PARENT MANUAL 2014 “A SUMMER TO DISCOVER”
“A SUMMER TO DISCOVER” PARENT MANUAL 2014 YMCA of Newark & Vicinity • 600 Broad Street • Newark, New Jersey 07102 Voice: (973) 624-8900 • fax: (973) 624-3024 • Website: www.newarkymca.org Message from the Camp Director Thank you for choosing the YMCA of Newark and the Vicinity as your Day Camp facility for Summer 2014! Our goal, at the center and foundation of our work, is to support working families, provide a safe environment, and to inspire our children to discover. The vision of our camp program is to help campers grow physically, mentally and emotionally by providing a safe, clean, and positive environment with activities that promote cooperation, team building, self-esteem, and family involvement. At the YMCA, your child will have the opportunity to experience new adventures, make new friendships, go on fantastic trips and have an overall great time at camp this year! Camp Observable Expectations (S.E.E.): - Supervision Engagement Empowerment This Parent Manual has been carefully planned to ensure that families receive the information needed to feel comfortable that their child is safe and having a good time while at the Y camp. Please read this guide so that you will have a complete understanding of our camp program. I appreciate your cooperation and please do not hesitate to contact me if you have any questions or concerns. I can be reached at (973) 624-8900 ext. 6893 or via email at [email protected] Sincerely, Patty Zito Patty Kelly Zito Camp Director YMCA of Newark & Vicinity • 600 Broad Street • Newark, New Jersey 07102 Voice: (973) 624-8900 • fax: (973) 624-3024 • Website: www.newarkymca.org Table of Contents I. General Information - Locations & Hours Registration Fees Camp Staff Camp Meals Camp Attire Field Trips II. Supervision & Safety - Emergencies Phone Numbers Weather Restrictions Health Information Sign-in/out Procedures III Policies - Policy on Release of children Code of Conduct Policy on the Management of Communicable Diseases YMCA Summer Day Camp Staff Attachments - (A) Social Contract (B) Parent Authorization form and field trip permission slip (C) Health History Form (D) Session & T-shirt info YMCA of Newark & Vicinity • 600 Broad Street • Newark, New Jersey 07102 Voice: (973) 624-8900 • fax: (973) 624-3024 • Website: www.newarkymca.org I. General Information: Camp Locations 1) Newark YMCA Camp Site 600 Broad Street, Newark, NJ 07102 (973) 624-8900 2) Belleville School # 8 Camp Site 600 Broad Street, Belleville, NJ 07109 (973) 844-0088 Camp Hours Full Day AM Extended Care PM Extended Care 9:00 a.m. - 5:00 p.m. 7:30 a.m. - 9:00 a.m. 5:00 p.m. - 6:00 p.m. Camp Fees per session (2 weeks) Full day Extended Care $280 $340 Payment Due Dates Session Session Session Session 1 2 3 4 May 23, 2014 June 6, 2014 June 20, 2014 July 4, 2014 Session 5 (Fun Week) Aug 8, 2014 (Newark Branch ONLY) Payment/Registration Failure to pay balances by deadline may result in possible loss of camp registration. Child will not be allowed to attend camp unless all balances are paid. A $25 late fee will be added if camp balance is not paid in full. If Program for Parents is paying for Summer Camp you will be responsible for daily attendance (swiping in and out), any co-payments and whatever portion of the program fees Program for Parents does not cover (example: registration fee, late fees, before or after care, forgetting to swipe etc.). Please check with the Camp Director to make sure payments are correct amount. Program for Parents vouchers YMCA of Newark & Vicinity • 600 Broad Street • Newark, New Jersey 07102 Voice: (973) 624-8900 • fax: (973) 624-3024 • Website: www.newarkymca.org must stay current. It is the parent’s responsibility to renew their voucher. Please note that refunds will not be granted for camp days missed (i.e. illness, vacation, lateness, suspensions, etc.) Newark Branch Program: Payments can be made by cash, credit card, check or money order, payable to the Newark YMCA, at the front desk or by mail. Clearly mark camper’s name and session dates on checks. Be sure to present the Registration form or invoice with your payment, so that payments can be properly recorded. Include a telephone number and driver license number, check will not be accepted without it. Belleville Program: Payments can be made by check or money order, payable to the Newark YMCA, given to the Site Supervisor, taken to the Newark YMCA branch or by mail. Clearly mark camper’s name and session dates on checks. Be sure to present the registration form or invoice with your payment so that payments can be properly recorded. Include a telephone number and driver license number, checks will not be accepted without it. Checks are mailed directly to: Newark YMCA (please indicate the name of the camp your child is attending in the memo area) 600 Broad Street, Newark, NJ 07102 Attn:Program Office. - All Cash Payments must be made at the YMCA at 600 Broad Street, downtown Newark. - All Checks must be made payable to the Newark YMCA. Camp Staff The staff working in each YMCA day camp is selected on the basis of their abilities, education, skills, enthusiasm, and concern for helping young individuals develop. All day camp