Branch: FLUSHING
Camp Office Phone: 718-551-9372 / Day, Teen, Swim, Sports, Art & Science Camp – Ages 5.9-15
(Campers finishing Kindergarten in June 2017)
PARTICIPANT INFO
Child’s Name ______Age ______
D.O.B. ______Gender ______
Grade in September 2018 ______School ______
Mailing Address ______Apt.# ______
City ______State ______Zip ______
Home Phone (______) ______Email Address ______
My child will:Be picked upWalk home (Only 10 yrs. or older, please sign bottom of page 2)
T-Shirt SizeChild:S M L XL Adult:S M L XL
PARENT/Guardian INFO
Name of Parent/Guardian registering child ______Home Phone (______)______
Work Phone (_____) ______Cell Phone (_____) ______Email ______
Name of Parent/Guardian ______Home Phone (______)______
Work Phone (_____) ______Cell Phone (_____) ______Email ______
EMERGENCY CONTACT INFO
Please list two (2) contacts not already listed on this form, to be used if the parents/guardians cannot be reached
Name ______Relation ______Home Phone (_____)______
Work Phone (_____) ______Cell Phone (_____) ______
Name ______Relation ______Home Phone (_____)______
Work Phone (_____) ______Cell Phone (_____) ______
PHYSICIAN INFO
Name ______Telephone Number (______)______Address ______City ______State ______Zip ______
AUTHORIZATION / CONSENT
EMERGENCY AUTHORIZATION: I understand that in the event of an emergency affecting my child while participating in a YMCA program, a designated employee of the YMCA will attempt to contact me and inform me as soon as possible. In the event I cannot be reached, I hereby give permission for my child to be treated or hospitalized by a licensed physician or hospital selected by the YMCA.
______Parent/Guardian Name Parent/Guardian Signature
______Participant Signature Date
YMCA OF GREATER NY SUMMER CAMP REGISTRATION FORM 2018
PERMISSION FORM
I hereby grant permission for my child to use all equipment and participate in all activities of the Flushing YMCA.
I hereby grant permission for my child to leave the Flushing YMCA premises, under proper supervision of Flushing YMCA staff, for neighborhood walks, park activities and field trips. It is my understanding that these trips will be taken over the camp session without further consent from me.
______Child’s Name Camp Type
______Parent/Guardian Signature Date
AUTHORIZED PICK-UP FORM
The following individuals are 18 years old or older and are allowed to pick up my child from the Flushing YMCA Programs:
I understand that no one else will be allowed to pick up my child unless I notify the Flushing YMCA in advance and in writing. This person will also be asked for their photo ID for verification.
______
Parent/Guardian SignatureDate
Contact Telephone Number: ______
Unescorted dismissal authorization
My child is ten years of age or older and may go home without an escort at the end of the day.
______
Parent/Guardian SignatureDate
Contact Telephone No.: ______
2018 FLUSHING YMCA SUMMER CAMP FEE SCHEDULE
* Session dates DO NOT include Saturday and Sunday. *
SESSION
Session I
Session II
Session III
Session IV / MEMBER
$480.00
$480.00
$480.00
$480.00 / Day Camp
Ages 5.9 to 11
NON-MEMBER
$550.00
$550.00
$550.00
$550.00 / DATES
July 2 – July 13
July 16 – July 27
July 30 - August 10
August 13 - August 24 / Ages 7-9
SESSION
Session II
Session IV
Ages 9-11
Session I Session III / MEMBER
$580.00
$580.00
$580.00
$580.00 / Swim Camp
NON-MEMBER
$650.00
$650.00
$650.00
$650.00 / July 16 – July 27
August 13 - August 24
July 2 – July 13
July 30 - August 10
SESSION
Session I
Session II
Session III
Session IV / MEMBER
$480.00
$480.00
$480.00
$480.00 / Teen Camp
Ages 12 to 15
NON-MEMBER
$550.00
$550.00
$550.00
$550.00 / DATES
July 2 – July 13
July 16 – July 27
July 30 - August 10
August 13 - August 24 / Ages 7-9
SESSION
Session II
Ages 9-11
Session I / MEMBER
$480.00
$480.00 / Art Camp
NON-MEMBER
$550.00 July 16-July 27
$550.00 July 2-July 13
Ages 6-8
SESSION
Session I
Session III
Ages 9-11
Session II
Session IV /
MEMBER
$480.00
$480.00
$480.00
$480.00 / Sports Camp
NON-MEMBER
$550.00 July 2-July 13
$550.00 July 30-August 10
$550.00 July 16-July 27
$550.00 August 13-August 24 / Extended Camp Hours
Ages 3-15
SESSION *1, 2, 3, 4Member FEE
AM Session (7:30-9:00a)$75.00
PM Session (5:00-6:00p)$75.00
AM & PM Session $115.00
Non Member FEE
AM Session $95.00
PM Session $95.00
AM & PM Session $135.00
Ages 7-9
SESSION
Session IV
Ages 9-11
Session III / MEMBER
$480.00
$480.00 / Science Camp
NON-MEMBER
$550. 00 August 13-August 24
$550.00 July 30th-August 10th / Camp Fees cover Monday – Friday 9:00am-5:00pm and includes
- All camp activities including field trips
- Instructional Swimming (Day, Art, Sports, Science, Swims 3x/wk, Swim Camp 8x/wk)
- Light snack
- 2 camp tee shirts
- 1 camp backpack
PARENT AGREEMENT
I, the undersigned, give permission for my child to participate in the camp for the days he/she attends. I am aware that a completed medical form signed by a physician is required before my child may begin camp. In addition, I am fully aware that to reserve a space, I must make a deposit of $100 per two-week session and submit a registration form. I am fully aware that should my child change camps after the start of the session there is a $25 change fee. I fully understand and approve of my child being photographed for Flushing YMCA publicity. Lastly, I fully understand that my child is responsible for his/her possessions. I have read, signed, and agreed to the registration requirements.
