6/3
6/6-6/10
6/13-6/17
6/20-6/24
6/27- 7/1
7/4-7/8
TWHF
MTWHF
MTWHF
MTWHF
MTWHF
TWHF
7
8
9
10
11
12
7/11-7/15
7/18-7/22
7/25-7/29
8/1-8/5
8/8-8/12
8/15-8/19
MTWHF
MTWHF
MTWHF
MTWHF
MTWHF
MTWHF
Payment Options
1. Bank Drafting (Please include a voided check)
 Weekly  Bi-Weekly  Monthly
Account Type:
 Checking  Savings
Bank ______________________________________________________________________________________________
Bank Address/City/State/Zip ________________________________________________________________
Transit & Routing # _______________________________________________________________________________
Account # ________________________________________________________________________________________
2. Credit Card Draft
 Weekly  Bi-Weekly  Monthly
 Credit Card  Debit Card
 MasterCard  VISA  Discover  American Express
Issuing Bank Name _________________________________________________________________________
Name on Card __________________________________________________ Exp. Date ______________
Account # _____________________________________________________________________________________
3. On-line Payments at www.ymcastark.org
Payment Policy:
 Camp fee payment is due one week in advance of attendance.
 ODJFS Co-pays are due weekly.
 Accounts that have a balance of 2 weeks or more will be considered delinquent – Y staff will be
contacting the responsible parent to reconcile balance and keep account current.
 Payments/Refunds will be applied to any outstanding Y balances first then to current programming
fees.
 The Lake Community YMCA Day Camp closes at 630PM. A $1 per minute per child late fee is charged
after those times.
 I understand I will be charged for the program and rate for which I signed up my child.
 I understand that weekly tuition is not adjusted for days missed due to illness.
 A 2 week written notice is required for any change in camp schedule, otherwise the account will be
charged based on the schedule for which you signed up.
 All correspondence regarding billing should be directed to the Child Care Director, Christina Collins.
___________________________________________
Parent/Guardian Signature
Staff Initials ___________________
____________________________________________
_____________
Print Name
Date
Date______________________
CHILD’S NAME _____________________________________________
DOB ______________
FIELD TRIP PERMISSION
By initialing & signing below, I hereby grant permission to the Lake Community YMCA for my child to travel by foot or by
Petermann bussing from the Lake Community YMCA to the following locations for summer field trips on the dates indicated.
Y
N
I give permission for my child to participate in swimming activities in the program.
*** My child is a _________ swimmer _________ non-swimmer ***
DATE
FIELD TRIP
June 1,
2016
Quail Hollow State Park** & Pump It Up
June 8,
2016
June 15,
2016
Cleveland Zoo
June 22,
2016
June 29,
2016
July 6,
2016
July 8,
2016
July 13,
2016
July 20,
2016
Massillon Recreation Center**
July 27,
2016
Cinemark Movies 10 & Price Park
Aug. 3,
2016
Aug. 10,
2016
Aug. 17,
2016
Dover Park & Pool**
(13480 Congress Lake Ave. Hartville OH)
(1135 W Maple St Hartville OH 330.877.7867)
(3900 Wildlife Way 216.635.3391)
TIMES
PARENT
INITIALS
9AM-330PM
830AM-4PM
North Canton Skate Center & Price Park
(5475 Whipple Ave NW North Canton OH 330.499.7170)
(1000 W Maple St. North Canton OH)
(505 Erie St. N. Massillon OH 330.832.1621)
Great Lakes Science Center
(601 Erieside Ave. Cleveland OH 216.694.2000)
Pizza Hut & Brian’s Park
(925 W Maple St. Hartville OH 330.877.8333)
Character Olympics at the Lake Community YMCA
(428 King Church Ave. SW Uniontown OH 330.877.8933)
Clearwater Park**
(12712 Hoover Ave. NW Hartville OH 330.877.9800)
9AM-4PM
10AM-4PM
830AM430PM
9AM-330PM
10AM-2PM
1030AM-4PM
Hot Pots Alliance & Huston-Brumbaugh Nature Center**
(1828 W. State St. Alliance OH 330.823.3333)
(1972 Clark Ave. Alliance OH 330.823.7487)
(6284 Dressler Rd. NW North Canton OH 330.497.9118)
(1000 W Maple St. North Canton OH)
(3000 Tremont St. Dover OH 330.343.0731)
Boettler Park
(5300 Massillon Rd. North Canton OH 330.896.6621)
Uhrichsville Water Park**
(401 E 12th St Uhrichsville OH 740.922.8780)
9AM-4PM
9AM-4PM
830AM-4PM
9AM-4PM
930AM-4PM
I give permission for my child to walk to the Lake Community Branch Library (565 Market Ave. SW,
Uniontown, OH 330.877.9975) during the weeks of May 30th-August19th, 2016 to participate in the
Summer Reading Program and related events.
