MORRISON FAMILY YMCA - YMCA of Greater Charlotte

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PARTICIPANT info/MEDICAL inforMATIONLast Name:__________________________________________________________________ First Name:________________________________ MI:________INSURANCE AND MEDICAL inforMAtion:Carrier/Plan Name: ___________________________________________________________ Group #: ____________________________________________Name of Insured: _____________________________________________________________ Relationship to Participant: ________________________PREFERRED proVIDer:Physician: _____________________________________________________________________________Phone:_______________________________________Preferred Hospital: _________________________________________________________________________________________________________________Is participant cover by insurance: Yes NoI HAVE inCLUDED A COPY of MY ChilD IMMuniZAtion reCORDS.Is the Member/Participant currently taking prescription/over the counter medications? Yes NoList Medication/Dosage/Purpose: _____________________________________________________________________________________________________Any condition requiring special care? Yes No(e.g. Diabetes, Gastrointestinal, Motor Disorder, Seizures, ADHD, Autism, Cognitive Disorder, Asthma, etc.)If yes, please specify: ____________________________________________________________________________________________________________________Has the Member/Participant had surgeries, illness, or any severe injuries? Yes NoIf yes, please specify: ____________________________________________________________________________________________________________________Please provide information we may not have asked that you feel is important for us to know as we incorporateyour child into our program ___________________________________________________________________________________________________________Does the member/participant have allergies? Yes No (e.g. food, medication, seasonal, etc.)Describe all known allergies in detail: ________________________________________________________________________________________________Does member/participant have dietary restrictions? Yes NoExplain Dietary Restrictions: ___________________________________________________________________________________________________________WAIVerS and AuthoriZAtion for treATMentThe health history is complete and accurate and participant has permission to engage in all activities unless otherwise specified in writing. Iunderstand that the YMCA of Greater Charlotte assumes no responsibility for injuries or illness which my child may sustain as a result of his/herparticipation in Summer Camp, athletics, sports programs, the use of any equipment, exercise or other activities. I expressly acknowledge that mychild has been medically cleared to participate in vigorous physical activities. I also understand that there is a risk of injury while participating inphysical activities. I agree to hold harmless the YMCA, its staff and volunteers for accidents of injuries arising out of my child’s participation inactivity.While the YMCA of Greater Charlotte will make every effort to provide reasonable accommodations for mentally and physically challenged children,we will not enroll children who are (1) of danger to themselves, (2) of danger to others, (3) a disruption to the normal activities making itunreasonably difficult for other children to enjoy the day camp programs. Any of the above reasons will be grounds for dismissal from the program.The YMCA follows the guidelines of the ADA. If my child requires special accommodations, I understand that I must contact the camp director prior tomy child’s participation in the program.I agree to have my child examined medically within a reasonable time period by family physician stating he/she is free from communicable disease andhas not been exposed to such. I hereby give my permission to the medical personnel selected by the YMCA director to order x-rays, routine tests,treatment; to release any records necessary for insurance purposes, and to provide or arrange necessary related transportation for myself/or mychild. In the event that I cannot be reached in an emergency, I herby give permission to the physician selected by the YMCA director to secure andadminister treatment including hospitalization for my child. I understand that no accident or medical insurance is provided with this activity.I give my consent for my child to leave the YMCA site, participate in authorized YMCA trips, swim at approved facilities and to ride in authorizedvehicles for the purpose of transportation in connection with the YMCA program.PRINT NAME: ___________________________________________________________________________________ DATE: ____________________________SIGNATURE: ________________________________________________________________________________________________________________________
Summer Camp NamesWk 0 Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 Wk 9 Wk 10 Wk 116/3-6/7 6/10-6/14 6/17-6/21 6/24-6/28 7/1-7/5 7/8-7/12 7/15-7/19 7/22-7/26 7/29-8/2 8/5-8/9 8/12-8/16 8/19-8/23Afternoon Exploration (PM) 16 (1st-8th) (1st-8th) (1st-8th) (1st-8th) (1st-8th) (1st-8th) (1st-8th) (1st-8th) (1st-8th)Aliens in Space Camp: Boys Only (PM) 6 (3rd-5th) (1st-2nd)All About Pink Camp: Girls Only (AM) 17 (1st-2nd) (1st-2nd)Animal Camp (AM) 16 (1st-2nd) (1st-2nd) (1st-2nd)Art Around the World Camp (AM) 6 (1st-2nd) (K) (3rd-5th)Art Around the World Camp (PM) 6 (K) (1st-2nd)Art Sampler Camp (AM) 6 (K) (1st-2nd) (3rd-5th) (6th-8th)Art Sampler Camp (PM) 6 (K) (3rd-5th)Babysitting & Safe Sitter Cert. Camp (AM) 18 (6th-8th) (6th-8th)Baseball Camp (AM) 11 (1st-8th) (3rd-8th) (1st-2nd)Basketball Camp: Co-ed (AM) 11 (1st-2nd) (1st-8th) (1st-8th)Basketball Camp: Girls (AM) 11 (3rd-8th) (3rd-8th)Boot Camp (PM) 11 (6th-8th)Ceramics Camp (AM) 7 (1st-2nd) (3rd-5th)Ceramics Camp (PM) 7 (1st-2nd) (6th-8th) (3rd-5th)Cheer/Tumble Camp (AM) 10 (3rd-5th) (K-2nd) (K-2nd)Cooking Camp (AM) 15 (1st-2nd) (3-4 yrs) (K) (K) (3rd-5th) (3-4 yrs) (1st-2nd) (3rd-5th) (1st-2nd)Cooking Camp (PM) 15 (6th-8th) (1st-2nd) (3rd-5th) (1st-2nd) (3rd-5th) (1st-2nd) (6th-8th) (1st-2nd) (3rd-5th)Dance Camp (AM)9(3-5 yrs) (1st-2nd)(3-4 yrs) ;(K)(3rd-5th) (3-5 yrs) (1st-2nd) (3-5 yrs)Detective Camp (AM) 16 (3rd-5th) (1st-2nd) (3rd-5th)Digital Photography Camp (PM) 7 (6th-8th) (3rd-5th)Dodgeball Camp (AM) 11 (3rd-8th) (3rd-8th)Drama Camp (AM) 8 (1st-2nd) (1st-2nd) (1st-2nd) (1st-2nd) (1st-2nd) (1st-2nd)Drama Camp (PM) 8 (1st-2nd) (1st-2nd)Entrepreneur Camp (AM) 18 (6th-8th)Express Yourself Camp: Girls Only (PM) 6 (3rd-5th)Fanciful Fairies Camp: Girls Only (AM) 6 (1st-2nd)Fashion and Design Camp (AM) 7 (3rd-5th)Flag Football Camp (AM) 11 (3rd-8th) (1st-2nd) (1st-2nd) (1st-2nd) (3rd-8th)Girls Rock Camp (AM) 15 (1st-2nd) (1st-2nd)Gymnastics Camp (AM) 10 (3rd-5th) (1st-2nd)Gymnastics Camp (PM) 10 (3rd-5th) (3rd-5th)MORRISON FAMILY YMCA 2013 Summer CampsGuide Pg.#Gymnastics/Dance Combo Camp (AM) 9 (3-5 yrs) (3-5 yrs)Intensive Dance Camp (AM) 9 (1st-8th) (1st-8th)Juggling & Illusions Camp (AM) 17 (3rd-5th)July 5th Camp (Full Day) 4 (K-11th)
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MORRISON FAMILY YMCA - YMCA of Greater Charlotte

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