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