Summer Day Camp 2015
Danville Family YMCA
Registration Packet
THINGS TO KNOW:
• Only campers registered for before- and/or after-care may attend
prior to 9am and after 4pm.
• Please be sure to indicate which specialty camps your child will
attend
•
APPLY SUNSCREEN EVERY DAY BEFORE ARRIVAL.
•
PACK YOUR LUNCH EACH DAY IN A REUSABLE LUNCH BOX (if you choose
not to eat lunch provided)
•
· No candy or pop
BRING YOUR SWIMSUIT AND TOWEL
•
BRING AN EXTRA SET OF CLOTHES (We will get messy from time to time.)
•
BRING A REUSABLE WATER BOTTLE WITH NAME ON IT
•
WEAR SHOES AND SOCKS EVERYDAY (no sandals or crocks)
•
WATER SHOES ARE HIGHLY RECOMMENDED TO BE KEPT WITH YOUR
SWIMMING ITEMS
•
CHILDREN MUST WEAR THEIR CAMP SHIRTS ON FIELD TRIP DAYS
•
ALL CHILDREN SHOULD LEAVE THEIR MONEY AT HOME
•
LEAVE DS, GAMEBOYS, I-PODS and CELL PHONES AT HOME
•
PUT YOUR NAME ON EVERYTHING THAT COMES TO THE CENTER
•
Camp Staff are CPR, First Aid, Communicable Disease & Child Abuse
Awareness Certified
•
Afternoon Snack, and Lunch (milk included) provided
WEEK
THEME
SPECIALTY CAMP
Hydro Mania Pt. 1
JR Lifeguard
Week #2 June 15-19
Hydro Mania Pt. 2
Begin to Swim/Water Safety
Week #3 June 22- 26
Ball Out!
Basketball Camp
Week #4 June 29-July3
Mad Science
Science Camp
Week #5 July 6-10
Karate Kid
Tae Kwon Do Camp
Week #6 July13-17
Beauty & the Beast
Football Camp/ Dance Camp
Week #7 July 20- 24
STEM Discovery
Club Invention
Week #8 July 27-31
Wilderness Skills
Nature Camp/ Girls Rock Camp
Week #8 August 3-7
SPY Kids
Mystery Camp
Week #10 August 10-14
Best of the Best
M.A.D. (Music, Art, Drama)
Week #1 June 8-12
Fill out and return the following pages:
•
•
•
•
Child Information
Schedule and Tuition Agreement
Field Trip Permission
Behavior Expectations and Discipline Policies
**Special Care Plans & Medication Distribution forms are required for children with
allergies or special medical conditions.
•
Only campers registered for before- and/or after-care may attend prior to 9am and
after 4pm.
• Please be sure to indicate which specialty camps your child will attend
Welcome!!
Dear Day Camp Parents,
Welcome to the Danville Family YMCA Summer Day Camp Program! We are pleased that you have chosen
our program and promise you a staff committed to providing quality care and a curriculum that will be safe,
fun and creative. The summer staff and administration have enthusiastically prepared for a great summer.
In this packet please find valuable information you will need to prepare your camper for this exciting
adventure!
The following information is designed to acquaint you with the necessary policies, procedures and program
information that will make this a memorable summer.
YMCA day camp helps kids grow positively, meet healthy role models and learn good values—all while
having fun. We not only provide memories that last a lifetime, but we also assure parents that their kids
are in good hands during the summer. If you ever feel we are not meeting your expectations, I want to
know; you may call me at 217-442-0563 ext. 18 anytime with any concerns or questions.
Thank you for choosing the YMCA as your choice for Summer Adventure!
Sincerely,
Brittny Woodard
Director of Youth & Family Well-Being
Danville Family YMCA • 1111 N. Vermilion St. • Danville, IL 61832
Phone (217) 442-0563 • FAX (217) 442-0513 • www.danvilleymca.org
Our Mission: To put Christian principles into practice through programs that build healthy spirit, mind, and body for all.
YMCA of Danville
SUMMER DAY CAMP REGISTRATION 2015
2015
CHILD’S INFORMATION
Child’s Name (first/last) ______________________________________________________________ Home Phone # ________________________
Address ______________________________________________________________________________________________________________________________
City_________________________________________________________________________ State ____________ ZIP _________________________________
Male
Female Birth date _______/_______/_______ Age __________ Grade (School year 2015/2016) ________________
Membership Status (Please circle one):
Member
Non-Member
1st Parent ____________________________________________________Birthdate __________________Contact Phone # ___________________
2nd Parent __________________________________________________Birthdate __________________Contact Phone # ___________________
Parent Email ________________________________________________________________________________________________________________________
Marital Status:
Married
Separated
Divorced
Single
Custody/Contact restrictions (Equal access to the center and child will be granted to each parent in the absence of a Court
order, which must be provided to the YMCA, specifying otherwise).
