Ymca of Greater Ny Summer Camp Registration Form 2018

• 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

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.

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SignatureDate

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Name (printed)Name of Parent/Guardian

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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

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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: ______

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HEALTH HISTORY: (Check and give approximate dates)

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.

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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.

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 ______

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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: ______

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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: ______