2015 SUMMER CAMP
ENROLLMENT PACKET
The Enrollment Packet consists of required information that must be completed in full prior to your child’s first week. Also due at
that time is a certified copy of your child’s up-to-date Immunization Certificate.
Name of Child
Child's DOB
Name of Parent
Child's Age
Camp Outback @ RC Durr Y
Camp Location
Summer Camp @ Arnett
This Section is for Office Use ONLY / This CAMP OUTBACK camper is registered for:
□ Full Time (4 to 5 Days)
□ Part Time (1 to 3 Days) If PT, circle which days: M
□ Pre
□ Post
□ Preschool
□ Preschool
(1/2 Day)
(Full Day)
□ Day
□ Teen
T
W
□ LIT (1/2 Day)
R
F
Varies
□ LIT
(Full Day)
□ Sport _______________________________________________________________________________________________
□ Specialty ____________________________________________________________________________________________
Emergency Contact Information
Child lives with:
Both Parents
Marital Status:
Married
Additional Siblings in Camp:
No
Mother Only
Father Only
Other:
Divorced
Separated
Single
Yes
(If yes, please list name and ages below)
If applicable, please print the name and age of any sibling(s) who would also be enrolled.
Name:
Name:
Age:
Age:
Name:
Name:
Age:
Age:
In the event of an illness/emergency, the following individuals will be contacted in the order listed. These individuals also have
authorization to pick up the above named child. Two contacts must be listed! Adults authorized to pick up a child must be
at least 18 years of age.
1st Called
This person will be called first in the event of
an illness/emergency. This must be a
parent/guardian.
2nd Called
Parent/Guardian Name
Name & Relationship
Address
Address
(Including City, State, Zip)
(Including City, State, Zip)
Home Phone
Home Phone
Cell Phone
Cell Phone
Employer
Employer
Employer’s Phone
Employer’s Phone
If the main parent/guardian cannot be reached,
this person will be the second to be called.
Pick Up Authorization Codes
During pickup, we utilize a code word system. You may also
choose to be identified through “ID only.” Please review the
information below and fill out all required information.
● It is imperative that your codes be confidential, and only told
to adults who pick up your child. To help ensure this, please
do not tell your child their code words! If your code
words are compromised, please see the Camp Director to
change them.
● Adults picking up a child must know and use the code words
or provide an ID. This includes parents/guardians.
● Parent/Guardian must provide legal documents upon any
custody agreements/arrangements made within the court
system, etc. regarding who can and/or cannot pick up
children.
Option 1: Check here if you wish to establish Code
Words for your pickup service. Code Words are:
Code #1
Code #2
Option 2: Check here if you wish to utilize the “ID
Only” format when picking up your child. The person
picking up child must show a valid ID, matching the
authorized information outlined in the Enrollment
Packet.
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2015 SUMMER CAMP
ENROLLMENT PACKET
Emergency Medical Authorization
To attend camp a parent/guardian must provide the YMCA consent for emergency medical treatment to be initiated for their child in
the event of an emergency. If a parent/guardian would like to deny consent, they must contact the Y Camp Director.
In the event reasonable attempts to contact me or a second individual at the numbers listed in my Emergency Contact
information from page one of this packet have been unsuccessful, I hereby give my consent for: (1) the administration of any
treatment of physician or dentist listed below, or in the event the designated preference is not available, by another licensed
physician or dentist; or (2) the transfer of the child to the designated preferred hospital listed or any hospital reasonably
accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or
dentists, concurring in the necessity of such action, are obtained prior to the performance of the surgery.
Parent/Guardian Signature
Date
Medical Preferences and Health History
This section allows you to indicate preferences in doctors/medical facilities and also allows an opportunity to communicate any
health history information that can help us ensure a safe and happy experience for your child. Please list any information regarding
special medical issues, special dietary needs, allergies, behavioral considerations, etc. for your child. In order to avoid a delay in
your child's enrollment, please fill out all requested information.
Name:
An Administration of Medication form is available upon
request if your child is to take medications
during program hours.
Designated
Preferred
Address:
Physician
Phone:
Name:
Designated
Preferred
Address:
Hospital
Name:
Designated
Preferred
Dentist
Phone:
Phone:
Current
Diagnoses
Dietary
Modifications
Current
Medications
(Foods, Meds, Insects, etc.)
Disabilities/Operations/
Injuries/Chronic
Illnesses
Kentucky Immunization Certificate
 A copy of your child's immunization record must be received
prior to your child's attendance!

