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

YMCAs across Southwestern Ontario
YMCA Youth Centre
16 Municipal Drive
Grand Bend, ON N0M 1T0
519-238-1155
Name: Gender: M F
Date of Birth (MM/DD/YYYY): Health Card #:
Address: City: Postal Code:
Home Phone:
Family Email:
Parent/Guardian 1:
Primary day time phone number:
Parent/Guardian 2:
Secondary Phone:
Relationship:
Relationship:
Primary day time phone number:
Secondary Phone:
Is there a custody arrangement we should be aware of? □ Yes □ No (If yes, please supply the YMCA with a copy of court
documents)
Alternative Contact if parent/guardian can not be reached and is authorized for pick up
Alternate 1:
Alternate 2:
Primary #: 2 nd #:
Primary #: 2 nd #:
Relationship:
Relationship:
Programs Basketball $50 Cooking $60 Babysitting $40 Ball Hockey $50 At Home Alone $40
Allergies:
□ Penicillin □ Hay Fever □ Foods: □ Peanuts (nuts) □ Bee stings
□ Other:
If allergies are noted, please list type of reaction:
Does your child require an Epi-Pen? □ Yes □ No Severity of reaction: □ Mild □ Moderate □ Severe
Does your child have any medical conditions? (please list)
Is your child currently on any medications?
□ Yes* □ No
If yes, please list 1. Purpose
*If your child is bringing medication to camp, please fill out a
medication dispensing form
2. Purpose
Has your child been diagnosed with special needs or
behavioural considerations?
□ Yes □ No
Does your child receive
support at school?
□ Yes □ No
If yes, please describe

Cancellation & Refund Policy
Requests for refunds must be made at least one week prior to the start of the selected program session and are subject to a $25 administration
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
issued if a participant is sent home for misconduct. Please refer to Standards of Behaviour in the parent handbook.
NSF Payment/Stop Payment/Closed Account
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.
Code of Conduct
It is our goal to provide a healthy, safe and secure environment for all participants, the YMCA values diversity and the differences that form. The
instructors use a positive, values based approach to guide appropriate behaviors and seek to reward and reinforce positive behavior. Students are
expected to follow YMCA behavior guidelines and to interact appropriately with their fellow students.
The safety of each individual is of the utmost importance to the YMCA. Parent/guardian(s) and students must recognize a personal responsibility
to learn and follow safety and other rules established by the YMCA. Behavior that impacts other students physically or emotionally (including
harassment and/or bullying) may result in dismissal or removal from the program. Children will be dismissed from the program due to intentional
behavior that places them or others at risk.
Refunds will not be granted for dismissal before the end of the program session/week.
Behavior Guidelines
All Students are responsible for their actions
All students will respect each other and the environment
All students will be honest and true to their word
All students will care for themselves and those around them
All students will make healthy and safe choices
All students will value diversity and seek to include others
Consent
1. I will fill out a National YMCA photo and video consent release and waiver form.
2. Field trips (if applicable) are an extension of the Day Camp program that enhance and broaden a child’s perspective. Your child will leave the
premises under supervision for community field trips and you will be notified of field trips in advance.
3. I consent to have my child participate in a supervised swim program (if applicable). □ Yes □ No
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
held liable for any accident or injury that may occur.
5. I understand it is my responsibility to provide sunscreen for my child.
6. Every attempt to contact the parents/guardians or the emergency contact will be made in the event my child requires emergency medical
treatment.
7. I will be responsible for any costs incurred due to ambulance or medical fees.
Parent/Guardian signature
Date