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. 1 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! 2 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. 3 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 4