Copyright © 2007 by Vermont Works for Women, Inc. All Rights Reserved. No part of this Administrator’s Toolbox may be reproduced or distributed in any form or manner without prior written permission of Vermont Works for Women, Inc.
2014 APPLICATION
Rosie’s Girls Construction Trades Exploration
Girls Ages 11-13
July 7- 25, 2014
Woodward Career and Technical High School
Sponsored by the YWCA of Greater Cincinnati
Contact: Rhonda L. Lindon-Hammon at 513-503-0056 or
This entire application must be completed with all documents signed and the $25.00 registration fee paid to be accepted.
To ensure equal opportunity applications are accepted on an ongoing basis. Acceptance letters will be sent by June 15, 2014. If your child is not accepted into the program the registration fee will be returned. We will maintain a waiting list after June 15, 2014. If your child does attend July 7, 2014 the registration fee will not be returned.
PARTICIPANT APPLICATION 2014
$25 CASH REGISTRATION FEE DUE AT TIME OF APPLICATION
Return Completed Application to: YWCA-Rosie’s Girls 898 Walnut Street Cincinnati, OH 45202
Camp Dates: July 17 – 25, 2014
______/_____/______
Camper name Date of birth CURRENT Grade (this year 2013-2014)
______
Mailing address School Attending
______
City State Zip Home phone
OPTIONAL (for statistical reporting purposes only, not for use in application decisions) Race/ethnicity of camper (please check all that apply):
___ African American ___ Asian/Pacific American ___ Latina/Hispanic ___ Native American ___ White/Caucasian ___ Other (please specify)
______
Primary custodial guardian Relationship to camper
______
Mailing address
______
Home phone Work phone E-mail
______
Second custodial parent/guardian Relationship to camper
______
Mailing address
______
Home phone Work phone E-mail
Additional emergency contacts:
______
Name Phone Relationship to camper
______
Name Phone Relationship to camper
The following people, in addition to her parents/guardians named above, are approved to pick my child up from camp:
1)______2) ______
How did you hear about Rosie’s Girls? ______
Camper t-shirt size: (Adult Sizes) S M L XL XXL Camper shoe size: _____
The goal of the Rosie’s Girls summer program is to accept every camper (up to our total enrollment capacity) who can have a successful & safe experience at camp. We will review the ability of each camper to fully participate in camp & will discuss with parents any situations in which Rosie’s Girls activities would be an unsafe or inappropriate experience.
Our experience shows that Rosie’s Girls is most beneficial to campers who ATTEND ALL THREE WEEKS. Please initial here to confirm that you plan for your camper to attend all three weeks of camp. ______( Initial Here)
In order to make this the best experience for your camper, we would appreciate your answers to the following (please attach another page if needed):
1) During Rosie’s Girls activities, campers work together as a group. Please describe any issues we should know about your camper’s ability to work with peers/adults in a group.
______
2) Some activities at Rosie’s Girls (carpentry, welding, etc) require girls to follow set safety procedures & explicit directions to use good judgment/common sense to ensure their own & other campers’ safety. Please describe any concerns you have about your camper’s ability to follow set procedures &/or to use good judgment.
______
3) Rosie’s Girls staff members make every reasonable effort to accommodate the various needs of campers. Please describe any disabilities (learning challenges &/or physical) or other limitations or concerns about which Rosie’s Girls staff should be aware. Please note any special accommodations (including aides, equipment, or other assistance) your camper will need to have a successful experience at camp. Please include allergies &/or dietary restrictions.
______
4) Is there anything else you believe would be important or useful for Rosie’s Girls staff to know about your camper?
______
5) Can your daughter ride a bike? ______
6) Has your daughter participated in Rosie’s Girls Camp before? If so what year?______
PERMISSIONS WAIVERS
Waiver for Participant by Parent/Guardian
I hereby grant my permission for ______(camper’s name) to participate in all activities at Rosie’s Girls summer camp.
Program Evaluation
Information from Rosie’s Girls Summer Program participants is collected at the beginning & at the end of the program in order to evaluate the effectiveness of the program in meeting its stated goals. The information is gathered through surveys that the participants fill out on the first & last days of the program.
The collection of data involves no risk to the participants & offers potential benefits to future participants in the program as well as girls in other programs, as the results will be used to refine the Rosie’s Girls programs & potentially to inform the development of other programs as part of “best practices.”