I give permission for my child to walk to Lake Community Park (11858 Market Ave. NE, Uniontown, OH
44685) one to two days each week they attend between the dates of May 30th and August 19th, 2016 to
utilize the park playground and to participate in planned activities.
*Field Trip schedules are subject to change based on extenuating circumstances.
** Water with a depth greater than 2-feet will be present on the grounds of this trip.
The Center will provide one additional staff member for every 18 children when we are offsite and one additional staff member
per 10 children for swimming field trips and routine trips.
Field trips will leave promptly each day. All children who go will participate in the activities planned on that trip. I understand
that swimming will be part of some of these activities. I understand my child must be at the Lake Community YMCA by time
listed above on field trip days or he/she may miss transportation to the field trip location. If this happens, the YMCA will not
provide care for my child that day. We will return from trips by time listed above unless extenuating circumstances arise.
Parent/Guardian Signature ____________________________________________________________________________________Date _____________________________
ADDITIONAL PERMISSION
Camp Mid Only
CHILD’S NAME _____________________________________________
DOB ______________
By initialing & signing below, I hereby grant permission to the Lake Community YMCA for my child to travel by foot or by
Petermann bussing from the Lake Community YMCA to the following locations for summer field trips on the dates indicated.
Y
N
I give permission for my child to participate in swimming activities in the program.
*** My child is a _________ swimmer _________ non-swimmer ***
DATE
FIELD TRIP
June 10,
2016
Center Ice Sports Complex & Boettler Park
June 17,
2016
June 24,
2016
July 1,
2016
July 15,
2016
Clearwater Park**
July 28-29
2016
(8319 Port Jackson Ave. NW Canton OH 330.966.0169)
(5300 Massillon Rd. North Canton OH)
(12712 Hoover Ave. NW Hartville OH 330.877.9800)
Hartville Marketplace
(1289 Edison St. NW Hartville OH 330.877.9860)
Pro Football Hall of Fame
(2121 George Halas Dr. NW Canton OH 330.456.8207)
NTR Canoe Livery
(11358 OH-212 Bolivar OH 330.874.2002)
YMCA Camp Tippecanoe-Camp Mid Overnighter
(81300 Stewart Rd. Tippecanoe, OH 800.922.0679)
TIMES
PARENT
INITIALS
830AM-3PM
10:15AM-4PM
9AM-3PM
830AM-4PM
830AM-4PM
Thursday:
730AM-630PM
(Overnight)
Friday:
630AM-630PM
Aug. 5,
Pump It Up
1130AM-215PM
(1135 W Maple St Hartville OH 330.877.7867)
2016
Aug. 11,
Uhrichsville Waterpark
930AM-430PM
(401 E. 12th St. Uhrichsville OH 740.922.8780)
2016
I give permission for my child to walk outside of the YMCA Program building with the staff for
the occasional walking trip. Any trips requiring a specific permission slip would be provided
including the exact nature of the activity, destination, transportation being used, specific time
period, time of departure and return to the center.
*Field Trip schedules are subject to change based on extenuating circumstances.
** Water with a depth greater than 2-feet will be present on the grounds of this trip.
The Center will provide one additional staff member for every 18 children when we are offsite and one additional staff member
per 10 children for swimming field trips and routine trips.
Field trips will leave promptly each day. All children who go will participate in the activities planned on that trip. I understand
that swimming will be part of some of these activities. I understand my child must be at the Lake Community YMCA by time
listed above on field trip days or he/she may miss transportation to the field trip location. If this happens, the YMCA will not
provide care for my child that day. We will return from trips by time listed above unless extenuating circumstances arise.
Parent/Guardian Signature __________________________________________________________________________________________ Date _____________________________
Child’s Name:
Child’s Date of Birth:
____
Y
N
I give permission for my child to be included in publicity pictures connected with the program, including
those used in online media such as on our website and Facebook page.
Y
N
My child is up to date on all vaccinations required by the Department of Health.
His/her last tetanus vaccination was received on ______/______/______.
