2012 CAMP ARROWHEAD - YMCA of Greater Rochester

Feel the Arrowhead
Experience -
Register Today!
2012 CAMP ARROWHEAD
REGISTRATION FORM
585.383.4590 • www.rochesterymca.org/camparrowhead
AT CAMP, I CAN!
SWIM • BIKE • GAIN CONFIDENCE • HIKE • CRAFTS • MAKE FRIENDS • ENJOY UNPLUGGED FUN

2012 Camp Arrowhead Regis
Camper Name _______________________________________________________________________________________________________________
Registration is as easy as... 1Review Camp
Sessions & Dates
CAMP SESSIONS
June 11 - August 31
PRESCHOOL CAMP PROGRAMS
Full Day Program
Ages 3-5 • 9 am- 4 pm
Members $179
Prog. Members $234
Half Day Program
Ages 3-5
9 am-12 pm or 1-4 pm
Members $106
Prog. Members $142
SCHOOL AGE CAMP
Entering Grades K- 9 in Sept. 2012
9 am- 4 pm
Members $179 • Prog. Members $234
FULL DAY HALF DAY SELECT PROGRAM SELECT SESSIONS
Oneida AA Preschool Week: June 11-15 FULL DAY AM PM Cayuga
Entering
Oneida BB Preschool Week: June 18-22 FULL DAY AM PM Grades K-1
Session 1: June 25-29 FULL DAY AM PM Session 1
Seneca
Session 2: July 2-6* FULL DAY AM PM
Entering
Session 2*
Session 3: July 9-13** FULL DAY AM PM Grades 2-3 Session 3**
Session 4: July 16-20 FULL DAY AM PM Session 4
Session 5: July 23-27** FULL DAY AM PM Onondaga Session 5**
Entering
Session 6: July 30-Aug 3 FULL DAY AM PM Grades 4-5 Session 6
Session 7: Aug 6-10** FULL DAY AM PM Session 7**
Session 8: Aug 13-17 FULL DAY AM PM Teen Trekkers Session 8
Session 9: Aug 20-24
Entering
FULL DAY AM PM Session 9
Grades 6-9
Session 10: Aug 27-31 FULL DAY AM PM Session 10
*Camp CLOSED on July 4th **Indicates an overnight week
Health Information
Immunization History (required by New York State Department of Health):
I certify that all of my child’s immunizations are up to date.
I understand that I must submit a full copy of my child’s immunization
history before he/she may attend YMCA Camp Arrowhead. Please
provide the most current immunizations history to the YMCA by
June 1, 2012.
Health History
_______Hay Fever
_______Asthma
_______Special Diet
_______Behavior Problems
_______Hearing
_______Vision
_______Ear Infections
2Select Camp
Program & Sessions
_______Rheumatic Fever
_______Convulsions
_______Diabetes
_______Chicken Pox
_______Mumps
_______Medication (Name
and Dose)
SELECT PROGRAM
3Check Additional
Services Available
4Select Summer Camp
Payment Option
SPECIALTY CAMPS & LEADERSHIP TRAINING
Mountain Bike, Members: $240, Prog. Members: $348
Archery Camp, Members: $240, Prog. Members: $348
Golf Camp, Members: $285, Prog. Members: $392
Camp Cory Sampler, Members: $352, Prog. Mem. $477
Rock & Ropes Camp, Members: $352, Prog. Members: $ 477
Sailing Camp, Members: $381, Prog. Members: $505
SELECT SESSIONS
Mountain Biking (grades 5-8) 3 4 5 6 7 8
Archery (grades 5-8) 3 4
Golf Camp (grades 5-8) 3 4 5 6 7 8
Camp Cory Sampler (ages 7-12) 1 8
Rocks & Ropes Camp (grades 5-8) 5 7
Sailing (grades 5-8) 5 7
Kayaking (grades 5-8) 6 8
Arrowhead Leadership Training (ALT) 3 & 4 5 & 6 7 & 8
Counselor in Training (CIT) 2 - 4 6 - 8
Allergies
_______Nuts/Peanuts
_______Insect Stings
_______Poison Ivy, etc.
_______Penicillin
_______Other Drugs
_______Foods (supply list)
_______Latex
Doctor’s name: ________________________________________________________________________________________ Phone: ________________________________________________________________________________________________
Insurance Carrier: _____________________________________________________________________________________ Policy Holder Name: ___________________________________ Policy No.: _____________________________
Recommendations and Restrictions While at Camp
Recent Surgery (type & date): ________________________________________________________________________________________________________________________________________________________________________________
Are there any medical or developmental conditions requiring attention? __________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________
Serious Injury (type & date): ____________________________________________________________________________ Chronic or Recurring Illness: _________________________________________________________________
Other Conditions or details of above: ______________________________________________________________________________________________________________________________________________________________________
Have any significant events occurred in your family within the last few years? ___________________________________________________________________________________________________________________
Will your child need any medication at camp? Yes No If yes, list name(s) and dosage(s)* _______________________________________________________________
Does your child have any serious fears? If so, please explain. ______________________________________________________________________________________________________________________________________
Are there any problems that may confront your child at camp (homesickness, anxiety, moodiness, allergies, etc.)? _______________________________________________________
*Note on Medication: All prescriptions and over-the-counter medications must be in original bottle and have complete instructions from the doctor.