___________________________________________________________________________________________
Please list the persons permitted to pickpick-up your child.
___________________________________ Phone # _______________ Relationship _______________
___________________________________ Phone # _______________ Relationship _______________
___________________________________ Phone # _______________ Relationship _______________
___________________________________ Phone # _______________ Relationship _______________
___________________________________ Phone # _______________ Relationship _______________
Danville Family YMCA
Schedule and
and Tuition Agreement Summer 2015
Child’s Name _________________________________________________
Start Date _______________________________________
Are you responsible for entire tuition payment? ____________ (If “no” please explain)
_______________________________________________________________________________________________________________________________________
Please check () each week that your child will attend camp.
CAMP
Adventure Camp
(Entering grades K-5)
Camp Mid
(Entering grades 6-8)
Member/
non-member
6/8
6/12
6/15
6/19
6/22
6/26
6/29
7/3
7/6
7/10
7/13
7/17
7/20
7/24
7/27
7/31
8/3
8/7
8/10
8/14
$110/$130
$110/$130
Sibling Discount Applied Y_____ or N______
Y
Y
N
N
My Child will need care before camp (7-9am)
My Child will need care after camp (4-6pm)
*You must indicate if you wish to utilize after hours in order for the camper to stay in
attendance
Payment Policy:
• Camp fee payment is due three (3) days prior (Friday) to the following Monday
• IDHS Co-pays are due weekly.
• Accounts that have a balance of 2 weeks or more will be considered delinquent – Y staff will be
contacting the responsible parent to reconcile balance and keep account current.
• Payments/Refunds will be applied to any outstanding Y balances first then to current programming
fees.
Returned Check Policy:
• A returned check will be turned over to E-cashflow collection and a $25 processing fee will
automatically be assessed to your account.
• 2 NSF checks will result in payments being accepted via money order or cash only.
___________________________________________
Parent/Guardian Signature
____________________________________________
_____________
Print Name
Date
Specialty Camps Registration:
Please indicate (√) which specialty camp you wish to register your child
Space is limited with certain camps. Non-refundable fees ARE DUE at the time of registration to guarantee
a spot
_____ Week 1 JR Lifeguard: 4th -8th grade * Limit 40
_____ Week 2 Begin to Swim: K-3rd grade * Limit 40
______ Week 3 Basketball Camp: 3rd -8th grade
______ Week 4 Science Camp: 2nd- 5th grade * Limit 25
______ Week 4 Science Camp: 6th-8th grade * Limit 25
______ Week 5 Tae Kwon Do Camp: K-2nd grade
______ Week 5 Tae Kwon Do Camp: 3-6th grade
______ Week 6 Football Camp: K-8th grade
______ Week 6 Dance Camp: 2nd -8th grade
_____ Week 7 Club Invention K-8th grade *Limit 22 Nonrefundable $20 fee
_____ Week 8 Nature Camp: 5th – 8th grade
______ Week 8 Girls Rock Camp K-8th grade
_____ Week 9 Mystery Camp: K-8th
_____ Week 10 M.A.D. (music, art, drama): K-8th
CHILD’S NAME _____________________________________________
Rising Grade ____________
FIELD TRIP PERMISSION
By initialing & signing below, I hereby grant permission to the Danville YMCA for my child to travel by foot or by authorized
bussing from the YMCA to the following locations for summer field trips on the dates indicated.
Y
N
I give permission for my child to participate in swimming activities in the program.
*** My child is a _________ swimmer _________ non-swimmer ***
DATE
FIELD TRIP
Day Camp &
Camp Mid
June 12,
2015
June 19,
2015
June 26,
2015
July 3,
2015
July 10,
2015
July 17,
2015
July 24,
2015
July 31,
2015
August 7,
2015
August 14,
2015
TIMES
PARENT
INITIALS
Field Day @ YMCA
Bumper Cars @ Palmer Arena
Bowling @ Lincoln Lanes
Am & PM
1:30pm
Field Day @ YMCA
Movies @ AMC Village Mall
AM
Miniature Golf, Bloomington IL TBD
Skating @ Illini Skateland
Timber Pointe, Bloomington IL TBD
TBD
Back to School Summer Camp Talent Show & Luau @
YMCA
3-5pm
*Field Trip schedules are subject to change based on extenuating circumstances. The YMCA will provide one additional staff
member for every 18 children when we are offsite. We also provide our own lifeguard during off site swimming trips.
