HOW TO REGISTER for Middle School U programs Register online at www.wisconsinyouthcompany.org Registration forms may be requested through the administrative office or downloaded from our website. Parent Registration Checklist Please complete all forms entirely for each student or registration may be delayed as we will need to contact you to collect this required information. Parts IA, IB, III and IV are carbon copy forms (white & yellow), please return all carbon copy forms to the administrative office. Parts IA & IB - Registration, Agreement & Program Selection Forms Complete both parts entirely. Part IA: please provide complete information and check all appropriate boxes. Consent: be sure to read thoroughly before signing. Part IB: indicate the courses for which you are registering your student. Part II - Health History & Emergency Care Plan Form Your student’s health history and emergency care plans must be annually reviewed and updated by parents or guardians to ensure safety. Part III – Payment of Fees & Security Policies Form This form must be completed in order to protect the privacy of your account. Your account access password will be required for all account inquiries and requests to change account information. Part IV – Swim and Aquatic Activity Permission Form Check the appropriate swimming level for your student if the course selected involves aquatic activity. Enrollment and Fees Course fees include activities and special events, supplies, equipment, staff, field trips with related transportation and admissions, snacks, facilities and the full range of available program hours. A one-time summer processing fee of $25 is charged, part of which pays for your student’s program shirt. A $25 deposit per course is due at the time of registration. This deposit and processing fee is non-refundable and nontransferable. The deposit is applied toward the course fee. The remaining amount of fees are due by the end of the business day Friday (5:30 p.m.) six business days prior to the start of program. Fees may be paid by cash, check, money order, VISA or MasterCard. Make checks payable to Wisconsin Youth Company. A $20 fee will be assessed if your payment is late. Enrollment Deadline You may register or add courses any time until the end of the business day on Friday (5:30 p.m.) six business days prior to the week being requested, provided space is available. Programs are Enrollment Dependent In order to provide a quality experience for your child, we need to have sufficient enrollment to operate a program and specific courses. If we are unable to offer the specific program you registered for we will contact you to discuss available alternatives. Confirmation Process Families registering online and providing an email address will receive an emailed confirmation of their student’s registration, a welcome packet and a link to their program’s parent/student handbook. Families who register using paper forms who don’t provide an email address will be mailed confirmation of their student’s registration along with a welcome packet and parent/student handbook. Cancellation/Change Policy A written advance notice from the account holder (please include password) must be received by the WYC administrative office in order to change or cancel out of a course or to change location. This written notice must be received no later than the end of the business day Friday (5:30 p.m.) six business days prior to the course being cancelled or changed. If we don’t receive your written cancellation in time you will be liable for the remainder of the course fee. Scholarships Limited scholarship funds through Wisconsin Youth Company may be available on a first-come, first-served basis. In order to provide an enriching experience for as many eligible children as possible, partial scholarships are given. For scholarship information, please contact the administrative office. Contact Information: Wisconsin Youth Company 1201 McKenna Blvd. Madison, WI 53719 608-276-9782 or 800-238-1174 Fax: 608-276-4050 Program related questions: [email protected] Billing and account information questions: [email protected] Part IA WYC Middle School U: Registration & Agreement Form __________________________________________ Student’s Name ______________ Birthdate ______ Age __________________________________________________________________________ Mother / Father / Guardian (Circle one.)Primary Account Holder ________ _________________ _________________________ Gender Grade in Fall 2014 School Attending in Fall 2014 _________________________________________________________________________ Mother / Father / Guardian (Circle one.) Secondary Contact Person ___________________________________________________________________________ _________________________________________________________________________ AddressAddress _____________________________________________ City/State/Zip ___________________________ Home Phone ___________________________________________ City/State/Zip ____________________________ Home Phone Cell Work Home Cell Work Home _________________________ ________________________ _______________________ ________________________ ________________________ _______________________ Work Phone Cell Phone Best Phone # During Program Hours Work Phone Cell Phone Best Phone # During Program Hours ___________________________________________________________________________ E-mail Address Student previously attended a: WYC summer 2013 program? Yes __________________________________________________________________________ E-mail Address Program shirt size: (wicking sport/swim shirt) Adult: Purchase an additional t-shirt $12? Yes No No AFTER SCHOOL 2013-2014 program? Yes No S M L XL Invoices and program information will be emailed. I prefer for the information to be mailed. Middle School U Arrival/Departure Acknowledgement: (For safety, any changes during the summer must be made in writing to the administrative office.) I acknowledge my student will arrive at and depart from program independently. My student is expected to check-in with staff upon arrival and departure, and check themselves in and out on the attendance sheet. If my student is ill or will for another reason be absent, parents are to call the attendance message number at 608-276-9898. If my student does not arrive at Middle School U within a reasonable amount of time and the staff has not received a message that my student will be absent, staff will take steps to locate the student. Please read the Middle School U Parent/Student Handbook for details. Emergency Contact: (For safety, any changes during the summer must to be made in writing to the administrative office.) Primary and secondary contacts listed above are considered authorized emergency contacts unless otherwise noted. Name (First & Last) Best Phone # During Program Hours Alternate Phone # During Program Hours Relationship to Student Emergency Contact Person Parental Consent 1. I give my consent for WYC staff to act on my behalf to obtain emergency care and treatment if deemed necessary for my student. 2. I give my consent as indicated on part II for the application of sunscreen and/or insect repellent. 3. I give my consent for my student’s participation in any field trips scheduled as part of his or her summer enrollment. 4. I give my consent for my student to be transported to and from any scheduled program activity for which transportation is provided. 5. I understand that WYC reserves the right to remove or suspend a student from the program if the student has needs that cannot be accommodated within the normal staffing pattern or if the safety of the student, staff or other students are jeopardized. 6. I understand I must list a minimum of one, preferably local, emergency contact other than parents on the registration form. I will inform anyone listed as an emergency contact that WYC may contact him or her in an emergency. I give permission for WYC staff to share pertinent information, including health information, with emergency contacts as necessary. 7. If severe weather, physical plant problems or other emergencies exist in the community surrounding the program location or the facility itself, program may not operate or may relocate to an alternate site. There is no credit or fee reduction for program closings. 8. I acknowledge that I have carefully reviewed and accurately completed parts IA, IB, II, III and IV of this registration packet. Agreement Signature - I/We understand and agree to abide by the above policies and other WYC policies as stated in the parent/student handbook. Handbook is available online or in print. _____________________________________________________ Parent / Guardian - Please Print Name ____________________________________________ Signature of Parent / Guardian __________________________ Date Photo Release I grant Wisconsin Youth Company (WYC) permission to publish my student’s image in its newsletters, brochures, displays or other printed material and on its websites for purposes of promoting the programs. I understand that student’s names are not used when their images are displayed on our website or in widely distributed print materials. I understand that if I request, in writing, removal of my student’s image from WYC’s websites his/her image will be removed no later than 15 days from receipt of my request. Also, I release WYC, its employees, officers, directors and successors from any liability or claim related to the publication or disclosure for which I have hereby granted permission. I understand that the consent I grant here is completely voluntary. Yes, I accept the photo release. No, I do not accept the photo release. Signature of Parent / Guardian _____________________________________________________________________ Date _______________________ Office Use Only - Fees: Processing _______________ Deposit ______________ Amt Pd ______________ Ck #______________ Date Received ______________ Received by _______________ White: Administrative