Signature of Parent/Guardian:______Date: ______
There is a non-refundable $100.00 deposit per session per child which is applied to session fee.
Camp Fees
DEPOSIT/
SESSIONFEE / EXTENDED FEES / DISCOUNTS / SESSION TOTAL
Session I______/ _+ / AM/PM ______/ - / ______/ = / ______
Session II______/ _+ / AM/PM ______/ - / ______/ = / ______
Session III______/ _+ / AM/PM ______/ - / ______/ = / ______
Session IV______/ _+ / AM/PM ______/ - / ______/ = / ______
Session Total ______/ _ + / Total ______/ - / Total / ______/ =Grand Total ______
Payment Information
Credit Card Money Order
Last Four Digits of Credit Card # ______Exp. Date: ______
Authorized Signature: ______
YMCA OF GREATER NY SUMMER CAMP REGISTRATION FORM 2018
STANDARD RELEASE FORM
From time to time, the YMCA of Greater New York (the “YMCA”) takes pictures or records videos of members and non-members participating in YMCA programs, using its facilities, or attending one of its special events. Additionally, the YMCA may permit members of the media (the “Media”) to take such pictures or record such videos in order to promote the YMCA’s charitable mission and for other journalistic purposes.
The individual person named below is signing this Release for the purposes of allowing the YMCA and the Media to use one or more such photographs, video recordings, and/or sound recordings (collectively, “Recordings”) of such person for any purpose consistent with the YMCA’s charitable mission, which includes, but is not limited to, the YMCA or the Media publishing such Recordings in newspapers, web sites, and other print or electronic publications, on television, or on the radio. By signing this Release, such person acknowledges that he or she has freely consented to be photographed, filmed, or otherwise recorded and has signed this Release of his or her own free will. If the person named below is under age 18, a parent or guardian of such person must sign on such person’s behalf.
1. I agree that I am willing to be photographed, filmed, or otherwise recorded by the YMCA, its contractors, and the Media, either individually or as part of a group Recording, which may include my image, likeness, and/or voice. further agree that my name may be used to identify me as a subject of any Recordings featuring my image, likeness, and/or voice.
2. I understand that the YMCA will own all rights in the Recordings of me that the YMCA or a YMCA contractor takes or records (“YMCA Recordings”), and that the YMCA will have the exclusive right to use, or allow others to use, such YMCA Recordings in any medium for any purpose consistent with the YMCA’s charitable mission as determined by the YMCA.
3. I understand that the Media will own all rights in the Recordings of me that the Media takes or records (“Media Recordings”), and that the Media will have the exclusive right to use, or allow others to use, such Media Recordings in any medium for any lawful purpose.
4. I understand that I am waiving any and all rights that may preclude the YMCA’s or the Media’s use of the Recordings as described above.
5. I acknowledge that neither the YMCA nor the Media has any obligation to use any Recordings of me or to use such Recordings for any particular purpose.
6. I understand that I will receive no monetary payment or other compensation in exchange for the rights to use Recordings of me.
______
______
SignatureDate
______
______
Name (printed)Name of Parent/Guardian
______
______
Mailing AddressPhone Number (optional)
______Email (optional)
Summer 2018
Dear Parent/Guardian:
Thank you for choosing the Flushing YMCA Summer Day and Early Childhood Camps for your child(ren).
All medical forms are due at least 2 weeks before your child is scheduled to attend camp. Please return completed forms to our Member Services Desk in an envelope labeled with the camp name your child is attending. For your records please make a copy of the medical form for yourself.
All payments both camp fee and extended hour fees are due by the following due dates:
Session 1 – full payment due June 4th
Session 2 – full payment due June 18th
Session 3 – full payment due July 6th
Session 4 – full payment due July 23rd
Failure to make payments by the due date will result in your child being removed from the roster and will no longer be registered for the program.
The Parent Orientation is a mandatory meeting for the parent. At this meeting you will get detailed information on the camp program (program calendars, trip forms etc), policies and procedures. The meeting is approximately 1 hour however it may be shorter or longer depending on how many questions we receive. We ask that you choose one of the dates below to attend. The location of the meeting will be given to you when you arrive.
