session2 june18-june22 - the YMCA of Delaware

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GENERAL QUESTIONS: Explain “yes” answers below) (circle one) (circle one) 1. Had recent injury, illness or infectious disease? yes no 11.Dizzy during/after exercise yes no 2. Have a chronic or recurring illness/condition? yes no 12. Had seizures yes no 3. Ever been hospitalized? yes no 13. Skin problems? (rash, itchy) yes no 4. Ever had surgery? yes no 14. ADHD yes no 5. Have frequent headaches? yes no 15. Asthma yes no 6. Ever had a head injury? yes no 16. Have an orthopedic appliance yes no 7. Been knocked unconscious? yes no 17. Heart murmur? yes no 8. Wear glasses, contacts or protective eyewear yes no 18. Mononucleosis in past 12 months yes no 9. Had frequent ear infections? yes no 19. Eating disorder? yes no 10. Passed out during or after exercise? yes no 20. Emotional difficulties for which yes no professional help was sought? Please explain any “yes” answers, noting the number of the question ________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________ Please provide any additional information about the camper's behavior and/or physical, emotional, mental health behavior camp should be aware of: __________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________ IMMUNIZATION RECORD Please attach a copy your child’s immunization record. Immunizations records need to be on file before your child can attend camp. MEDICATIONS BEING TAKEN Please list ALL medications (including over-the-counter or nonprescription drugs) taken routinely. 24 This person takes NO medications on a routine basis. This person takes medications as follows: Med #1________________________________________ Dosage___________________________________________________________________________________Times________________________ Reason for Taking_______________________________________________________________________________________________________________________________________________________ Med #2________________________________________ Dosage____________________________________________________________________________________Times________________________ Reason for Taking_______________________________________________________________________________________________________________________________________________________ PARENT/GUARDIAN SIGNED RELEASES TREATMENT/EMERGENCY CARE This health history is correct and complete to the best of my knowledge and the camper described has permission to engage in all camp activities except as noted below. I hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me/or my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips out of camp. Signature of parent/guardian: ____________________________________________________________________________ Date_______________________________________________ FIELD TRIP & TRANSPORTATION RELEASE: The Y has permission to take my child on all pre-arranged field trips as indicated on the camp calendar. I also give the Y permission to take my child on short term trips, during rainy or excessively hot days, as part of the summer day camp. Parent/Guardian Signature:_________________________________________________________________________________ Date_______________________________________________ PHOTO RELEASE: I give permission for my child’s photo to be used in Y publicity. Parent/Guardian Signature:_________________________________________________________________________________ Date_______________________________________________ SUNSCREEN RELEASE: I will provide sunscreen and give permission for the Y to apply sunscreen to my child. Parent/Guardian Signature:_________________________________________________________________________________ Date_______________________________________________ BRANDYWINE YMCA • Summer Day Camp 2012 • (302) 478-YMCA • www.ymcade.org
BRANDYWINE Y CAMP REGISTRATION FORM 2012 My Child is: ____ A full privilege member ____ A program member Expiration Date ___________________________ ____ Not a member of the Y. I’ve enclosed $39.00 for a program membership. Attending camp at the Brandywine Y _________ Hanby Outdoor Center ___________ Child’s Name: ___________________________________________________________________________________________ Sex _________ Grade Completed as of 6/1/12 ___________ Age as of 8/31/12 ___________ Date of Birth ___________________________________ 1. The front desk will not accept registration forms without completed enrollment and health form. One complete set per child attending camp. 2. Full day camp deposit: $60 per session. Half day camp deposit: $30 per session. Deposits are not refundable but are transferable to another camp session in 2012. 3. All balances are due 2 weeks prior to camp session or registration will be cancelled. 4. Automatic deduction of your camp balances is available. Fill out the bank draft form enclosed in the back of camp guide. 5. Campers must have a current membership before faxing or mailing completed registration forms. 6. A confirmation form, payment schedule, parent handbook and packet will be sent to you once you have successfully registered for camp. Staff member of Y of Delaware: no yes Branch: ___________________________________________________________________________ I have applied for Open Doors financial assistance. no yes (Acceptance letter and deposit must be included with this form before registration can be processed) Camper request (1 request per child): Group my child with _______________________________________________________________________________ CHILD RELEASE: Parents should list themselves as authorized pick-up people. The following people are authorized to pick up my child from camp. Anyone picking up a child must have photo identification. Any changes to this information must be submitted in writing to the camp office. Early dismissals can only be honored when the camp office receives written notification from a parent or legal guardian indicating the time, date, and pickup person. If there is any question about dismissal, my child will be kept at camp and I will be responsible for picking him/her up at camp. Name Name 1._________________________________________________________________________________ 3._________________________________________________________________________________ 2._________________________________________________________________________________ 4._________________________________________________________________________________ Individuals who are not permitted to pick up my child: 1._________________________________________________________________________________ 2._________________________________________________________________________________ Parent/Guardian Signature _______________________________________________________________________________________________ Date ______________________ I certify that my child is in good health and is amiable to normal discipline necessary for successful group experience. I understand that the registration fee is non-refundable and will hold my child’s spot until the balance is due. Registration is not guaranteed until the balance is paid two weeks before the first day of each session. Failure to pay the balance when due could result in cancellation of my registration and I understand that I will be responsible for the balance due should I not cancel my registration at least two weeks in advance of the session. Parent/Guardian Signature __________________________________________________________________________________ Date ___________________ BRANDYWINE YMCA • Summer Day Camp 2012 • (302) 478-YMCA • www.ymcade.org 25
Page 2 and 3: WELCOME TABLE OF CONTENTS Welcome 2
Page 4 and 5: GENERAL INFORMATION 4 MEMBERSHIP Ca
Page 6 and 7: CAMP QUOOWANT ENTERING K - COMPLETI
Page 8 and 9: CAMP KODA AGES: 2 - 5 YEARS OLD A s
Page 10 and 11: DANCE CAMPS AGES: 3 - 12 YEARS OLD
Page 12 and 13: SPECIALTY CAMPS COMPLETED K-7TH GRA
Page 20 and 21: TEEN CAMPS COMPLETED 3RD - 9TH GRAD
Page 22 and 23: BUS ROUTES Bus 1 Stop # In Out 17th
Page 26 and 27: 26 BRANDYWINE YMCA • Summer Day C
Page 28 and 29: 28 BRANDYWINE YMCA • Summer Day C
Page 30 and 31: 30 CAMP CHANGE FORM - ONE PER CAMPE
Page 32: BRANDYWINE YMCA 3 MOUNT LEBANON RD

session2 june18-june22 - the YMCA of Delaware

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