Kayak Camp, Members: $381, Prog. Members: $505
A.L.T. Arrowhead Leadership Training, TWO WEEK PROGRAM,
Members; $333, Prog. Members: $442
C.I.T. Counselor In Training,15-Year Olds Only,
Members: $410, Prog. Members: $581
Payment Options
A one-time registration fee of $25 per child or $40 per family, a $20 per child
per session deposit for sessions 1-8 or a $35 deposit for sessions 9 & 10 and
full payment of all additional services is due with registration. All deposits and
registration fees are non-refundable.
Select Payment Option:
Easy Payment Option (EFT) I hereby authorize the YMCA of Greater Rochester
to debit the account listed below for summer camp fees on the Monday, two weeks
prior to each registered session.
Payment in Full: Enclosed is full payment for all registered camp sessions.
Select Payment Form:
Mastercard Visa Discover
Billing Name: _____________________________________________________________
Account No: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Exp. Date:___/___
Signature _______________________________________________ Date: ___/___/___
The Easy Payment Option (EFT) is the preferred billing method for Camp
Arrowhead. Simply provide a credit or debit card and tuition will be automatically
paid approximately two weeks prior to the session beginning. If you prefer not
to participate in the EFT payment option please contact our billing registration
specialist at 341-3236 to discuss a statement billing plan.
I need a Flex Receipt for Child Care Reimbursement.
My completed Financial Assistance Application is attached (due by 6/1/12).
I plan to receive DSS funding.
Split billing is available with written consent from both parties.
Visit www.rochesterymca.org/camparrowhead for an authorization form.
Additional Services
Extended Day Camper Care
(Included with Tuition)
AM Camper Care 7:00-8:45 am
PM Camper Care 4:15-6:00 pm
Busing Options
$40 /Week for Round Trip* ($32 for Session 2)
Bus 1 Bus 2
Indicate Stop Name________________________________
AM Session 1 2 3 4 5 6 7 8 9 10
PM Session 1 2 3 4 5 6 7 8 9 10
See brochure for bus schedule or reverse side on Registration Form.
*There is no adjustment in price for one-way.
Swim Lessons
SKILL LEVEL
Beginner - Polliwog (Ages 6-12)
Intermediate - Guppy (Ages 6-12)
Advanced - Minnow (Ages 6-12)
(Check the box for the desired session)
AM 8:00-8:40 3 4 5 6 7 8
Intermediate Advanced
AM 8:45-9:25 3 4 5 6 7 8
Beginner Intermediate Advanced
For AM Swim Lessons, camper must be registered for
AM Camper Care at no additional cost.
PM 3:00-3:40 3 4 5 6 7 8
Beginner Advanced
PM 3:45-4:25 3 4 5 6 7 8
Beginner Intermediate Advanced
For PM Swim Lessons, camper must be registered for
PM Camper Care at no additional cost.
Members $29 • Program Members $58
Camp Outs Camper entering Grades 2 and up
Friday, July 13th SESSION 3
Friday, July 27th SESSION 5
Friday, August 10th SESSION 7
Pick-up for campers is between 8:00-9:00 am on Saturday
morning and includes family breakfast for registered campers.
$18.00 per overnight per child fee includes dinner for camper,
all activities, snack and family breakfast.

2012 YMCA Camp Arrowhead Day Camp Registration
Complete one registration form per child. PLEASE NOTE: Application will not be processed without the one-time registration fee
($25 per child or $40 per family) and a $20 deposit ($35 for sessions 9 & 10) per child per session (which is applied toward the
camp fee). ALL DEPOSITS AND REGISTRATION FEES ARE NON-REFUNDABLE. ALL CHANGES AND CANCELLATIONS TO THIS
REGISTRATION FORM MUST BE SUBMITTED IN WRITING.
