Registration Form - YMCA

Day Camp 2013
Mother :
FAMILY INFORMATION
Child :
Family Name:_ _______________________________ First Name: _ ____________________________________
Date of Birth: ___________ / _ _____ / _ ______ Age: _ ___ Yrs □ M □ F
Grade completed on June 30 Th 2013: _ ____________________________________________________________
Languages spoken: □ English □ French □ Other: _ ___________________________________
Address: Num._ ______ St._ _______________________________________________________ Apt. _________
City :____________________________________________________ Postal Code :_ _______________________
Has your child taken swimming lessons
□ Yes □ No
What was the last level passed__________________________________________________________________
Where did your child take them_________________________________________________________________
Last Name:__________________________________________________ First Name:____________________________________________________
Tel. Home: (_ ______ )____________________________ Tel. Work: (_______ )________________________________ Ext.: ______________________
Cell: (_ _____ )_________________________________ E-Mail: _____________________________________________________________________
Father:
CHOOSE YOUR YMCA AND YOUR AGE GROUP
Cartierville YMCA :. . . . . . . . . . . . . . □ 4 ½ to 5**. . . . . . □ 5* to 6 . . . . . . . .□ 7 to 8. . . . . . . . . . . □ 9 to 12
Du Parc YMCA : . . . . . . . . . . . . . . . . . □ 5* to 6 . . . . . . . . . □ 7 to 8 . . . . . . . . .□ 9 to 10 . . . . . . . . . □ 11 to 12
Notre-Dame-de-Grâce YMCA : . □ Preschool (full day) - 4 to 5 . . . . . . .□ Kindergarten . . . □ Grade 1 . . . . . . . □ Grade 2 . . . . . . □ Grade 3
□ Grades 4-5 . . . . □ Explorers : Grade 6 - Sec. I
West Island YMCA : . . . . . . . . . . . . . □ Preschool (full day) - 4 to 5 . . . . . . .□ 5* to 6. . . . . . . . . . □ 7 to 8 . . . . . . . . . □ 9 to 12
□ Leaders-in-Training - 12 to 17
Westmount YMCA :. . . . . . . . . . . . . □ Preschool (full day) - 4 to 5 . . . . . . .□ 5* to 6. . . . . . . . . . □ 7 to 8 . . . . . . . . . □ 9 to 11
□ Explorers - 12 to 14
* Children must have completed kindergarten./ ** Children must be registered in kindergarten for the fall of 2013
Photo of your child
(Mandatory at registration)
Last Name:__________________________________________________ First Name:____________________________________________________
Tel. Home: (_ ______ )____________________________ Tel. Work: (_______ )________________________________ Ext.: ______________________
Cell: (_ _____ )_________________________________ E-Mail: _____________________________________________________________________
CHILDREN WITH SPECIAL NEEDS
EMERGENCY CONTACTS OTHER THAN PARENTS
1. Name: _ __________________________________________________ Relation to the child: _ __________________________________________
Tel. Home: (_ ______ )____________________ Tel. Work: (______ )_ __________________ Ext.: _______ Other : (_____ )________________________
2. Name: _ __________________________________________________ Relation to the child: _ __________________________________________
Tel. Home: (_ ______ )____________________ Tel. Work: (______ )_ __________________ Ext.: _______ Other : (_____ )________________________
INCOME TAX RECEIPT
Indicate the name of the person paying. He/she will receive the income tax receipt.
(PLEASE PRINT)
Our day camps aim to integrate children with special needs. The need and eligibility for a shadow will be determined according to specific criteria. For
more information on the registration process, please contact the manager of the day camp. Please refer to our website for the telephone number of
the centre (http://www.ymcaquebec.org/en/children/day_camps/).
Name : _________________________________________________________ S.I.N. : __________________________________________________

MEDICAL INFORMATION
For children with special needs, please contact the manager of the day camp for more information on the registration process. Please refer
to our website for the telephone number of the centre (http://www.ymcaquebec.org/en/children/day_camps/).
Medicare number: _ _______________________________________________________ Expiry date:______________________________________
Does your child have any of the following
□ Epilepsy □ Haemophilia □ Hearing problems □ Diabetes
□ Hyperactivity □ Attention deficit □ Incontinence □ Vision troubles
□ Asthma □ Speech impediment □ Allergies, specify: _______________________________________________________
□ Other, please specify: _ __________________________________________________________________________________________________
Is your child presently taking medication □ Yes □ No
If yes, which one _________________________________________________________________________________________________________
Does your child need to carry an EpiPen (medication) □ Yes □ No
Are there any other physical or emotional factors concerning your child that you would like us to be aware of
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
IN CASE OF AN EMERGENCY, I HEREBY AUTHORIZE THOSE RESPONSIBLE FOR MY CHILD’S CARE TO TAKE THE NECESSARY MEASURES TO
ENSURE MY CHILD’S HEALTH. □ Yes □ No
PEOPLE AUTHORIZED TO PICK-UP YOUR CHILD
□ MOTHER □ FATHER □ OTHER:
1. Name: _ __________________________________________________ Relation to the child: _ __________________________________________
Tel. Home: (_ ______ )____________________ Tel. Work: (______ )_ __________________ Ext.: _______ Other : (_____ )________________________
2. Name: _ __________________________________________________ Relation to the child: _ __________________________________________
Tel. Home: (_ ______ )____________________ Tel. Work: (______ )_ __________________ Ext.: _______ Other : (_____ )________________________
NON-AUTHORIZED*: Name: ______________________________________ Relation to the child: _________________________________________
* If the non-authorized person is the other parent, a court document must be submitted.
AUTHORIZATION TO LEAVE THE DAY CAMP UNSUPERVISED (12 yrs +)
I authorize my child to leave the day camp alone every day, releasing The YMCAs of Québec of all responsibilities.
□ Yes □ No
AUTHORIZATION FOR PHOTOGRAPHS AND VIDEOS
I am aware that The YMCAs of Québec day camps produce promotional materials (video, photographs) which may include my child.
□ Yes, I accept □ No, I do not accept
AUTHORIZATION FOR OUTINGS
I hereby authorize the YMCAs of Québec day camp to allow the afore-mentioned child to participate in all outings and all related activities.
□ Yes □ No
DAY CAMP PARENT INFORMATION GUIDE
I understand that I am responsible for reading the Parent Guide, which I can obtain from the customer service counter in my YMCA centre or by
consulting this Guide online (http://www.ymcaquebec.org/data/pdf/camp/ParentGuide_en_2013.pdf ) □ Yes □ No
HOW DID YOU FIND OUT ABOUT OUR DAY CAMP
□ Friend □ Returning camper □ Poster □ Banner □ Camp fair □ School
□ Advertisement □ Internet, please specify: ___________________________________________________
□ Other :________________________________________________________________________________