Address:
If the immunization document expires during your child's
enrollment in the program, you will be responsible for
providing a new one.
Allergies
Behavioral/Sensory
Considerations
If you feel we already have an Immunization Certificate on
file for your child, please indicate below from which
program and we will try to access it!
My child was in CAMP last year!
My child was/is in this year’s CHILDCARE program!
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2015 SUMMER CAMP
ENROLLMENT PACKET
Swim Authorization
Please indicate by checking only one level of authorization you will provide your child for swimming activities during camp/summer
programming. A child may only be in a particular section/depth of the pool in which a swim test has been administered and passed
and a parent gives permission for. If at any time you wish to change the level of permission you must notify the Camp Director in
writing using the Swim Authorization Update form. Swim test requirements are detailed in the Summer Camp Parent Handbook.
My child does not have permission to swim or enter the pool. All non-potty trained campers must choose this option. All
non-potty trained Preschool campers must choose this option.
My child has permission to swim only in the zero depth entry pool. (Depth = 0 to 2.5 ft.; Red Band) All potty-trained
Preschool campers must choose this option.
My child has permission to swim only in the intermediate depth of the pool.(Depth = 0 to 4 ft.; Yellow Band)
My child has my permission to swim in deep water depth of the pool. (Depth = 5 ft.; Green Band)
Permission to Participate Authorization
Please check which activities for which you give permission for your child to participate in during camp/summer programming.
Yes
No
I give my permission for qualified camp staff to provide routine health care checks, necessary first aid, etc.
Yes
No
I give my child permission to apply the sunscreen that I provide. I also give permission for staff assistance
with application of sunscreen if my child needs it.
Yes
No
I give my permission for my child to use all equipment and participate in all activities during the program.
Yes
No
I give my permission to the YMCA to use photographs, film footage, audio or video tape recordings, etc.
which may include my child’s image or voice for purposes of promoting and interpreting YMCA programs and
services to the general public.
Yes
No
I give my permission for my child to participate in any walking excursions near/around the program facility.
This includes but is not limited to areas of the Boone Woods Park , the Outdoor Garden, etc.
Yes
No
I give my permission for my child to participate in any off-site field trips. Transportation will by a reputable
leased bus/van service. This does NOT include Preschool Campers – they do NOT attend field trips! Refer
to your Parent Handbook for details on off-site field trips and which camp programs are included.
Acknowledgment of YMCA Policies
Your child's safety, privacy and security is our number one priority! Our staff goes through extensive training to help ensure
the wellbeing of each child in our program. Parents must agree to the following in relationship to their child:

I understand that the YMCA is not responsible for personal property lost, stolen or broken, while participating in the program. I
am also aware that items in the Lost & Found are donated weekly to Goodwill®.

My child and I will adhere to the YMCA Code of Conduct. I understand that the Y will hold us both accountable for the Code and
may restrict my access to any Y programming upon breach of this code. (Code of Conduct is outlined in the Parent Handbook.)

I understand that the Y assumes no responsibility for injuries or illness which my child may sustain as a result of their physical
condition or resulting from their participation in any program activities, use of equipment, exercise, or any other activity during
the program.

I expressly acknowledge on behalf of myself and my heirs that I assume the risk of any and all injuries and illness, which may
result from my child’s participation in program activities. I hereby release and discharge the Y, its agent’s servants, and
employees from any and all claims for injury, death, lose or damage, which my child may suffer as a result of their participation
in program activities.
 I understand to meet mandatory reporting responsibilities (i.e.: United Way requirements, state reporting mandates, Y Passport
programming, program evaluations, etc.) information is shared with internal and external identities as part of the process of
interpreting YMCA programs.
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2015 SUMMER CAMP
ENROLLMENT PACKET
Program Policy & Procedure Acknowledgments
 I understand that an up-to-date copy of my child’s immunization record must be on file. Immunization forms are due prior
to a child participating in any summer programming. I further understand that if the immunization form expires during my
child's enrollment, I will be responsible for providing a new one.