Field trips will leave promptly each day. All children who go will participate in the activities planned on that trip. I understand
that swimming will be part of some of these activities. I understand my child must be at the YMCA Day Camp Sites by time listed
above on field trip days or he/she may miss transportation to the field trip location. If this happens, the YMCA will not provide
care for my child that day.
day We will return from trips by time listed above unless extenuating circumstances arise.
Parent/Guardian Signature __________________________________________________________________________________________
Date _____________________________
Grant and United Way Information (Optional)
Agencies like the United Way allocate funds to the YMCA every year. We use this money to help with financial
assistance to those who need it which in turn keeps fees lower. Please fill in the information requested below to help
the Child Care Programs with our funding requests.
Child’s Gender (circle): Male
Female
Child’s Race (please circle one below)
American Indian/Alaska Native
Hispanic/Latino
Family Size (please circle one): 2
Asian
Native Hawaiian/Pacific Islander
3
4
5
6
7
Black/African American
White
8
Household Income Level (please check one):
$0-$9,999
$10,000-$19,999
$20,000-$29,999
$30,000-$39,999
$40,000-$49,999
$50,000+
Thank you for completing the information above.
It is greatly appreciated and will be very beneficial
in our grant application process.
Danville Family YMCA
BEHAVIOR GUIDANCE / MANAGEMENT POLICY
Our goal is to set guidelines and limitations to develop a feeling of self-worth and competence. Each site has rules that need to be
followed by each child. The Camp Director/Counselors will review these rules with the groups and they will be posted.
When children are on field trips or at the YMCA for swimming or other activities participants will be expected to abide by the rules
pertaining to each program area and on the bus.
When behavior management problems arise, staff will use a problem-solving approach to support children in resolving conflicts. In this
six step approach, a staff will:
1.
2.
3.
4.
5.
6.
Approach calmly, stopping any hurtful actions or language.
Acknowledge the children’s feelings using simple descriptive words.
When the children are calm, gather information by asking the children to describe the problem in their own words.
Restate the problem to clarify issues and restate any hurtful language.
Ask the children for ideas and choose a solution together involving natural consequences.
Give follow-up support to make sure the problem is solved and the children are satisfied.
All direct care staff and support staff (i.e. food service or janitorial) will follow this policy. At no time will any form of corporal
punishment or shaming be used. Children are never deprived of food as a form of discipline. The entire group is not punished for the
actions of one or a few. Children are not restricted from activities for extended periods of time. If the conflict resolution steps and
redirection to other activities fail, the next step will be a discussion with the parent or guardian to develop a behavior plan consistent
with our discipline policy and licensing guidelines.
If the behavior still continues, a suspension will result. The number of days suspended will be determined by the severity of the action. A
last resort will be to expel the child from the program.
Our disciplinary steps are always based on an understanding of the individual child’s needs and stage of development. It is our desire to
help each child develop self-control, as well as respect for the rights of others.
Staffing: Our goal is to recruit caring, mature, energetic staff who can be good role models for the children. All staff must
complete training in such areas as Health, Safety, Creative Activities, Behavior Management, Water Safety etc… before our
program starts.
Parent Visits: The YMCA has an open door policy for all parents. Parents are invited and encouraged to visit the YMCA at any
time and need not ask permission to do so, but must take care not to interfere or disrupt the ongoing activities. Parents are
also welcome to attend field trips. (Transportation and fees not provided)
YMCA Basic Rules:
•
•
•
•
•
•
•
Hands and feet to yourself AT ALL TIMES. Parents will be notified.
No bullying
Use an appropriate tone of voice
Follow directions and respect authority
Respect others, their belongings, and their space
SMILE & HAVE FUN!!
Swearing and foul language is not tolerated. Parents will be notified
General Guidelines
•
•
•
Parents must escort their child into the building every morning and sign them in as well as sign them out at the end of each day.
Children are not allowed to sign themselves in or out
A parent or guardian will pay a $1 per minute late fee for picking up a child after 6pm
Please do not hesitate to call the YMCA at any time with questions, concerns, or to speak with your child’s camp director.