Copy Yellow: Confirmation Mailing Process Copy 2014 WYC - Summer Registration Form_MSU Part IA.indd Part IB WI Youth Company Summer 2014: Course Selection Form Middle School U - Madison West (Jefferson) Child’s Name: _____________________________________________________ Date of Birth: ______________________________________________________ Directions: Rank first and second choice by checking the boxes to the left of the course name. Note: No courses on July 4. $25 deposit per course*. Dates Rank 1 2 Morning Courses 8:30–11:30 a.m. Fee ($25 deposit per course*) June 16-20 $80 $110 $90 $105 $100 June 23-27 Babysitter Training Cake Decorating I Digital Photography Kayaking I Rocketry II $160 $100 $100 $185 $115 June 30 July 3 (No courses 7/4) Fishing Kitchen Science Pie Making Take a Swing $105 $90 $85 $75 July 7-11 Cake Decorating II Glass Mosaics Hunter Education Strategy Board Games Table Tennis $110 $150 $90 $80 $85 July 14-18 Fencing Ice Cream Making Ice Skating Skills Set Construction Stained Glass $105 $95 $165 $100 $155 July 21-25 Archery Art Metals Babysitter Training Kayaking I So You Want to Be a Writer... $80 $115 $160 $185 $95 July 28 – August 1 Cooking South of the Border Disc Golf & Ultimate RPG Exploration Painting Yoga $110 $100 $90 $110 $110 August 4-8 Candy Making Fishing Rock Climbing I Sculpture & Ceramics I Summer Games $95 $105 $170 $105 $75 August 11-15 Archery Kayaking II Pasta Galore Photojournalism Sculpture & Ceramics II $80 $185 $100 $115 $110 August 18-22 Animal Science DJ-ing Experimental Writing Golf $100 $95 $95 $170 A.M. $ Bus Stops Here Hiking & Exploring Adventure Week I Travel Wisconsin Wilderness SkilIs Adventure Week II Biking Madison Geocaching 101 Wisconsin Art Archeology Mountain Biking Rank 1 2 ($25 deposit per course*) Fee $215 $185 $80 $105 $110 $170 $90 $300 Action Scene Skills Machine Sewing Mediterranean Cooking RPG Advanced Video Journalism $85 $105 $110 $90 $120 $240 Board & Card Games Cupcakes Galore Intro to Engineering Water 3.0 $70 $85 $75 $100 $230 Art on the Town Card & Paper Arts Fencing Ice Cream Making Improv Comedy $135 $105 $105 $95 $105 $300 $165 Breakfast Anytime Costume Crafts Manga Drawing I Rock Climbing II Scrapbooking $95 $100 $110 $190 $115 $230 Archery Baking I Fencing Recycled Art Songwriting 101 $80 $95 $105 $90 $95 $215 Baking II Gardening - Garden to Table Golf Mixed Media Art Tennis $100 $100 $170 $100 $90 $200 Bowling Cyber CSI Local Foods Manga Drawing II Outdoor Cooking Table Tennis $110 $80 $110 $110 $100 $85 $190 Archery Geology 101 International Cuisine Intro to Comics Paper Arts $80 $165 $110 $90 $95 Billiards Home Fix-It Rock Climbing II $115 $125 $190 P.M. $ Total a.m., all-day & p.m. course deposits $ One-time summer processing fee of $25 $ Total due $ Yellow: Confirmation Mailing Process Copy Afternoon Courses 1–4 p.m. Archery Jewelry Making Italian Cooking Rock Climbing I RPG Exploration All-day $ Reminder - The remaining amount of each course fee is due Friday (5:30 p.m.) six business days prior to the start of the course week. White: Administrative Copy Fee ($25 deposit per course*) 1 2 Archery Entrée Cooking Hunter Education Rocketry I UW Science Total *course deposits All-Day Courses 8:30 a.m.–4 p.m. Rank 2014 WYC - MSU Jefferson_Reg Part IB.indd Part II WYC: Middle School U Health History & Emergency Care Plan Form Directions: Please complete this form entirely. A review by parents/guardians and staff is required annually. This form remains with your student’s program during the hours your student is present in the care of Wisconsin Youth Company staff. Student Information: ___________________________________________________________________________________________________ _________________________________________ Student’s Name (Last) (First) (Middle) Birthdate (MM / DD / YYYY) ___________________________________________________________________________________________________ _________________________________________ Parent Name (Last) (First) Best Phone # During Program Hours Physician / Medical Facility Information: _________________________________________ ___________________________________________________________________________________________________ Name of Physician Name, Address and Phone Number of Medical Facility 1. Special Health Information: Please check yes or no for each statement. General Health - Does your student: Have asthma? Yes No Details: ______________________________________________________________________________________ Have diabetes? Yes No Details: ______________________________________________________________________________________ Have epilepsy/seizures? Yes No Date of last seizure: __________________________________________________________________________ Have cerebral palsy/motor disorder? Yes No Details: ______________________________________________________________________________________ Wear glasses or contacts? Yes No Have ADD/ADHD? Yes No Details: ______________________________________________________________________________________ Have Autism Spectrum diagnosis? Yes No Details: ______________________________________________________________________________________ Have emotional/behavioal health issues? Yes No Details: ______________________________________________________________________________________ Have cognitive/learning disabilities? Yes No Details: ______________________________________________________________________________________ Have diet restrictions or special food needs? Yes No Details: ______________________________________________________________________________________ Other conditions that may require special care? Yes No Details: ______________________________________________________________________________________ Food/Milk Yes NoDetails: ______________________________________________________________________________________ Medication(s) Yes NoDetails: ______________________________________________________________________________________ Environmental allergens (Insect stings, hay fever) Yes NoDetails: ______________________________________________________________________________________ Other Yes NoDetails: ______________________________________________________________________________________ My student will have an Epi Pen at site. Yes No My student will have an inhaler at site. Yes No My student will have other medication at site. Yes No Allergies - My student is allergic to: Medications: Medication name(s): _________________________________________________________________________ 2. Signs or symptoms to watch for or triggers that may cause problems and steps WYC staff should follow in response – Specify: 3. I have reviewed the activities of the program and feel my student can participate without restrictions: If no, my student can participate with the following restrictions or accommodations. 4. Do you have any other information you want our staff to know? If yes, please specify. Yes Yes No No In the event my student becomes ill or injured, I understand every effort will be made to reach me or an emergency contact person on file. I give my consent for Wisconsin Youth Company to act on my behalf to obtain emergency care and treatment if it is deemed necessary. ___________________________________________________________________________________________________ ______________________________ Signature of Parent / Guardian Date WYC Health Histrory & ER Care Plan Form_MSU 2014.indd Part III WYC Summer 2014: Payment of Fees & Account Security Policies Form Child’s Name ______________________________________________________________ Payment of Fees 1. I understand the one-time summer processing fee of $25 is non-refundable and non-transferable, unless a program is canceled by WYC. 2. I understand the $25 deposit towards each program is non-refundable and non-transferable, unless a program is full or canceled by WYC. ($100 deposit for Wander Wisconsin trips.) 3 I understand that full payment and all required information must be submitted at least six business days prior to the scheduled program start date, or my child’s enrollment may be cancelled. If registering within two weeks of the start of program, payment is due in full and all forms must be complete prior to the start of program date. 4. I understand that a late payment fee of $20 will be assessed for payments not received by Friday, six business days prior to the scheduled program, of a scheduled program and non-payment of fees may result in my child’s removal from the program. I understand that a $30 charge is assessed for each Non-Sufficient Funds (NSF) check or declined credit card transaction. 5. I understand written advance notice must be received by the administrative office to withdraw from or change scheduled attendance, provided space is available. Written notice must be received no later than the end of the business day six business days prior to the program start date being withdrawn from or changed. Failure to submit written cancellation on time will result in the liability of all fees paid and owed for that program. 6. I understand that no fee credit will be given if my child is absent from all or any portion of a confirmed program. 7. If a program is full or cancelled by Wisconsin Youth Company for any reason, registering families shall have no claim other than a full refund. 8. I understand I may request duplicate mailings to a second address for a fee of $15. 9. I understand early drop-off and/or late pick-up outside of program time may result in a $25 late fee per child for each 15 minute increment. Repeated infractions may result in removal from program. 