staff participate in mandatory and intensive training. Most of our day camp staff work for the YMCA all year around in programs such as the Before/After Care and Teen Programs. The staff is trained in CPR/First Aid, Responding-to-Emergencies (RTE’s) Department of Health Mandates, YMCA Camp. Camp staff are there to serve the children and their families and parents are encouraged to share as much information as possible about the child to make the child’s time in the day camp as pleasant as possible. Meals Provided to Campers YMCA of Newark & Vicinity • 600 Broad Street • Newark, New Jersey 07102 Voice: (973) 624-8900 • fax: (973) 624-3024 • Website: www.newarkymca.org • Newark campers will be provided with breakfast and lunch. Lunch will be provided by the City of Newark’s Sun-Up program from July 7th - August 22nd. Children may bring their own-bagged lunches as often as preferred. Food menus will be available the first day of camp. • Refrigerators are NOT available at the site. • Please do not send your child with money for lunch. They will not be allowed to leave the camp to purchase lunch. • Belleville campers must bring their own breakfast and lunch. All campers are advised to eat an adequate breakfast. • If the camper arrives to camp without lunch, lunch will be provided but parents will be charged $10 per occurrence. • Lunch containers must be clearly marked with the camper’s name. Make sure lunch containers are small so we can keep them in coolers when traveling. • Light snacks will be provided to all campers every afternoon. • Campers should not bring perishable items in their lunches on field trip/outside activity days. Camper Attire • The YMCA will provide each participant with (1) camp T-shirt for field trip days. These shirts must be worn on all field trips to identify Y camp participants. Participants without camp T-shirts are not allowed to attend field trips. Therefore, a camp T-shirt will be provided for an additional fee of $10.00, which must be paid by the next day of camp. • Participants must be dressed appropriately, in clean and loose fitting clothing during recreational activities. No revealing clothing such as skirts, dresses, tube tops, tank tops, short shorts, sandals, etc. Campers must bring and wear sneakers and socks daily. • If a camper does not have proper attire, they will NOT be allow to participate in the scheduled activity or trip. • If necessary, parents should provide a hat and sunscreen for outdoor activities. • Campers must bring a bathing suit or swim trunks and a towel EVERYDAY. • Campers with hair that hangs below their earlobes must also wear a swim cap. Swimming caps can be purchased from the camp for $5.00. • Campers are responsible for their own belongings; parents must write the camper’s name on all items. • We strongly suggest that parents do not allow campers to bring cell phones, mp-3, radios, hand held games, and other valuables to camp. The camp is not responsible for any valuables being lost, broken or stolen. YMCA of Newark & Vicinity • 600 Broad Street • Newark, New Jersey 07102 Voice: (973) 624-8900 • fax: (973) 624-3024 • Website: www.newarkymca.org Activity Schedules/Field Trips • • • Activity schedules will be posted near the participant drop-off/pick-up area and/or distributed to parents. Parents are required to notify camp office as soon as they are aware that their child will be absent from camp. When leaving a message, please state child’s name, reason for absence and the date they will return to camp. Field trips will be posted on the activity schedule. A general permission slip will be distributed with this packet. Some trips may require an additional permission slip. Please be aware of the schedule. • Field trips are a part of the regular summer day camp activity schedule. At least one all-camp site trip will be scheduled for each session. • Campers will be transported to all trips by chartered buses unless the trip is within walking distance. A bus evacuation drill will be held prior to departure of each trip. • Campers will be responsible for holding their own money and belongings on field trips. All campers are expected to attend all camp field trips. These trips will generally take place from 8:30a.m.until 4:30p.m. If individual schedules prevent certain campers from participating, then parents must inform the camp staff no later than two (2) days before the scheduled trip. Bus Trips: During scheduled field trips, a bus with a seat belt is chartered. Proper conduct on trips is expected. Please review the following: ☞ All children and adults MUST wear seat belts. ☞ Everyone must remain seated during trips. ☞ No hands or other body parts are permitted outside the window. ☞ No eating or drinking is permitted on the bus. YMCA of Newark & Vicinity • 600 Broad Street • Newark, New Jersey 07102 Voice: (973) 624-8900 • fax: (973) 624-3024 • Website: www.newarkymca.org II. Supervision & Safety Important Phone Numbers Newark YMCA Camp Site Rasheedah Tucker, Site Supervisor (973) 624-8900 ext.6899 Belleville School #8 Camp Site Luis Ayala, Site Supervisor 183 Union Avenue, Belleville, NJ 07109 (973) 844-0088 Patty Zito, Camp Director (973) 624-8900 ext 6899 Tammea Tyler, VP of Youth