ACCESS FOR ALL POLICY
Access for All, a YMCA for everyone!
At the YMCA, everyone matters. With this in mind, we offer financial assistance to promote equal access to our programs. Eligibility requirements
available upon request.
EARLY BIRD DISCOUNT
5 % discount on the weekly rate if you register your child before March 31 st 2013. Does not apply to the Pointe-Saint-Charles camps.
(Does not apply to pre and post-camp care).
DISCOUNT POLICY
• 10% discount applied to the 2 nd , 3 rd and 4 th child from the same family (applied to the lower-priced camp).
• 15% discount for Family membership holders.
• These two discounts cannot be combined (but each may be combined with the Early Bird discount).
• Does not apply to pre and post-camp care.
CAMP WEEKS
$180/week*
PRE AND POST-CAMP CHILD CARE** – check the time slots and days needed
WEEKS
DATE OF POSTDATED
PAYMENTS
1 □ June 24 th – June 28 th June 12 th □
2 □ July 1 st – July 5 th June 19 th □
3 □ July 8 th – July 12 th June 26 th □
4 □ July 15 th – July 19 th July 3 rd □
5 □ July 22 nd – July 26 th July 10 th □
6 □ July 29 th – August 2 nd July 17 th □
7 □ August 5 th – August 9 th July 24 th □
8 □ August 12 th – August 16 th July 31 st □
9 □ August 19 th – August 23 rd * August 7 th * □
PRE-CAMP
7:30 to 9 a.m. – $4.88/morning
POST-CAMP
4 to 6 p.m. – $6.50/afternoon
M T W T F M T W T F
1 June 24 th - June 28 th □ □ □ □ □ □ □ □ □ □
2 July 1 st - July 5 th □ □ □ □ □ □ □ □ □ □
3 July 8 th - July 12 th □ □ □ □ □ □ □ □ □ □
4 July 15 th - July 19 th □ □ □ □ □ □ □ □ □ □
5 July 22 nd - July 26 th □ □ □ □ □ □ □ □ □ □
6 July 29 th - August 2 nd □ □ □ □ □ □ □ □ □ □
7 August 5 th - August 9 th □ □ □ □ □ □ □ □ □ □
8 August 12 th - August 16 th □ □ □ □ □ □ □ □ □ □
9 August 19 th - August 23 rd * □ □ □ □ □ □ □ □ □ □
** Does not apply to the Leaders-in-Training camp.
CHEQUES RECEIVED
for office use only.
Registration deadline for each camp week is the
Wednesday prior to the week you are registering for.
After this deadline, please contact the manager of the
day camp.
You may switch weeks at any point after registration
providing there is space available. A $10 fee will apply to
any switch after June 1st.
* Week 9 : - Please add an additional fee of $15 for an excursion to
YMCA Camp Kanawana.
- Preschool groups will not participate.
PAYMENT
• A $15 reservation fee per week registered is required at the
time of registration. This amount will be deducted from the
total amount owed. Please note that in the event of a
cancellation, the reservation fee will not be reimbursed.
• The balance of the amount owed must be post-dated 12
days prior (on the Wednesday) to the first day of each
camp week registered. These post-dated payments must be
submitted at the time of registration.
• If paying by cheque, please make them payable to the
centre you are registering with.
• A $15 fee will be charged for any declined payments.
• A $10 fee will be charged for any switch of weeks
after June 1 st .
REIMBURSEMENT / CANCELLATIONS
• Full reimbursement, minus the $15 reservation fee, can be granted if a written request is received before 12:00 p.m. on the Monday (1 week
prior) preceding the start of a camp week for which your child is registered. A reimbursement will not be granted without the written request.
• No cancellations or changes will be accepted over the telephone.
• Absence from day camp does not constitute a withdrawal from the program. A reimbursement will not be granted for those days.
Signature :_ ______________________________________________
Date :________________________________________