When there are recurring problems, sufficient attempts to follow the above steps have failed, and the behavior involved may result in
unsafe conditions for the child, others or the program environment, immediate removal from the program may be necessary. Examples
may include running from staff to an unsafe area, bringing a weapon to child care, or physical or verbal confrontations with another child
or staff. Such confrontations will result in an immediate “pick-up” for the day.
Abusive language or actions of parents may also result in dismissal of the child.
Please initial each statement and sign below:
initials
I understand that in a crisis situation, my child may be physically held to prevent bodily harm to self
and/or others, or the destruction of property. Physical holding shall be utilized for the minimum frequency and duration
possible and shall not be used as punishment, convenience for staff, or as a means for compliance with behavioral
expectations.
I have read and understand the above stated Discipline Policy.
initials
SIGNATURE
____________________________
(Parent or Guardian)
DATE
______
SUMMER CAMP
HEALTH INFORMATION FORM
CAMPER INFORMATION – TO BE COMPLETED BY PARENT/GUARDIAN [ PLEASE PRINT ]
Name:__________________________________________________________ Birth Date ________/________/________ Age at Camp:__________ Gender:
□ Male □ Female 1ST Phone:____________________________
Home Address:_________________________________________________________________________ City:___________________________________ State:_______ Zip _______________ 2ND Phone:____________________________
PARENT(S)/LEGAL GUARDIAN(S) INFORMATION – TO BE COMPLETED BY PARENT/LEGAL GUARDIAN [PLEASE PRINT]
First Contact Last:__________________________________________________________________ First:________________________________________ Day Phone:_______________________ Eve Phone:_______________________
Relationship to Camper:___________________________________________________ Email:________________________________________________________________________________________ Cell Phone:______________________
Second Contact Last:_______________________________________________________________ First:_______________________________________ Day Phone:_______________________ Eve Phone:_______________________
Relationship to Camper:___________________________________________________ Email:________________________________________________________________________________________ Cell Phone:______________________
INSURANCE INFORMATION – TO BE COMPLETED BY PARENT/LEGAL GUARDIAN [PLEASE PRINT]
Insurance Holder Name:___________________________________________________ Address (if different than campers):________________________________________________________________________________________
Insurance Carrier:_________________________________________ Policy Number:_____________________________ Group ID Number:_____________________
Insurance Carrier Phone:__________________________
Family Physician:__________________________________________________________________ Office Phone:__________________________
PARENT(S)/GUARDIAN(S) AUTHORIZATIONS & AGREEMENTS – TO BE READ, SIGNED AND PRINTED BY PARENT/GUARDIAN
I/We grant permission for the named camper to participate in all planned camp activities under the supervision of camp staff, as is part of the program for which she/he
is registered unless otherwise specified in writing. I/We agree to waive any claims against the YMCA of Danville and its affiliates for injuries or damages that my result
from participating in YMCA of Danville programs. PERMISSION TO TREAT: IN CASE OF MEDICAL ILLNESS OR INJURY, I/We hereby give permission to YMCA Day Camp
personnel to provide routine health care, first aid, medication or treatment as determined by medical personnel. IN CASE OF MEDICAL EMERGENCY or medical care
beyond the scope of camp facilities, I/we understand that every effort to notify listed contact(s) will be made. I/we authorize YMCA Day Camp personnel to act on our
behalf and secure emergency medical treatment and grant permission to the attending physician to secure proper treatment for the named camper. PERMISSION TO
DISTRIBUTE: I/We authorize YMCA Day Camp personnel to administer medication(s) to the named camper. Upon check-in of the named camper, I/we will register all
medication(s) with YMCA Day Camp personnel and follow all medication distribution protocols. I/We understand that all prescribed medications brought to camp MUST
be in the pharmacy labeled container with camper’s name, dosage, health care providers name and phone number and that only the amount of medication needed by the
camper for his/her session will be included. I/We also understand that YMCA Day Camp personnel will verify all prescribed medication(s) information and will distribute
per the licensed physician instructions. PARENT/GUARDIAN ACKNOWLEDGEMENT: By signing below I/we fully agree to and understand all terms and conditions as
designated on this form and in the Parent Handbook. I/We have completed all information pertaining to the named camper to the best of my/our knowledge. I/We also
authorize the use of photographs, audio or video of my/our named camper for promotional purposes.
Parent/Guardian Signature
Date
___________________________________________________ Print Name
_________________________
Vaccinations
My child is up to date on all vaccinations required by the department of health. His/her last tetanus vaccination was received on _______/________/___________.