Parent Orientation Dates
Saturday June 16th – 10:30am
Wednesday June 20th – 6:30pm – Early Childhood Camp ONLY
Monday June 25th - 6:30pm – Day Camp ONLY
Monday July 2nd – 6:15pm
Monday July 16th – 6:15pm
**Your child will receive their camp shirts on the first day of camp at dismissal time**
To speak with one of the Camp Leadership Staff please call or email:
Sabrina Snyder – Senior Director for Youth and Family – 718-551-9375
Lillian Morales and Sarah Algu – Day Camp Unit Leaders – 718-551-9372
Lois Rothstein – Early Childhood Director (ages 3-5.8) – 718-551-9356
Thank you for choosing the Flushing YMCA Summer Camps!
We look forward to having your child spend the summer with us.
YMCA of Greater New York
HEALTH RECORD FOR CHILDREN IN DAY CAMPS & AFTERSCHOOL & YOUTH CENTERS
ATTENTION PARENTS –PLEASE COMPLETE ALL SECTIONS BELOW –
Due 2 weeks before your child is scheduled to attend camp
______
NAME OF PROGRAM: Flushing YMCA Camp 2018 Permit No. 85: ______
______/____/____ Male Female
Child’s Last Name First NameDate of BirthSex
Home Address: ______Tel. No. ______
Parent or Guardian: ______Tel. No. ______
Place of Employment:
Father Guardian: ______Tel. No. ______
Mother Guardian: ______Tel. No. ______
In Case of Emergency, please notify: ______Tel. No. ______
If Parent/Guardian are not available in an emergency, please notify:
1. ______Tel. No. ______
2. ______Tel. No. ______
Important: Has this camper been exposed to any communicable disease during the three weeks prior to camp attendance.
Yes No If yes, state type of exposure: ______
======
HEALTH HISTORY: (Check and give approximate dates)
Allergies / DiseasesEar Infections ______/ Hay Fever ______/ Check Pox ______
Rheumatic Fever ______/ Ivy Poisoning, etc. ______/ Measles ______
Convulsion ______/ Insect Stings ______/ German Measles ______
Diabetes ______/ Penicillin ______/ Mumps ______
Behavior ______/ Other Drugs ______/ Other Contagious Illnesses ______
Asthmas ______/ ______/ ______
Other Past Illnesses: ______
Operations or Serious Injuries (Dates): ______
Hospitalization (Dates): ______
Chronic or Recurring Illness: ______
Any specific activities to be encouraged? ______
Conditions that require activity to be restricted? ______
Permission for all program activities unless otherwise noted by doctor: ______
Appliance worn (glasses, contacts, etc.): ______
Medication taken: ______
Suggestion from Parent/Guardian: ______
CONSENT FOR EMERGENCY MEDICAL TREATMENT
I do hereby give authority to the Day Camp and Year Round Afterschool and Youth Center Program staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible.
______
Relationship Signature Date Telephone No.
Department of HealthThe City of New YorkBureau of Inspections
PHYSICAL EXAMINATION
(To be filled out by Physician. Please note information on reverse side)
The purpose of this health record is to provide the staff with pertinent information, which will help to serve the needs of this child in Day Camps and Afterschool and Youth Center programs.
IMMUNIZATION HISTORY: This is a record of dates of basic immunization and most recent booster doses.Type / Date / Date / Date / Date / Date
DtaP, DTP or TD
OPV/IPV
MMR
Hemophilus Influenza Type
Hepatitis B
Varicella
Other (Specify):
MEDICAL EXAMINATION: To be filled out by license physician
Examination is acceptable when performed no more than 12 months prior to arrival at camp.
Code:S = Satisfactory
X = Not Satisfactory, Explain:
O = Not examined
General Appearance: ______
Height: ______Weight: ______Blood Pressure: ______Hgb Test (Date): ______
Urinalysis: Date: ______Posture & Spine: ______Throat & Tonsils: ______
Eyes ______Vision ______W/ Glasses ______Extremities ______Heart ______
Ears ______Hearing ______Feet: ______Lungs ______Skin ______
Nose ______Teeth ______Abdomen ______Hernia ______
Genitalia ______
Neurological Findings ______
Describe Abnormal Findings and/or Handicapped Conditions ______
______
Has child ever received products containing horse serum? ______
Allergy: (Please specify) ______
Recommendations and restrictions while in After-school:
Special Diet: ______
Special Medicine (Name it) ______
Is parent/guardian sending special medicine? ______
Swimming ______Diving ______
Activity Restrictions ______
General Appraisal: ______
______
______
I have examined the person herein described, reviewed his/her health history and it is my opinion that he/she is physically able to engage in Day Camp/Year Round Afterschool and Youth Center activities, except as noted above.
______MD______
Physician’s Name (PLEASE PRINT)Examining Physician’s Signature
Telephone: ______Address: ______
Date of Examination: ______