2018 Summer Camp Registration Form

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1 INDEPENDENT HEALAMILY BRANCH YMCA 2018 Summer Camp Registration Form Child s Information Name (first/middle/last) Office Use Only [ ] Received registration packet Initials Nickname [ ] Male [ ] Female of Birth Grade entering Sept 2018 Phone Home Address City State Zip May we use your child s picture in publicity photos? [ ] Yes [ ] No Family Information Parent/Guardian Name of Birth Address City State Zip Cell Phone Work Phone Address Parent/Guardian Name of Birth Address City State Zip Cell Phone Work Phone Address EMERGENCY Information In case of emergency, please contact the following first: Name (p) Emergency Contact and Youth Pickups (if mother, father or guardian cannot be reached): People listed to pick up children must be 18 years of age or older and must have a photo ID with them when picking up children: Allergies Describe reaction and management of the reaction Medications (e.g., penicillin) Food (e.g., eggs, dairy) Other (e.g., insect stings, hay fever) Payment Information The deadline for financial assistance is June 1, [ ] Check [ ] MasterCard [ ] Visa [ ] Discover [ ] AMEX [ ] Automatic Draft (call branch for details) ly Deposit Enclosed $ (A non-refundable, non-transferable deposit must accompany each week selected, which is deducted from the weekly fee.) Card # Exp. Signature

2 INDEPENDENT HEALAMILY BRANCH YMCA SUMMER CAMP PROGRAM FORM Use this form to register for camp by checking the appropriate box for the desired weeks. The first price that is listed is for Y members, followed by program member price. For camps with the 3 day option, please circle the days attending. There is no camp July 4, Camps are prorated for the week of July 2-6, Questions? Call with questions or for more information! 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13 8/20 8/ Tech Dr, Amherst Fee Young Explorers Ages 3 - entering kindergarten 3 Day $130/$156 5 Day $190/$228 M T $190 $228 Teen Camp Entering grades 7 & up $190 $228 Bounce & Splash Camp Entering grades 1-6 $218 $262 CLARENCE CAMP Clarence Middle School, Greiner Rd, Clarence Sports Camp Entering grades 1-6 Teen Camp Entering grades 7 & up Travel Camp Entering grades 1-8 SWEET HOME Sweet Home High School, 1901 Sweet Home Rd, Amherst Day $218 $262 Young Explorers Ages 3 - entering kindergarten 3 Day $130/$156 5 Day / Sports Camp Entering grades 1-6 Teen Camp Entering grades 7 & up YMCA Camp Tahigwa 2432 Richley Rd, Corfu $195 LIT Entering grades 7 & up $195 Mountain Biking Camp Entering grades 3-8 $215 $245 YMCA Member [ ] Yes [ ] No