Development (973) 624-8900 ext 6871 Weather Restrictions • No outdoor activities will be planned when the temperature exceeds 95 degrees or humidity above 90%. • No participant will be allowed outside when the weather is rainy, unless being transported to an indoor trip. • Under no circumstance will participant be allowed outside or in a pool (including indoor pool) when lightening storms, flash floods, or hailstorms are in effect. Health Information • The YMCA is required by law to have a Health History Form on file for each participant prior to the start of the camp session. A recent copy of the participant’s immunization record must be attached to this form. • The YMCA summer day camp staff will not dispense medication or allow campers to dispense medication. • A copy of the policy on the management of communicable diseases is enclosed. • If a camper arrives to camp ill or with any type of skin irritation they will not be permitted into camp until a doctor note is provided or the symptoms clear. • If a participant becomes seriously ill or is seriously injured during the program, a parent or emergency contact person will be contacted. In case of extreme emergency, the physician listed on the registration form will be contacted and steps will be taken to ensure participant’s safety. YMCA of Newark & Vicinity • 600 Broad Street • Newark, New Jersey 07102 Voice: (973) 624-8900 • fax: (973) 624-3024 • Website: www.newarkymca.org Sign-In/Sign-Out Process Campers must be signed in by an adult upon arrival each morning. Campers must also be signed out by an adult before departure each afternoon. Campers should arrive no earlier than 5 minutes before the operating hours for the session in which they are enrolled unless they are enrolled, in the A.M. Extended Care. Furthermore campers will not be allowed to sign themselves in or out unless requested in writing by the custodial parents. Campers will only be released to the individual(s) whose names are specified on the Parental Authorization and Consent form. If a parent desires for the participant to be released, written permission from the parent is required in advance. Proper ID is required. Late Pick-up Fee • Those children not enrolled in P.M. Extended Care must be signed- out by 5:05pm. After 5:05 p.m., a late fee of $1 for every minute will be applied and paid before the child can return to the program. • Those children who are enrolled in P.M. Extended Care must be signed out by 6:05; otherwise parents will be charged a late fee of $1 for every minute after will be applied and paid before the child can return to the program. • NO EXCEPTIONS WILL BE GRANTED TO THE LATE FEE POLICY. All late fees must be paid before the participant is re-admitted into the program. • Continuous late pick-up will result in camper’s termination from the camp. Late Drop off Procedures • The YMCA summer day camp includes activities at locations throughout the local area. Weather permitting, campers will be transported to a park or a field. These include but are not limited to, Eagle Rock Reservation, Branch Brook Park, Rotunda Pool and JFK Pool. If you have a special situation requiring that you drop your child off late, please contact the appropriate Site Supervisor to make alternate arrangements. If camper is dropped-off after his/her group has left, the camper will not be allowed to attend camp that day. YMCA of Newark & Vicinity • 600 Broad Street • Newark, New Jersey 07102 Voice: (973) 624-8900 • fax: (973) 624-3024 • Website: www.newarkymca.org III. Policies & Procedures Policy on Release of children Campers may be released only to the child’s custodial parent(s) or person(s) authorized by the custodial parent(s) to take the child from the camp and to assume responsibility for the child in an emergency if the custodial parent(s) cannot be reached. A camper shall not be visited by or released to a non-custodial parent, family member or friend unless the custodial parent specifically authorizes the camp to allow such visits or release in writing. This written authorization, including name, address, and phone number, shall be maintained in the file. Proper ID is required for staff to release camper. If a non-custodial parent has been denied access to a child by a court order, the YMCA must receive such documentation from custodial parent to that effect and maintain a copy on file. Written procedures to be followed by staff member(s) if the parent(s) or person(s) authorized by the parent(s), as specified above, fail to pick up a child at the time of the camp’s daily closing time. The procedure shall require: 1. The child is supervised at all times; 2. Staff members attempt to contact the parent(s) or person(s) authorized by the parent(s). 3. An hour or more after closing time, and providing that other arrangements for releasing the child to his/her parent(s) or authorized person(s) have failed and the staff member(s) cannot continue to supervise the child at the camp, the staff member shall call the DYFS 24-hour Child Abuse hotline (1-800-792-8610) to seek assistance in caring for the child until the parent(s) or person(s) authorized by the parent is able to pick-up the child. Written procedures to be followed by staff member(s) if the parent(s) or person(s) authorized by the parent(s) appear to be physically and/or emotionally impaired to the extent, in the judgment of the director and/or staff member, the child would be placed at risk of harm if released to such an individual. The procedures shall require that: 1. The child may not be released to such an impaired individual. 