Danville_YMCA_Summer_Camp_Registration_Packet_2015
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
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