___________________________________________________________________________________________________________
Parent/Guardian
_____________________________________
Date
Does/Has the camper shown any signs of the following conditions: [Please check appropriate box and if possible date condition was diagnosed]*
diagnosed]*
Frequent Headaches
□ Yes
Asthma/Trouble Breathing □ Yes
Mononucleosis
□ Yes
Anemia/Blood Disorder
□ Yes
Diabetes/Blood Sugar
□ Yes
Bedwetting
□ Yes
Frequent Urinary Infections □ Yes
Head Lice
□ Yes
Mental Health Concerns
□ Yes
Anxiety/Social Disorder
□ Yes
Date:_________
Date:_________
Date:_________
Date:_________
Date:_________
Date:_________
Date:_________
Date:_________
Date:_________
Date:_________
Frequent Sore Throats
Hearing Impairment
Heart Defect/Disease
Hypertension
Intestinal Problems
Epilepsy
Convulsions/Seizures
Frequent Ear Infections
Tubes in Ears
Muscle/Bone/Joint
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
Date:_________
Date:_________
Date:_________
Date:_________
Date:_________
Date:_________
Date:_________
Date:_________
Date:_________
Date:_________
PMS/Menstruation
□ Yes Date:_________
Last period prior to camp Date:____________________
ADD/ADHD
□ Yes Date:_________
Behavior Problems
□ Yes Date:_________
Constipation/Diarrhea
□ Yes Date:_________
Eating Disorder
□ Yes Date:_________
Anorexia/Bulimia
□ Yes Date:_________
Sleep walking/Talking
□ Yes Date:_________
Fainting/Dizziness
□ Yes Date:_________
Other Concerns:___________________________________________________
List any surgeries/serious injuries with date:________________________________________________________________________________________________________________________________________________________________
List any ongoing treatments/therapies or special consideration needed at camp:___________________________________________________________________________________________________________________
List any restrictions or limitations while at camp:__________________________________________________________________________________________________________________________________________________________
Has the camper been exposed to any communicable diseases in the last 21 days? □ No □ Yes
Has the camper been sick in the last 72 hours? □ No □ Yes
Does the camper have any known allergies: [Please check all appropriate boxes and date of last instance]
Epi Pen Usage
□ Yes Date:_________
Insect/Bee Stings
□ Yes Date:_________
Food Allergies
□ Yes Date:_________
Poison Ivy Allergy
□ Yes Date:_________
□ Serious/Life threatening reaction
□ Serious/Life threatening reaction
Animal Allergy
□ Yes Date:_________
List:_______________________________________________________________ List:________________________________________________________________
Please list:____________________________________________
Medication Allergies
□ Yes Date:_________
Dietary Restrictions
□ Yes Date:_________
Hay Fever/Seasonal Allergy □ Yes Date:_________
□ Serious/Life threatening reaction
□ Cramping, diarrhea, upset stomach, headache
Other Allergies:___________________________________________________ List:_______________________________________________________________ List:________________________________________________________________
MEDICATION INFORMATION – COMPLETED BY LICENSED PHYSICIAN [All medications must be registered with
with the Day Camp Staff]
Use Of Over The Counter (OTC) Medications (Topicals, Tylenol, Ibuprofen, Sudafed, Benadryl, Pepto Bismal, Chloraseptic, Antihistamine, Etc.) □ Yes □ No
Current Medication:_________________________________________________ Dosage:______________________ How is it given?________________________ Time of Day: □ AM □ PM □ EVE □ BED
Current Medication:_________________________________________________ Dosage:______________________ How is it given?________________________ Time of Day: □ AM □ PM □ EVE □ BED
Current Medication:_________________________________________________ Dosage:______________________ How is it given?________________________ Time of Day: □ AM □ PM □ EVE □ BED
RECEIPT FOR SUMMER CAMP REGISTRATION & HANDBOOK PACKET
I have received and read the policies of the Danville Family YMCA Summer Camp Registration & Handbook
Packet. I understand and agree to follow these policies. Failure to follow these policies may result in
termination of the child care service.
_____________________________________________________
Child’s Name
_____________________________________________________
Parent’s Signature
__________________________
Date
T-Shirt Size (circle one):
one)
AL
XS (2-4)
S (6-8)
M (10-12)
L (14-16)
AS
1x
Danville Family YMCA • 1111 N. Vermilion St. • Danville, IL 61832
Phone (217) 442-0563 • FAX (217) 442-0513 • www.danvilleymca.org
Our Mission: To put Christian principles into practice through programs that build healthy spirit, mind, and body for all.
AM