YMCAs across Southwestern Ontario Name - The Municipality of ...

YMCAs across Southwestern Ontario Name - The Municipality of ...

YMCAs across Southwestern Ontario Name - The Municipality of ...


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<strong>YMCAs</strong> <strong>across</strong> <strong>Southwestern</strong> <strong>Ontario</strong><br />

YMCA Youth Centre<br />

16 Municipal Drive<br />

Grand Bend, ON N0M 1T0<br />

519-238-1155<br />

<strong>Name</strong>: Gender: M F<br />

Date <strong>of</strong> Birth (MM/DD/YYYY): Health Card #:<br />

Address: City: Postal Code:<br />

Home Phone:<br />

Family Email:<br />

Parent/Guardian 1:<br />

Primary day time phone number:<br />

Parent/Guardian 2:<br />

Secondary Phone:<br />

Relationship:<br />

Relationship:<br />

Primary day time phone number:<br />

Secondary Phone:<br />

Is there a custody arrangement we should be aware <strong>of</strong>? □ Yes □ No (If yes, please supply the YMCA with a copy <strong>of</strong> court<br />

documents)<br />

Alternative Contact if parent/guardian can not be reached and is authorized for pick up<br />

Alternate 1:<br />

Alternate 2:<br />

Primary #: 2 nd #:<br />

Primary #: 2 nd #:<br />

Relationship:<br />

Relationship:<br />

Programs Basketball $50 Cooking $60 Babysitting $40 Ball Hockey $50 At Home Alone $40<br />

Allergies:<br />

□ Penicillin □ Hay Fever □ Foods: □ Peanuts (nuts) □ Bee stings<br />

□ Other:<br />

If allergies are noted, please list type <strong>of</strong> reaction:<br />

Does your child require an Epi-Pen? □ Yes □ No Severity <strong>of</strong> reaction: □ Mild □ Moderate □ Severe<br />

Does your child have any medical conditions? (please list)<br />

Is your child currently on any medications?<br />

□ Yes* □ No<br />

If yes, please list 1. Purpose<br />

*If your child is bringing medication to camp, please fill out a<br />

medication dispensing form<br />

2. Purpose<br />

Has your child been diagnosed with special needs or<br />

behavioural considerations?<br />

□ Yes □ No<br />

Does your child receive<br />

support at school?<br />

□ Yes □ No<br />

If yes, please describe

Cancellation & Refund Policy<br />

Requests for refunds must be made at least one week prior to the start <strong>of</strong> the selected program session and are subject to a $25 administration<br />

charge. A refund cheque will be mailed within 14 days. A doctor’s note is required for all cancellations due to medical reasons. Refunds will not be<br />

issued if a participant is sent home for misconduct. Please refer to Standards <strong>of</strong> Behaviour in the parent handbook.<br />

NSF Payment/Stop Payment/Closed Account<br />

A $25.00 charge will be applied to all NSF’s. Access to YMCA programs may be suspended until the account is returned to good standing.<br />

Code <strong>of</strong> Conduct<br />

It is our goal to provide a healthy, safe and secure environment for all participants, the YMCA values diversity and the differences that form. <strong>The</strong><br />

instructors use a positive, values based approach to guide appropriate behaviors and seek to reward and reinforce positive behavior. Students are<br />

expected to follow YMCA behavior guidelines and to interact appropriately with their fellow students.<br />

<strong>The</strong> safety <strong>of</strong> each individual is <strong>of</strong> the utmost importance to the YMCA. Parent/guardian(s) and students must recognize a personal responsibility<br />

to learn and follow safety and other rules established by the YMCA. Behavior that impacts other students physically or emotionally (including<br />

harassment and/or bullying) may result in dismissal or removal from the program. Children will be dismissed from the program due to intentional<br />

behavior that places them or others at risk.<br />

Refunds will not be granted for dismissal before the end <strong>of</strong> the program session/week.<br />

Behavior Guidelines<br />

All Students are responsible for their actions<br />

All students will respect each other and the environment<br />

All students will be honest and true to their word<br />

All students will care for themselves and those around them<br />

All students will make healthy and safe choices<br />

All students will value diversity and seek to include others<br />

Consent<br />

1. I will fill out a National YMCA photo and video consent release and waiver form.<br />

2. Field trips (if applicable) are an extension <strong>of</strong> the Day Camp program that enhance and broaden a child’s perspective. Your child will leave the<br />

premises under supervision for community field trips and you will be notified <strong>of</strong> field trips in advance.<br />

3. I consent to have my child participate in a supervised swim program (if applicable). □ Yes □ No<br />

4. It is understood that adequate supervision will be provided by YMCA staff, and while every care will be taken, the YMCA Day Camp will not be<br />

held liable for any accident or injury that may occur.<br />

5. I understand it is my responsibility to provide sunscreen for my child.<br />

6. Every attempt to contact the parents/guardians or the emergency contact will be made in the event my child requires emergency medical<br />

treatment.<br />

7. I will be responsible for any costs incurred due to ambulance or medical fees.<br />

Parent/Guardian signature<br />


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