Mayfield Graves County YMCA
2012 Summer Camp
Permission Form
Please initial each statement and sign below:
______I authorize the YMCA camp staff to assist my child in the application of sunscreen before going outdoors and every two to three hours while engaged in an outdoor activity. Sunscreen must be provided in a pump spray or continuous spray form of SPF 35 or higher, in order for the staff to assist in proper application.
_____I authorized the YMCA to us any sunscreen of SPF35 or higher on my child.
_____I understand that if my child attends camp with sunburn he/she will come to camp with adequate protective clothing to prevent further burning. If the child does not come with proper clothing the parent will be called and arrangements made for the child to be picked up.
_____(optional) I authorize the YMCA to photograph my child for uses in brochures, marketing and mailings.
_____I understand that my child’s swimming ability will be assessed. This will determine where my child may swim in the YMCA pool. Swim tests will be given on the first swim day of swimming and occasionally thereafter.
_____I authorize the YMCA camp staff to take my child outdoors for physical recreational activity; including free choice activities, walking field trips, on the outdoor walking track and sidewalks, the new city park connected to the YMCA walking track located behind the YMCA and the small park on the town square next to Cabalas.
_____I give Mayfield Graves County YMCA summer camp staff permission to administer first aid, or in the event of an emergency, to transport my child, via ambulance service, to the nearest hospital.
_____I authorize the transportation of my child during summer camp via Graves County school bus to field trips and to the YMCA for swimming.
I, the undersigned, do for myself, my heirs, personal representatives and assignee waive any and all rights and claims for damages filed against the Mayfield-Graves County YMCA, its Board of Directors, and agents, or authorized representatives for any and all injuries that may be suffered by my child in any YMCA activities including injuries suffered in any vehicles going to and from said YMCA activities except that provided through insurance benefits. My child will be sent to the YMCA in good health.
Parent/Legal Guardian: __________________________________ Date: ______________
Office Use Only
Supply Fee Paid ($25): YES NO Receipt #: _______
T-Shirt Fee Paid ($5): YES NO Receipt #: ________
_____ Parent Handbook Signature Page
_____ Child Care Registration
_____Health Care Form
_____ YMCA Waiver
_____Permission Form
_____ Rules and Regulations (attached to handbook: both parent and child must sign)
Employee Name: ____________________________________ Date: ______________
Mayfield Graves County YMCA
2012 Summer Camp
Parent Handbook Signature Form
2012 YMCA Summer Camp agrees to provide child care for:
1)_____________________________________________________
(Child’s first and last name)
2)_____________________________________________________
(Child’s first and last name)
3)_____________________________________________________
(Child’s first and last name)
Is your child a member of the YMCA: YES NO
My child/children will be attending: (please circle one)
5 Day Camp 3 Day Camp Drop In
(Please note: If registering for 3 days and the child comes an additional day parent will be responsible for the Drop In rate on the 4th and/or 5th day.)
The child care rate will be $ ________per week.
T-Shirt Size:
YS YM YL AS AM AL
Parent’s agree to the following:
1. The supply fee is due by the first day of attendance and is NON-REFUNABLE.
2. Weekly fees are due the Monday morning for that week of care.
3. There will be a $25 charge on each returned check. More than two returned checks will result in “cash only” payment.
4. If my child is ill or does not attend the program for any reason, I understand that the FULL AMOUNT of the weekly fee remains due.
5. YMCA Summer Camp closes each day at 5:30pm. A late charge of $5.00 per minute will be assessed passed 5:30pm.
6. I agree to phone the program by 8:00am if my child will not attend or be coming later than usual.
7. If I should find it necessary to withdraw my child from the camp, I agree to give the program one week notice in writing. If notice is not given, fees will be charged for the week.
8. I have read the 2011 YMCA Summer Camp Parent Handbook and agree to abide by the policies and procedures stated within.