I, the undersigned parent/guardian, do hereby accept all responsibility for, and assume the risk of any injury or
damage to my person or dependent children which might arise directly or indirectly as a result of, and/or participation
in a YMCA of Central Stark County program. I hereby expressly release, discharge and hold harmless from any liability
whatsoever the YMCA, the various branches and subdivisions expressly including but not limited to the Board of
Trustees of the YMCA, except for injuries caused intentionally, or by willful misconduct. I certify that I am familiar
with the contents of the release, that I have read and understand the same, and that it is my intention by signing this
release that the same be binding not only on me, but my heirs, administrators, executors, successors, and assigns.
The YMCA of Central Stark County is not responsible for misplaced or stolen items. PERMISSION TO TREAT: IN CASE
OF MEDICAL ILLNESS OR INJURY, I hereby give permission to YMCA Day Camp personnel to provide routine health
care, first aid, medication or treatment as determined by medical personnel. IN CASE OF MEDICAL EMERGENCY or
medical care beyond the scope of camp facilities, I understand that every effort will be made to notify listed
contact(s). I authorize YMCA Day Camp personnel to act on my behalf and secure emergency medical treatment and
grant permission to the attending physician to secure proper treatment for the named camper.
Parent/Guardian Signature
Date
Grant and United Way Information
Agencies like the United Way allocate funds to the YMCA every year. We use this money to help with financial
assistance to those who need it which in turn keeps fees lower. Please fill in the information requested below to help
the Child Care Programs with our funding requests.
Child’s Gender (circle): Male
Female
Child’s Race (please circle one below)
American Indian/Alaska Native
Hispanic/Latino
Family Size (please circle one): 2
Asian
Native Hawaiian/Pacific Islander
3
Household Income Level (please check one):
$0-$9,999
$10,000-$19,999
$20,000-$29,999
4
5
6
7
Black/African American
White
8
$30,000-$39,999
$40,000-$49,999
$50,000+
Thank you for completing the information above. It is greatly appreciated and will be very beneficial in our grant
application process.
YMCA of Central Stark County Summer Day Camp
BEHAVIOR GUIDANCE / MANAGEMENT POLICY
Our goal is to set guidelines and limitations to develop a feeling of self-worth and competence. Each site has rules
that need to be followed by each child. The Camp Director/Counselors will review these rules with the groups and
they will be posted.
When children are on field trips or at the YMCA for swimming or other activities participants will be expected to abide
by the rules pertaining to each program area and on the bus.
When behavior management problems arise, staff will use a problem-solving approach to support children in resolving
conflicts. In this six step approach, a staff will:
1. Approach calmly, stopping any hurtful actions or language.
2. Acknowledge the children’s feelings using simple descriptive words.
3. When the children are calm, gather information by asking the children to describe the problem in their own
words.
4. Restate the problem to clarify issues and restate any hurtful language.
5. Ask the children for ideas and choose a solution together involving natural consequences.
6. Give follow-up support to make sure the problem is solved and the children are satisfied.
All direct care staff and support staff (i.e. food service or janitorial) will follow this policy. At no time will any form of
corporal punishment or shaming be used. Children are never deprived of food as a form of discipline. The entire
group is not punished for the actions of one or a few. Children are not restricted from activities for extended periods
of time. If the conflict resolution steps and redirection to other activities fail, the next step will be a discussion with
the parent or guardian to develop a behavior plan consistent with our discipline policy and licensing guidelines.
If the behavior still continues, a suspension will result. The number of days suspended will be determined by the
severity of the action. A last resort will be to expel the child from the program.
Our disciplinary steps are always based on an understanding of the individual child’s needs and stage of development.
It is our desire to help each child develop self-control, as well as respect for the rights of others.
When there are recurring problems, sufficient attempts to follow the above steps have failed, and the behavior
involved may result in unsafe conditions for the child, others or the program environment, immediate removal from
the program may be necessary. Examples may include running from staff to an unsafe area, bringing a weapon to
child care, or physical or verbal confrontations with another child or staff. Such confrontations will result in an
immediate “pick-up” for the day.
Abusive language or actions of parents may also result in dismissal of the child.
Please initial each statement and sign below:
initials
I understand that in a crisis situation, my child may be physically held to prevent bodily harm to self
and/or others, or the destruction of property. Physical holding shall be utilized for the minimum frequency
and duration possible and shall not be used as punishment, convenience for staff, or as a means for
compliance with behavioral expectations.
I have read and understand the above stated Discipline Policy.
initials
SIGNATURE
____________________________
(Parent or Guardian)
DATE
______
Aug. 30, 2015 – Aug. 29, 2016
Aug. 30, 2015 – Aug. 29, 2016
Lotion
Enough to cover skin
For preventative care after swimming or showering
Aug. 30, 2015 – Aug. 29, 2016
Lotion
Enough to cover skin