The participant’s identities, & all identifying information, will be kept strictly confidential under all circumstances.
I hereby grant permission for ______(camper’s name) to fill out surveys & participate in the program evaluation of the Rosie’s Girls Summer Program by YWCA & NAWIC as described above.
Photo Release
The undersigned hereby consents and authorizes the reproduction, publication and other use of my photographic or cinematic image, voice and/or property by the YWCA of Greater Cincinnati or any program of the YWCA, however designated. The undersigned further consents and authorizes the use of the above-mentioned cinematic image or photographic likeness in any motion picture, video, television broadcast, advertisement, publication or program at such time and in such places as the YWCA of Greater Cincinnati shall determine. The undersigned also consents and authorizes the irrevocable right to use his/her name, fictional name, written copy and/or photograph for the purposes outlined in the above paragraph.
Field Trip Photo & Video Release
I hereby give my permission for my camper to be photographed and/or videotaped by Administrators, faculty or staff of Rumpke Consolidated Companies, Inc. and its subsidiaries and affiliates and permission to use my likeness and/ or voice in a photograph or video in any and all of its publications or films including website entries, without payment or any other compensation.
Pictures or videotapes which may include my camper’s name may also be published. ______(Initial Here)
Electronic Equipment
Please be advised that we do not allow any type of electronic equipment to be used at camp. This includes I-pods, cell phones, CD players, & other devices. Campers must turn in cell phones each morning when they arrive at camp and it will be returned at the end of the day. We are not responsible for theft or loss. You will be able to reach your daughter via the camp staff telephone as necessary.
Parent/Guardian Signature
My signature below indicates my permission for my camper to participate in all camp activities, to attend field trips, to receive medical treatment, & to take part in photo or video sessions as indicated above.
In consideration of your accepting my camper’s entry, I hereby, for myself, my child, my heirs, executors & administrators, waive & release any & all rights & claims for damages I or my child may have against Rosie’s Girls, YWCA, NAWIC or their sponsors their representatives, successors & assigns for any & all injuries suffered by myself or my child in any activity sponsored by this group.
______
Parent/guardian Signature Printed name Date
Education CenterCincinnati Public Schools
P.O. Box 5381
Cincinnati, Ohio 45201-5381
Phone: (513) 363-0075
Fax: (513) 363-0055
www.cps-k12.org
Parent/Guardian Consent For
Partner Access to Student Computerized Records
The YWCA of Greater Cincinnati, a CPS partner, may access CPS's computerized records for my child. This consent allows the partner access my child's grades, disciplinary records, individual education plans, and other personally identifiable student data. The partner organization may use this data to identify and assign services to your child, but must otherwise maintain the confidentiality of the records. However, the partner organization is only permitted to access student records in their program and only to the extent necessary to perform his/her assigned duties.
I have read the above and permit the partner to access my child’s personally identifiable information.
______
Parent/Guardian Name (print) Student Name (print)
______
Parent/Guardian Signature Date Phone Number
______
Parent/Guardian Email Address
This MEDICAL FORM must be completed & signed by both parent/guardian & physician. This form must be received by the YWCA NO LATER THAN JUNE 5, 2014. Campers will not be allowed to attend without this completed form.
CAMPER'S NAME: ______
Camper’s home address: ______City: ______State: ______ZIP: ______
Custodial parent/guardian: ______Second custodial parent/guardian: ______
Address: ______Address: ______
City: ______State: ____ ZIP: ______City: ______State: ______ZIP: ______
Home phone: ______Home phone: ______
Work phone: ______Work phone: ______
Name of emergency contact other than parents/guardians listed above: ______
Relationship to camper: ______
Home phone: ______Work phone: ______
DATE OF BIRTH: SEX HEIGHT WEIGHT
IMMUNIZATIONS: Please attach immunization history.
The Rosie’s Girls program involves using hand-held power tools & welding equipment, as well as physical activities such as a ropes course, swimming, & outdoor games. Please describe any physical restrictions related to this kind of activity:
______
______
Has the camper been treated for any medical problems in the following areas?
Seizures Length of seizure
Cardio Vascular Restrictions
Orthopedic Observations Restrictions
Pulmonary Restrictions
Asthma Medications? Inhaler?
Any limitations with sight or hearing? __ Does the camper wear glasses or contacts?
Does the camper have any contagious or infectious diseases?