My child needs to wear closed-toed shoes each day. (Flip flops, mules, sliders, sandals, crocs, etc. are not acceptable or safe.)

I understand that the program will often enlist special programming from outside resources and that non Y individuals may
engage in activities with my child. At no time, under any circumstances will a child be engaged in that said activity without a Y
staff member. (i.e.: Library bus visits, special event visits, off-site field trips, tutoring sessions, etc.)

I understand that under no circumstances will my child bring their own toys or electronic devices, which include but are not
limited to: electronic devices/games, iPod, video watches, cell phones, card games, or other personal items such as nail polish,
makeup, etc. If my child does so, the staff will confiscate the item and return it to the parent at the end of the day.

I understand that the YMCA is not responsible for my child until the parent/guardian signs them into the program, and that all
children must be signed out of the program upon pickup. All “in” and “out” times must also be noted on the attendance sheets.

There will be no refrigeration/microwave provided. All campers must bring a daily snack and a refillable water bottle. I
understand that a full description of camp meal policies can be found in the Parent Handbook.

I understand that my child will need a bathing suit, swim towel and sunscreen daily, not only for pool time but also for outdoor
water activities. I further understand that the Parent Handbook has detailed information about swimming activities and policies.

I acknowledge that I have access to the 2015 Summer Camp Parent Handbook online thru the www.myy.org website
under the RC Durr Y Program information and I am responsible for reading and adhering to all policies, procedures, and
guidelines referenced in the Parent Handbook. Handbooks are also available in hardcopy form upon request.
I understand that camp activities are based outdoors and my child will be outside all day, weather permitting. I am aware that
my child should wear and bring waterproof sunscreen protection daily. It is also suggested that my camper bring a hat for hot
days and bring a jacket/sweatshirt for cooler days.
Financial Policy & Procedure Acknowledgments
 I understand if I am receiving financial aid/state assistance, I will be required to participate in additional reporting and
documentation of information.

Absences are not prorated. I understand that if my child will be absent for the day, I am responsible for calling the Camp
Director using the Camp Hotline prior to 9:00 am.

I understand that there is a late fee of $1.00 per minute/per child after the designated pickup time. The person picking up the
child will sign the late fee slip to acknowledge charges and the parent's credit/debit card on file will be charged.

I understand that if I need to add, change or withdraw my child from a selected week of camp or programming, I must
complete a Change of Camp form and return it by the Thursday prior to the start of the selected week or I will be charged
the full fee. No verbal or over the phone withdrawals or changes are accepted. I am aware that it is recommended that I keep
my duplicate copy of the Change of Camp form as a receipt.

I understand that if I cancel a week, the non-refundable and non-transferable deposit that I paid will be forfeited. I also
understand that if I am switching/adding a week, the deposit for the new week is due with my Change of Camp form.


I understand that fees will be charged against my credit/debit card on file the Friday prior to the week of attendance.

Registration will be denied to any individuals who have any outstanding Y balances from last year's camp or from any other
additional YMCA programming. All outstanding balances must be paid in full prior to registration.
If payment was unable to be processed, I will be notified and full payment for the upcoming week is expected prior to my
child's attendance. If full payment for the week is not received by the end of the camper's first day, an additional $20 late
payment fee will also be added to the overdue weekly payment. The child may not return to the program until the weekly fee
and late payment fee is received and all balances are paid in full.
Parent Acceptance Agreement
Camper's Name:
By signing and dating below, I acknowledge that I have access to and am responsible for reading and adhering to all policies,
procedures, and guidelines referenced in this Camp Enrollment Packet and the Camp Handbook that is accessible online or available
upon request. I agree to all terms and conditions and the authorizations I have presented.
Parent/Guardian Signature
Date
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