10. I understand that if I am receiving assistance, I am responsible for any amount not paid by my funding source. Written verification from the funding source must be on file in the administrative office prior to confirmation of my child’s enrollment. My funding source is ___________________________________________________ Contact person _____________________________________ Phone number __________________________ Signature: __________________________________________________ (Account Holder) ______________________ Date Summer 2014 Payment Schedule Enrolled Program Date Payment Due Date Enrolled Program Date Payment Due Date Processing Fee* Upon Enrollment Deposit Balance July 14-18 July 3 June 9-13 (Camp Glacier Creek Only) May 30 July 21-25 July 11 June 16-20 June 6 June 23-27 June 13 June 30-July 3 June 20 July 7-11 June 27** July 28-August 1 July 18** August 4-8 July 25** August 11-15 August 1 August 18-22*** August 8 August 25-29*** August 15 Deposit Balance *One-time summer processing fee of $25 per child. **If enrolled in Circus Advanced and/ or Theater Immersion Camps (2 weeks), remaining amount of fees for both weeks is due Friday (5:30p.m.) six business days prior to the start of the first program week. I agree to the 2014 summer payment schedule. Signature of Parent / Guardian: ______________________________________________ (Account Holder) Reminder, subtract all deposits paid in advance. • ($25/week for day camp, Immersion Camp and Middle School U) • ($25 daily deposit if you register for less than five days: Waukesha Wander Wisconsin Travel Club) • ($100/trip for Wander Wisconsin) ________________ Date Account Access Password - Required ***Friday, August 22 & 29 - There will be no after camp care. All campers are to be picked up by 4 p.m. The security of your enrollment information is important and we’ve taken steps to help keep it secure. When enrolling your child, you are required to create a unique password and answer at least one security question listed below. This verification is REQUIRED whenever you or someone you authorize calls or emails us regarding your information (i.e. balance due, pick-up persons) and whenever account holders submit written requests and information updates so that we can protect your privacy and only give the information out to you or the person you designate. We can ONLY provide enrollment information when the correct PASSWORD and/or SECURITY ANSWER are provided by an authorized user. You may choose to keep your same password from previous Wisconsin Youth Company programs; however, you must confirm the password below. Please give us a password and the answer to at least one of the security questions listed below. Account Access Password ______ ______ ______ ______ ______ ______ (Maximum: 6 characters) Security Questions (Please answer at least one of the following.): 1. What street did you live on during high school? _____________________________________________________________ 2. Who was your childhood hero? ______________________________________________________________________ 3. What is your Grandmother’s maiden name? _________________________________________________________ Account Access - Optional In order to protect your privacy, we are unable to provide information to anyone other than an account holder or authorized user. Account holders are liable for the account, are able to request information and are able to make changes to the account. Authorized users are individuals authorized by the account holder to access information only. As the account holder, you may authorize other individuals (e.g. a spouse and/or other parent) by listing their name(s) below. I authorize the following person(s) to be an authorized user, allowing him/her to access information on the account: ________________________________________________________________________________________________________________________________________________________________________ I authorize the following person(s) to become an account holder, allowing him/her to make changes to account information: ________________________________________________________________________________________________________________________________________________________________________ Authorized Account Holder’s Name and Signature - Required Primary Account Holder Name: _______________________________________________ Print Name Optional Additional Account Holder Name: _______________________________________________ Print Name Signature: __________________________________________________ (Primary Account Holder) _________________________ Date Signature: _______________________________________ (Additional Account Holder) _________________________ Date White: Administrative Office Copy Yellow: Confirmation Mailing Process Copy 2014 WYC - Summer Payment of Fees & Account Security Policies Form.indd Part IV WYC Summer 2014: Swim & Aquatic Activity Permission Form Read this swim and aquatic activity permission form completely and carefully and indicate the appropriate swim level for your child. You are encouraged to complete this form even if the program(s) you selected do not include swimming or aquatic activities, so we have the information in the event you add a program for which swimming or aquatic activity permission is necessary. Child’s Name _______________________________________________________________________________ Age ________________ (Please print) (as of 6/1/14) Day Camp Campers will participate in recreational swimming activities off-site at a designated swimming pool or beach at least once during the camp week, weather permitting. Please note: Immersion Camps in Dane County do not include swimming or aquatic activities. Wander Wisconsin and Wander Camps Programs include swimming in natural bodies of water or in swimming pools as well as other aquatic activities in a variety of settings such as canoeing, kayaking, rafting, tubing and water park attractions. A swim level of 2 or higher is required to participate in Wander Wisconsin. Specific activities, as well as the swim level required for those activities, are outlined in the program descriptions. Middle School U Some courses include swimming in natural bodies of water or in swimming pools as well as other aquatic activities in a variety of settings such as canoeing, kayaking, tubing and water park attractions. Specific activities, as well as the swim level required for those activities, are outlined in the course descriptions. I Understand: 1. There is a greater risk in having my child participate in swimming and other aquatic activities, however, I feel that the added risk is acceptable because of the benefits to my child and agree to absolve WYC of any greater responsibility by virtue of my child’s participation in swimming or aquatic activities. 2. WYC adheres to state licensing regulations, American Camp Association accreditation standards (for applicable programs), and program policies regarding supervision of children while swimming. 3. Swimming will only take place at beaches and swimming pools where there is a certified lifeguard on duty. 4. Swimmers will be supervised by camp staff at a ratio of one adult staff member for every eight swimmers. 5. At beaches, all swimmers will stay in water no deeper than chest level. (Day camp only) 6. Swim levels, as defined below, will be used to divide swim groups during swim activities and to ensure that participants are only allowed to use watercraft within their swim level classification. 7. Aquatic environments may vary and the swim levels, as defined below, will be translated accordingly. 8. Aquatic or WYC staff members reserve the right to decrease participant swimming levels for any reason. 9. My child will receive a program shirt (the cost of which is included in the processing fee), and will be required to wear the program shirt for all program swimming activities at public facilities. The program shirt will help WYC staff and lifeguards supervise my child and has the added benefit of providing sun protection. My child will not be allowed to swim without a program shirt. (Please indicate program shirt size on part IA of the registration packet.) Please select one of the swim levels below: NO SWIMMING - My child is not allowed to go in the water but may play in a designated area away from the water. Level 1 – Beginning Swimmer: My child has little or no swimming experience. My child can enter and exit the water unassisted; put his/her face into water; and float on front and back. My child may enter the water, but must stay in water no deeper than waist level. Level 2 – Swimmer: My child has intermediate swimming skills. My child can tread water for at least 20 seconds; swim 20 yards on front with arm action and some side breathing; and has been introduced to deep water. My child may swim anywhere within the designated swim area of the swimming pool with water levels up to 6 feet. My child may participate in canoe and tubing activities if applicable. In a beach setting at day camp my child will still be expected to remain in water no deeper than chest level. Level 3 – Advanced Swimmer: My child has intermediate to advanced swimming skills. My child can tread water (without touching bottom) for at least one minute; swim front crawl for 25 yards; and is comfortable in deep water. My child may swim in the deep water area of the swimming pool. In a beach setting in day camp my child will still be expected to remain in water no deeper than chest level. My child may participate in canoeing, tubing, kayaking and rafting activities if applicable. Level 3 Swimmers ONLY - Swimming Pool Diving Board Permission: If available, my child may jump off (low) diving boards (feet first only and no flips). Flips and diving head first are not allowed. Do you have any concerns about your child participating in water activities? Comments: YES NO I give permission for my child to participate in swim and aquatic activities as indicated above. _________________________________________________________ Parent / Guardian - Please Print Name White: Administrative Copy ________________________________________________________ Signature of Parent / Guardian Yellow: Confirmation Mailing Process Copy _______________________ Date WYC - 2014 Summer Swim & Aquatic Activity Permission Form.indd
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