YMCA Camp Pine Crest Little Critters Day Camp Registration Form

YMCA CAMP PINE CREST
Little Critters Day Camp (ages 4-8) REGISTRATION FORM 2016
Welcome and thank you for choosing the YMCA. Please note: Registrations must be submitted 1 week prior to the
start date of the session you are registering for. This is for staffing purposes. Thank you.
CAMPER INFORMATION Last Name:
First Name:
Gender:
Address:
City:
Postal Code:
Age (as of July 1, 2015)
D.O.B.
Health Card # (optional)
Swim Level:
Grouped with:
Legal Custody:
SESSION INFORMATION Week
Date
Base Fee
Pls 
1
$185 July 11-15
2
$185 July 18-22
3
$185 July 25-29
4
$148
August 2-5
5
$185 August 8-12
6
$185 August 15-19
7
$185 August 22-26
August 29-September 2
$185 8
Please note: We will not be offering camp during the week of July 4 - 9 and August 1. All campers must be signed in and signed out by a parent/guardian or a person over the age of 16 years. Program day starts at 8:00
am and ends promptly at 4:30 pm.
After care: 4:30-5:30
□ $15 / week
PARENT/GUARDIAN 1
Pine Crest t-shirt
□ $15/ shirt
PARENT/GUARDIAN 2
(Authorized pickup and primary emergency contact)
(Authorized pickup and secondary emergency contact)
Last Name:
First Name:
Relationship to camper:
Work Phone:
Home Phone:
Cell Phone/Pager:
Email:
PAYMENT INFORMATION Last Name:
First Name:
Relationship to camper:
Work Phone:
Home Phone:
Cell Phone/Pager:
Email:
To secure your child's spot - a deposit of $25.00 per child/per week is required at the time of registration.
$25 deposit with scheduled payments (until June 30)
Full Payment
Payment total: Program fee X # weeks
Cheque (please include)
After care X # weeks
Visa
T-shirt ($15)
Pine Crest Annual Giving Campaign Donation
Mastercard
Cash (please include)
Total
Please make cheques payable to "YMCA of Greater Toronto". Camp payment must be paid in full by June 30, 2016 **Please note we
are no longer able to request written credit card information and so if you are paying by credit card, please call 1-877-303-2267 to
speak to our registrar directly. Your YMC!’s charitable registration number is: 11930 7080 RR0001
CANCELLATIONS AND REFUNDS Requests for cancellations or refunds must be made in writing and submitted to YMCA Camp Pine Crest for review. Please contact our registrar directly for refund criteria.
Refunds are not granted for inclement weather or for inability to attend each day of the session. Refunds will not be issued in instances where the camper is removed from
the camp program at the choice or request of the camper, camper's parent/guardian, or is dismissed from the camp for contravention of camp guidelines or the camp code
of conduct for behaviour.
YMC! Camp Pine Crest reserves the right to cancel registrations and to not accept responsibility for the camper at camp if the camper’s medical information is not
completed and if the authorization is not signed by the parent/guardian and returned to YMCA Camp Pine Crest prior to the commencement of the camp session. YMCA
Camp Pine Crest reserves the right to cancel programs by June 15, 2016 due to inadequate registration.
YMCA CAMP PINE CREST
Little Critters Day Camp (ages 4-8)
CAMPER HEALTH INFORMATION
Camper's Name:
Parent's Name:
Condition
Allergies
Medications
Food
Insects
Other
Does your child carry an epi pen?
Yes





No





Doctor's Name:
Phone:
Please provide full details


Asthma


Seizures


Diabetes


Dietary Restrictions


Medications


Does your child receive medication at camp?


ADD/ADHD


Is your child on a medication holiday at camp?


Behaviour Issues


Does your child receive support at school?


AUTHORIZATION- Registration will not be processed without a signature below
While YMCA staff and instructors will make every reasonable effort to minimize exposure to known risks, I understand that in registering my child/children in a YMCA Camp
Pine Crest program, my child/children will be involved in physical activities and that with any physical activity, there is risk of injury. I do hereby release the YMCA of Greater Toronto (YMCA), and its respective officers, directors, employees, volunteers and agents, and their successors and assigns, from all
liability for damages sustained in consequence of loss, injury or damage to myself or my child/children, and from all other actions, causes of action, claims, demands or
damages of any kind with respect to death, injury, loss or damages to any person or property including myself or my child/children arising out of or connected with
preparation for, or participation in YMCA programs or activities.
I have provided a complete and accurate health history and permit my child/children to participate in the full range of camp activities, except as noted by me in the health
information section of the YMCA registration form.
In the event of an accident, injury or illness involving my child, and immediate contact by the YMCA with a parent/guardian cannot be made, I authorize and grant permission
to YMCA staff to secure proper medical treatment and authorize on my behalf all procedures, including admission to an emergency unit, hospital and treatment therein,
ordering of x-rays, tests or treatment, injections, anesthesia and/or surgery, as deemed necessary by the attending medical professional(s). I agree not to hold the YMCA of
Greater Toronto responsible for any costs or injury arising out of an emergency situation.
The YMCA may wish to use photographs, images or recordings containing my child/children's picture or image for promotional, advertising, public relations and/or
informational purposes. Such photographs, images or recordings may be used or published in YMCA brochures, newsletters, annual reports, posters and/or on
website/internet materials.
The safety of each individual is of the utmost importance to the YMCA. I and my child/children recognize a personal responsibility to learn and follow at all times safety and
other rules established by YMCA staff. I and my child/children understand that any behavior that places my child/children, or others, at risk may result in immediate
dismissal from the program. I agree to assume any expense(s) arising from program dismissal. I understand no refund will be granted for dismissal or removal of my
child/children at my or my child's/children's request before the end of a camp session. I have carefully read, understand and accept Assumption of Risk and Release, Authorization, and Code of Conduct information outlined above. I have
the authority to sign on behalf of the child's/children's, I am the parent/s and or legal guardian/s. In registering, I am permitting my child ______________________ to attend YMCA Camp Pine Crest, operated by the YMCA of GTA.
Signature of Parent/Guardian
Camp Contact: 1-877-303-2267
Printed Name
Date
[email protected]