3 Child s Information Name (first/middle/last) of Birth Camper Health History The following information must be completed by the parent/guardian. The intent of this information is to provide camp staff the background to provide appropriate care. Provide complete information so that the camp is aware of your child s needs. Child s Physician (p) Insurance Carrier Identification # Group # Name of insured Relationship to child Medications Medications require a separate form. Please contact the camp director or staff for more information. Immunization History - Attach a copy of child s immunization records and list the month/day/year administered below. DPT Series / / / / / / / / / / / / MMR / / / / Tetanus/Diphtheria / / / / / / / / / / / / or measles / / / / Tetanus / / / / / / / / / / / / or mumps / / / / Polio OPV (Sabin) / / / / / / / / or rubella / / / / HIB Vaccine / / / / / / / / Varicella / / / / Hepatitis B / / / / / / TB Mantoux Test / / Haemophilus Influenza B / / TB Test Results [ ] Positive [ ] Negative Has participant had: 1. Measles [ ] Yes [ ] No 15. Recent injury, illness or infectious disease [ ] Yes [ ] No 2. Chicken Pox [ ] Yes [ ] No 16. Chronic or recurring illness/condition [ ] Yes [ ] No 3. German Measles [ ] Yes [ ] No 17. Heart defect/disease/murmur [ ] Yes [ ] No 4. Mumps [ ] Yes [ ] No 18. Eating disorder [ ] Yes [ ] No 5. Hepatitis A/B/C [ ] Yes [ ] No 19. Diarrhea/constipation [ ] Yes [ ] No 6. Mononucleosis [ ] Yes [ ] No 20. Wear glasses, contacts or protective eye wear [ ] Yes [ ] No 7. Frequent ear infections [ ] Yes [ ] No 21. Orthodontic appliance (e.g., retainer) [ ] Yes [ ] No 8. Asthma [ ] Yes [ ] No 22. Hypertension (high blood pressure) [ ] Yes [ ] No 9. Diabetes [ ] Yes [ ] No 23. Emotional difficulties for which professional [ ] Yes [ ] No 10. Seizures/Convulsions [ ] Yes [ ] No help was sought 11. Frequent headaches [ ] Yes [ ] No 24. Any specific activities that child cannot [ ] Yes [ ] No 12. Head Injury [ ] Yes [ ] No participate in or needs assistance 13. Knocked unconscious [ ] Yes [ ] No 25. Dizzy/passed out after physical activity [ ] Yes [ ] No 14. Skin Problems [ ] Yes [ ] No (e.g., itching rash, acne) of last physical Please explain any YES answers, noting the applicable number Any additional information about the participant s behavior and physical, emotional or mental health the camp should be aware of: PERMISSION TO PROVIDE NECESSARY TREATMENT OR EMERGENCY CARE [ ] Yes [ ] No I hereby give permission to the medical personnel selected by the camp director to order x-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me/or my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for the participant. This completed form may be photocopied for trips out of camp. Field Trip AcknowledgemenT [ ] Yes [ ] No I give my son/daughter permission to attend all Y field trips for the sessions that he/she is registered. My child also has my permission to participate in swimming activities on field trips, including aquatic amusement park activities.

4 mission to supervise application of topical items (Sunscreen, Bug Spray, Lip Balm) Type of Topical Item Prescription # Start End Days to be Taken Time of Day Amount (Dosage) [ ] Yes [ ] No I request that the camp staff supervise my child taking the above medication or applying the topical items as indicated. I acknowledge that the information stated on this form is accurate and factual. Parent/Guardian Signature ONLY: : Registration & Refund Policies Space is limited in all YMCA programs. We encourage early registration for our popular camp programs to avoid being closed out of the sessions of your choice. Registration begins January 1 for the 2018 season. A non-refundable, non-transferable deposit must accompany each week selected. This is deducted from the weekly fee. $10 registration fee per child per week 1/1/18-2/28/18. $30 registration fee per child, per week 3/1/18-9/2/18. In the case of serious or prolonged illness or injury, all paid fees (except the deposit) will be refunded with a written note from your child s physician. Payment in full is required two (2) weeks before each week of attendance. Children will not be admitted into camp without a completed health form and proof of immunizations. Failure to make payment on time may forfeit your child s spot. Campers are assigned by the grade they will be entering in September Requests to be assigned with other campers cannot be guaranteed. If you pick up your child after 6:00 pm, a late fee of $20.00 per child will be applied to your bill. Consistent late pick-up will result in dismissal from the program. Prices are subject to change without notice. FINANCIAL ASSISTANCE Financial assistance is available through our Annual Campaign, which helps us to make camp accessible to everyone. Additionally, the YMCA accepts third-party payments through the Department of Social Services. YMCA Buffalo Niagara also allows children to earn their way to camp through a candy sale January 1-July 1. The deadline for financial assistance is June 1, Call or visit your branch for more information.