Parent Signature: ____________________________________ Date: ___________
Mayfield Graves County YMCA
2012 Summer Camp
Child Care Registration Form
PLEASE PRINT
TODAY’S DATE: __________________
Child’s Name: ______________________________________________________________
Address: ______________________________________________City: ___________Zip: ________
Home Phone Number: _________________ Cell Phone Number: _____________________
Date of Birth: ______/______/______ Sex: (please circle) Male Female
What school does your child attend: _______________________ Grade Going Into 2012/2013: ______
(If you have more than one child attending summer camp, please complete the reverse side of this form)
First Parent
Name: ____________________________________________________________________
Address (if different than child’s): ______________________________ City: ___________ Zip:________
Home Phone Number: ______________________ Work: ___________________ Cell: ________________
Email: _____________________________________________________________________
Company/Employers Name: ___________________________________________________
Address: __________________________________________________________________
Second Parent
Name: ____________________________________________________________________
Address (if different than child’s): ______________________________ City: ___________ Zip:________
Home Phone Number: ______________________ Work: ___________________ Cell: ________________
Email: _____________________________________________________________________
Company/Employers Name: ___________________________________________________
Address: __________________________________________________________________
PICK UP AUTHORIZATION (MUST BE COMPLETED)
NAME PHONE RELATIONSHIP
1)_________________________________________________________________________________
2)_________________________________________________________________________________
3)_________________________________________________________________________________
4)_________________________________________________________________________________
5)_________________________________________________________________________________
Are there any people who MAY NOT pick up your child? YES NO
1)_________________________________________________________________________________
2)_________________________________________________________________________________
2nd Child’s Name: ______________________________________________________________
Address: ______________________________________________City: ___________Zip: ________
Home Phone Number: _________________ Cell Phone Number: _____________________
Date of Birth: ______/______/______ Sex: (please circle) Male Female
What school does your child attend: _______________________ Grade Going Into 2011/2012: ______
3rd Child’s Name: ______________________________________________________________
Address: ______________________________________________City: ___________Zip: ________
Home Phone Number: _________________ Cell Phone Number: _____________________
Date of Birth: ______/______/______ Sex: (please circle) Male Female
What school does your child attend: _______________________ Grade Going Into 2011/2012: ______
4th Child’s Name: ______________________________________________________________
Address: ______________________________________________City: ___________Zip: ________
Home Phone Number: _________________ Cell Phone Number: _____________________
Date of Birth: ______/______/______ Sex: (please circle) Male Female
What school does your child attend: _______________________ Grade Going Into 2011/2012: ______
Mayfield Graves County YMCA
2012 Summer Camp
Health Form
PLEASE PRINT
Child’s Name: ____________________________________________________________________________
Social Security Number: ___________________________ (For insurance purposes only)
Emergency Numbers: Please note the emergency numbers will be used to pick up your child if we are unable to reach you in the case of illness, emergency cancellations of the program or behavior problems.
NAME PHONE RELATIONSHIP
1)________________________________________________________________________________________
2)________________________________________________________________________________________
3)________________________________________________________________________________________
Insurance Company: ______________________________________ Policy Number: ___________________
Legal Guardian: ___________________________________________________________________________
Family Physician: __________________________________ Phone Number: _________________________
Hospital of Choice: ________________________________________________________________________
(If no hospital is listed child will be taken to Jackson Purchase)
Known Allergies:
Child: _______________________________________
Allergy: __________________________________________________________________________________
Are there any special food/eating instructions we should know about? (If yes, please explain):
__________________________________________________________________________________________
__________________________________________________________________________________________
Other Medical Problems: ___________________________________________________________________
Date of Last Tetanus Shot: ______________________
Child: _______________________________________
Allergy: __________________________________________________________________________________
Are there any special food/eating instructions we should know about? (If yes, please explain):
__________________________________________________________________________________________
__________________________________________________________________________________________
Other Medical Problems: ___________________________________________________________________
Date of Last Tetanus Shot: ________________________
Child: ________________________________________
Allergy: __________________________________________________________________________________
Are there any special food/eating instructions we should know about? (If yes, please explain):
__________________________________________________________________________________________
__________________________________________________________________________________________
Other Medical Problems: ___________________________________________________________________
Date of Last Tetanus Shot: _________________________
I hereby authorize the YMCA staff or other medical personnel to obtain or give medical treatment for my child.
Parent/Legal Guardian Signature: __________________________________ Date: ___________________