If yes, explain
Has the camper been exposed to any contagious or infectious diseases in last 6 months? Be specific:
ALLERGIES: Has the camper had any allergic reactions to the following (be specific) - If so, list in detail the reaction:
Drugs: Reaction:
Insect Bites: Reaction:
Foods: Reaction:
Other: Reaction:
MEDICATION: Please list all medication patient is currently taking (or attach a current medication schedule for this person):
MEDICATION DOSAGE SCHEDULE
1.
2.
3.
4.
Please describe any other conditions about which Rosie’s Girls program staff should be aware.
DATE OF MOST RECENT EXAM: (must be within last two years)
PRACTITIONER’S NAME (please print):
TITLE (circle one): MD PA NP
Complete Address:
Phone(s):
PRACTITIONER’S SIGNATURE: DATE:
______
Parental Signature Date
MEDICAL TREATMENT
I give permission to the medical personnel selected by the YWCA of Greater Cincinnati staff to provide routine health care; to administer x-rays, routine tests & treatment; to release any records necessary for insurance or treatment purposes; & to provide or arrange necessary transportation for my child or ward. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the YWCA of Greater Cincinnati staff to secure & administer treatment, including hospitalization, for my child or ward.
I hereby give permission to give my child/ward over the counter medications according to standard dose & written doctor’s order:
Ibuprofen (e.g., Advil) __ YES __ NO Acetaminophen (e.g., Tylenol) __ YES __ NO Benadryl __ YES __ NO
Medications, both over the counter and prescribed, must be in original bottles in order to be given at Camp by Staff.
PLEASE FILL OUT COMPLETELY.
Parent/guardian signature: ______Date: ______
FINANCIAL AID INFORMATION
This form must be completed for your camper to qualify for full or partial scholarship
to the Rosie’s Girls program.
Name of camper: ______
Name of Parent/Guardian:______
Please be sure to answer all questions. If you have questions about this form, please call
Rhonda L. Lindon-Hammon at (513) 503-0056. Thank you!
1. Does your child receive a free or reduced lunch at her school? Yes ___ No ___
2 What is your monthly household income? $ ______
3. How many household members are dependent on this income? # ______
4. How many of these household members are under the age of 18? # ______
5. Please check all that apply:
q One or more family members have a disability or have been ill
q One or more adults is unemployed or under-employed
q Financial difficulty related to divorce or separation
q One or more adults is a college student or studying for a GED
q Debt payments that are difficult to meet
q Mortgage is more than 30% of income
q Unable to meet Credit card payments
q Student loan debt
q We cannot afford the tuition without help
6. Is there anything else you would like us to know in determining financial assistance?
The Cost of camp is $500.
Registration fee $25 required
How much can you pay? $______
Amount of assistance requested $______
______
Parent/Guardian Signature Date
All information on this form will be kept confidential.
Summer Program
Behavior & Safety Contract
We agree to follow the basic guidelines for Rosie’s Girls’ campers.
We understand that if any camper does not follow these guidelines, the camp staff will take appropriate corrective action. In certain cases, a decision may be made to ask a camper not to return to the camp. Rosie’s Girls campers will:
· seek to participate fully in all Rosie’s Girls activities;
· follow directions given by Rosie’s Girls staff members, including, but not limited to, requests to protect a camper’s own safety or the safety of other campers and requests to maintain the camp’s facilities;
· Campers will turn in their cell phone and all electronic devices at the beginning of each day and it will be returned at the end of the day.
· follow the guidelines for safety, personal responsibility and behavior in the Parent Toolbox;
· not participate in the verbal or physical harassment of other campers or Rosie’s Girls staff members. This includes, but is not limited to, using offensive language, calling people names and causing physical harm to another individual.
Campers:
I understand and agree to the above Behavior and Safety Contract.
______
Camper Signature Date
Parents:
I have received and read the Rosie’s Girls Parent Toolbox. I understand the camp policies and agree to terms stated in the Toolbox, including first aid and emergency procedures, medications requirements, and grounds for discipline or dismissal. I have read the above “Behavior & Safety Contract” with my camper and we understand and agree to the terms in the contract.
______
Parent/Guardian Signature Date
898 Walnut Street Cincinnati, Ohio 45202
Phone- 513-241-7090 / Fax- 513-768-4381 / www.ywca.org/cincinnati
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