Registration Form - YMCA

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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 :________________________________________
Page 1: Day Camp 2013 Mother : FAMILY INFOR

Registration Form - YMCA

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