5 INDEPENDENT HEALAMILY BRANCH YMCA 2018 Summer Day Camp Draft Agreement BILLING INFORMATION First Name Last Name Address Phone Work Phone PAYMENT INFORMATION YMCA Buffalo Niagara will automatically draft your account according to the schedule below. Balances are drafted two weeks prior (Monday) to the camp date and are due on the draft date. Cancellation notice is due two ½ weeks prior (Wednesday) to the camp date. # Camp Cancellation Notice Due Draft/Due Payment Method 1 6/25/18 6/06/18 6/11/18 Card Type MC VISA AMEX DISC EFT 2 7/02/18 6/13/18 6/18/18 Acct. # 3 7/09/18 6/20/18 6/25/18 Exp. 4 7/16/18 6/27/18 7/02/18 5 7/23/18 7/04/18 7/09/18 6 7/30/18 7/11/18 7/16/18 7 8/06/18 7/18/18 7/23/18 8 8/13/18 7/25/18 7/30/18 9 8/20/18 8/01/18 8/06/ /27/18 8/08/18 8/13/18 All summer day camp payments must be automatically drafted. Please contact Sara Hannon at ext.2320 or shannon@ymcabn.org with billing inquiries. Signature INDEPENDENT HEALAMILY YMCA P F YMCABuffaloNiagara.org

6 Summer Day Camp - mission to Supervise Medication Medication Information The following section is to be completed by parent/guardian. Child s Name (Last, First) Type of Medication Prescription Number (if applicable) Start : Month Year End : Month Year Days to be taken (circle days) Time of Day Medication is to be taken: Amount (Dosage) to be taken: Parent Authorization The following statement must be completed and signed by parent/guardian. I,, hereby request that the staff of YMCA Buffalo Niagara supervise my child, taking the above medication or as indicated as part of the Summer Day Camp Program. Parent/Guardian Signature Camp Staff The following items MUST be submitted in order for a child to receive medications. Staff are to indicate receipt of items below. YMCA Buffalo Niagara mission to Supervise Medication Form Medication is in its original container with the child s complete name, dosage, time intervals and method of administration. Expiration date and prescriber s name and license number (if applicable for over the counter prescription meds) Written consent from health provider stating that the YMCA Program any administer such medications and specifying their circumstances, if any, under which the medication may be administered (For over the counter and prescription medications ONLY) All items received by: YMCA Staff Signature INDEPENDENT HEALAMILY BRANCH YMCA 150 Tech Drive Amherst, NY P F YMCABuffaloNiagara.org

ASSUMPTION OF RISK WAIVER Name of Participant Although serious injuries are very uncommon in professionally supervised Indoor Adventure Programs, it is impossible to eliminate risk.

7 ASSUMPTION OF RISK WAIVER Name of Participant Although serious injuries are very uncommon in professionally supervised Indoor Adventure Programs, it is impossible to eliminate risk. By its nature, participation in these programs includes risks of injury ranging in severity from minor to serious. All participants have the responsibility to help reduce the chance of injury. Participants must obey the instructions of the facilitator or person in charge, follow all safety rules, report all relevant physical and psychological problems to their instructors, and follow the proper instructional program. operates on a challenge by choice philosophy. At all times participants are in complete control of their own level of risk/participation. Release of Liability By signing this form, the parent/legal guardian an/or participant acknowledges that they have read and understood the above information and are signing this form to assure Independent Health Family Branch YMCA that parent/legal guardian and/or participant assumes all risks during the program. Furthermore, by signing this form, the parent/legal guardian grants permission to to use their child s photo for promotional purposes without compensation. Guardians or participants who do not wish to accept risks described in this document should not sign this permission form. I hereby give my consent: 1. To participate in the Indoor Adventure Programs. 2. To receive emergency medical care, which may become reasonably necessary in the course of such activities or travel. I further agree not hold or anyone acting in its behalf responsible for any injury occurring to the named participant during Independent Health Family Branch YMCA Indoor Adventure Program activities. Signature of Participant or Parent/Legal Guardian (If participant is under the age of 18) : I have read the aforementioned information and will abide by the principles and regulations contained herein. Signature of Participant : 150 Tech Drive Amherst, NY (716)

YMCA OF GREATER NEW YORK SUMMER CAMP REGISTRATION FORM

YMCA OF GREATER NEW YORK SUMMER CAMP REGISTRATION FORM Branch: Camp Site: Camp Group: PARTICIPANT INFO Child s Name Age D.O.B. Female Male Grade in September School Mailing Address Apt.# City State Zip