CAMPER INFORMATION
Camper Name: _______________________________________________________________________________________ Gender: M F YMCA Member: Yes No
Date of Birth: _____/_____/ ________ Age: ______________Grade (entering 9/12): ______________________ No. of Years at Camp Arrowhead: __________________________
Address: _________________________________________________________________________________ City: _________________________________ State: _________________ Zip: _________________
This will be my first summer at Camp Arrowhead: Yes No Number of Years at Camp Arrowhead: _______________
PARENT/GUARDIAN 1 INFORMATION
Relation to Camper: ______________________________________________________
Title: __________ First Name: _______________________________________________
Last Name: _________________________________________________________________
Occupation: ________________________________________________________________
Address: _____________________________________________________________________
City: _________________________________ State: ___________Zip:_________________
Home Phone: (_____) ________________ Cell Phone: (_____) ________________
Work Phone: (_____) _________________ Email: ______________________________
PARENT/GUARDIAN INFORMATION
Parent/Guardian Agreement: I hereby register my child for designated session(s) of YMCA Camp Arrowhead. I will receive the
Parent Packet upon registration and understand I am responsible for reading and reviewing the camp policies including but not limited to
payment procedures and deadlines, refund policy, camper release policy, camp hours of operation and behavior policy. I understand that
the New York State Department of Health requires my child to have completed health information including immunization dates in order
to attend camp. It is understood that the YMCA will make every reasonable effort to contact the parents and emergency contacts listed
should any type of emergency arise. In the event I cannot be reached I authorize the YMCA staff to act for me according to his/her best
judgment in any emergency requiring medical or surgical care. I authorize the physician selected to hospitalize, secure proper treatment
for, and to order injection, anesthesia, or surgery for my child named above. I expect the YMCA to attempt to contact me immediately. I
further understand I am responsible for the cost of all medical care. The health form is correct as far as I know, and the person described
has permission to engage in all camp activities except as noted by me and his/her physician. I have provided the staff with any pertinent
information which may assist the YMCA in caring for my child including but not limited to allergies, previous existing illness or condition,
sunburn sensitivity , diet requirement, long term medications, disability or limiting conditions or emotional, developmental, or behavioral
challenges. I agree to notify YMCA Staff immediately, in writing, of any changes in address, phone number, places of employment, or
persons authorized to pick up child, etc. I understand that not fully disclosing the above may put my child’s health and safety at risk. I
give consent for my child to take part in all typical day camp programming, field trips or excursions off camp property, including hiking
to Powder Mills Park and the Fish Hatchery under proper supervision. Finally, I give consent that the YMCA may use photographs, slides,
and video of my child, as may be needed for its records or promotional purposes including website material. I further understand that
my child’s spot is reserved only upon receipt by the YMCA of the fully completed registration form and health information,
a $20 deposit per child for sessions 1-8 and $35 deposit for sessions 9 & 10 and the $25 per child or $40 per family
registration fee and that failure to pay balance due by the deadline, may forfeit my child’s registration. First time camper
registrations received after Thursday at 5pm for the next session will incur a $20 late fee per child.
Signature of Parent/Guardian ________________________________________Date ______________
The YMCA is required to report membership and program participation information to the
United Way and various government agencies in support of annual allocation, grant, and
community service requests. This information is not reported on an individual basis and is
used for statistical purposes only. Please check the correct answer for both A and B:
A. Racial Status: African American Asian Caucasian
Hispanic Native American Other
B. Annual Household Income: Less than $15,000 $25,000-$44,999 $75,000 or over
$15,000-$24,999 $45,000-$74,999
PARENT/GUARDIAN 2 INFORMATION
Relation to Camper: ______________________________________________________
Title: __________ First Name: _______________________________________________
Last Name: _________________________________________________________________
Occupation: ________________________________________________________________
Address: _____________________________________________________________________
City: _________________________________ State: ___________Zip:_________________
Home Phone: (_____) ________________ Cell Phone: (_____) ________________
Work Phone: (_____) _________________ Email: ______________________________
Camper lives with: (please check) Parent 1 & Parent 2 Parent 1 Parent 2 Yes, I would like to receive the Arrowhead weekly e-newsletter
EMERGENCY CONTACTS AND PERSONS AUTHORIZED TO PICK UP CAMPER
Name: ______________________________________________________ Relationship: _______________________________________ Cell Phone: _______________________________
Name: ______________________________________________________ Relationship: _______________________________________ Cell Phone: _______________________________
Name: ______________________________________________________ Relationship: _______________________________________ Cell Phone: _______________________________
ADDITIONAL INFORMATION
Turn page to complete Registration & Health Form
I will be enrolling
multiple children.
$15 sibling discount per
additional child for full day &
$10 for half day sessions.
Group placement: If possible, I would like to request my child
with these two campers:
1. _______________________________________________________________
2. _______________________________________________________________
Child’s T-Shirt Size___________________________________________
BUS 1
AM
PM
Metro Center YMCA - 7:45 Camp Departure - 4:15
Cornell Cooperative Extension - 8:00 Southeast YMCA - 4:20
Brighton High School - 8:15 French Road Elementary - 4:40
French Road Elementary - 8:25 Brighton High School - 4:50
Southeast YMCA - 8:45 Cornell Cooperative Extension - 5:05
Camp Arrival - 8:55 Metro Center YMCA - 5:20
BUS 2
AM
PM
Mercy High School - 7:45 Camp Departure - 4:15
Eastside YMCA - 8:05 Pines of Perinton - 4:30
Techniplex Parking Lot - 8:20 Techniplex Parking Lot - 4:40
Pines of Perinton - 8:30 Eastside YMCA - 5:00
Camp Arrival - 8:45 Mercy High School - 5:15
For Official Use Only: Date Received ______ Initials ______