2. Staff members attempt to contact the child’s other parent or an alternate person(s) authorized by the parent(s). 3. If the YMCA is unable to make alternative arrangements, as noted above, a staff member shall call the DYFS 24-hour Child Abuse Hotline (1-800-792-8610) to seek assistance in caring for the child. YMCA of Newark & Vicinity • 600 Broad Street • Newark, New Jersey 07102 Voice: (973) 624-8900 • fax: (973) 624-3024 • Website: www.newarkymca.org Code of Conduct Camper Conduct In order to provide children with a safe, healthy, educational environment, structure and rules MUST maintained at all times. These guidelines and expectations be discussed with the children on their first day of camp will be reviewed daily. Please review the rules expectations below with your child. and be will and and The guidelines and expectations of Day Camp are: ☞ Listen and respect the counselors and other children. ☞ Respect each others feelings and personal belongings. ☞ Keep hands and feet to yourself-NO fighting, screaming, or cursing. ☞ Cooperate with each other. ☞ Stay with your group at all times ☞ Remain with your buddy during buddy times ☞ Stranger is DANGER- DO NOT TALK TO STRANGERS. ☞ Tell a counselor if someone is bothering or upsetting you. ☞ Clean up after yourself. ☞ HAVE FUN! The staff monitors the behavior of each child and attempts to work through conflicts and problems as they occur. If a child continuously disrupts the program, then the Unit Leader and Site Supervisors will call the parents. If a difficulty can’t be resolved, the camp reserves the right to suspend a child without reimbursement for a specified period of time. Continued difficulties following the behavior codes may also result in dismissal from the program. The safety of your child, other children and staff will be first priority when determining any suspensions or dismissals. Discipline Procedures 1. Philosophy The Newark YMCA staff philosophy concerning discipline is to plan structured, fun activities that encourage positive participation. When discipline problems arise, safety of staff and participants is our main goal. This will include a review of leadership style, program content, and distractions that may have impact on discipline issue. YMCA of Newark & Vicinity • 600 Broad Street • Newark, New Jersey 07102 Voice: (973) 624-8900 • fax: (973) 624-3024 • Website: www.newarkymca.org 2. Typical Behavior Management Sequence: Redirect behavior by stating the expected behavior for the activity, e.g. “We walk in the lobby.” The behavior is to be addressed, not the participant personally. If the participant does not accept redirection, the counselor will remove the participant from the group. The counselor will look for issues causing the behavior (e.g. argument with another participant, put downs, boredom, etc.). Counselors will again state the expected behavior for the activity. If agreement is reached, the participant will return to group. If agreement cannot be reached or for repeated problems, the staff may send participant for a “time out” period, not to exceed 15 minutes. If discipline problems continue, a camp staff member will contact parents or emergency contact to take participant out of the program. If the parent or emergency contact is unable to pick up the camper, they will not be allowed to participate in the activities planned for the remainder of the day. For the first incident, participant may be suspended for 1 to 2 days from the program. The second incident stemming from behavior problems may result in permanent removal from the camp. Immediate Participant Removal 1. Immediate, permanent removal from the camp will result for any of the following reasons: Child • • • • • • Possession of any weapons (knives, guns, sharp objects, etc.). Physical fighting, repeated rebellion and disrespect to staff. Open defiance to staff, especially when safety is an issue. Bullying or the use of profane language. Excessive tardiness. Excessive unexcused absentees. Parent • Expired Program for Parents voucher. • Failure to swipe in and out (Programs for Parents) • Parent refusal to escort child to and/or from the camp. • Failure to pay any camp fees by the deadline. 2. A refund will NOT be given if participant is removed from the program for any of the above reasons. YMCA of Newark & Vicinity • 600 Broad Street • Newark, New Jersey 07102 Voice: (973) 624-8900 • fax: (973) 624-3024 • Website: www.newarkymca.org POLICY ON THE MANAGEMENT OF COMMUNICABLE DISEASES If a child exhibits any of the following symptoms, he/she should not attend camp. If such symptoms occur at camp, the child will be removed from the group, and you will be called to take him/her home. ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ Severe pain or discomfort Acute diarrhea Episodes of acute vomiting Elevated oral temperature of 101.5 degrees Fahrenheit Sore throat or severe coughing Yellow eyes or jaundice skin Red eyes with discharge Infected, untreated skin patches Difficult or rapid breathing Skin lesions that are weeping or bleeding Skin rashes lasting longer than 24 hours Swollen joints Visibly enlarged lymph nodes Stiff neck Blood in urine Once the child is symptom-free, or has a doctor’s note stating that he/she no longer poses a serious health risk to himself/herself or others, he/she may return to the center. TABLE OF EXCLUDABLE COMMUNICABLE DISEASES A child who contracts any of the following diseases may not return to the center without a physician’s note stating that the child presents no risk to himself/herself or others: Respiratory Illnesses Illnesses Chicken Pox** German Measles Hemophilus Influenza Meningococcus* Mumps* Strep Throat Tuberculosis Whooping Cough Gastrointestinal Illnesses Contact Giardia Lamblia* Hepatitis A* Salmonella* Shigella Impetigo Lice Scabies . **Note: /if your child has chicken pox, a doctor’s note is not required for readmitting the child to the camp. A note from the parent is required, stating either that at least six days has elapsed since the onset of the rash, or that YMCA of Newark & Vicinity • 600 Broad Street • Newark, New Jersey 07102 Voice: (973) 624-8900 • fax: (973) 624-3024 • Website: www.newarkymca.org all sores have dried and crusted. If your child is exposed to any excludable disease at the camp, you will be notified in writing. January 1, 2014 Information Regarding Newark YMCA Summer Day Camp Programs This letter is to confirm that reference and background checks have been performed on all Newark YMCA Summer Day Camp Employees. All reference check forms as well as their background results are placed in their personnel files and are kept in the Human resources office located at the main branch of the YMCA of Newark and Vicinity on 600 Broad Street, Newark, New Jersey 07102. This letter is to be placed in the Newark YMCA Summer Day Camp Program office and to be maintained on file. April Hill Jones, Human Resources Associate CC: File YMCA of Newark & Vicinity • 600 Broad Street • Newark, New Jersey 07102 Voice: (973) 624-8900 • fax: (973) 624-3024 • Website: www.newarkymca.org Information to Parents Under provisions of the Manual of Requirements for Child Care Centers (N.J.A.C. 10:122), Every licensed child care center in New Jersey must provide to parents of enrolled children written information on parent visitation rights, State licensing requirements, child abuse/neglect reporting requirements and other child care matters. The center must comply with this requirement by reproducing and distributing to parents this written statement, prepared by the office of Licensing- Out center must post listing or diagram of those rooms and areas approved by the Office for the children’s use. Please talk to us if you have any questions about the center’s space. Our center must offer parents of enrolled children ample opportunity to participate in and observe the activities of the center. Parents wishing to participate in the activities or operations of the center should discuss their interest with the center director, who can advise them of what opportunities are available. Parents of enrolled children may visit out center at any time without having to secure prior approval from the director or any staff member. Please feel free to do so when you can. We welcome visits form our parents. Our center must inform parents in advance of every field trip, outing, or special event away for the center, and must obtain prior written consent from parents before taking a child on each such trip. Our center is required to comply with the New Jersey Law Against Discrimination (LAD), P.L 1945, c. 169 (N.J.S.A 10:5-1 et seq.), and the Americans with Disabilities Act (ADA), P.L. 101-336 (42 U.S.C. 12101 et seq.). Anyone who believes the center is not compliance with these laws may contact the Division on Civil Rights ion the New Jersey Department of Law and Public Safety for information about filing and LAD claim at (609) 292-4605 (TYY users may dial 711 to reach the New Jersey Relay Operator and ask for (609) 292-7701) , or may contact the United Stated Department of Justice for information about filing an ADA claim at ( 800) 514-0301 (voice) or (800) 514-0383 (TTY). Anyone who has reasonable cause to believe that an enrolled child has been or is being subjected to any form from of hitting, corporal punishment, abusive language, ridicule, harsh, humiliating or frightening treatment, or any kind of child abuse, neglect, or exploitation by any adult, whether working at the center or not, is a required by State law to report the concern immediately to the State Central Registry and Child Abuse Hotline, toll free at 1-(877) NJ ABUSE (652-2873). Such reports may be made anonymously. Parents may secure information about child abuse and neglect by contacting: Community Education Office, Division of Youth and Family Services, PO BOX 717 Trenton, New Jersey 08625-0717. YMCA of Newark & Vicinity • 600 Broad Street • Newark, New Jersey 07102 Voice: (973) 624-8900 • fax: (973) 624-3024 • Website: www.newarkymca.org ATTACHMENTS: (A) YMCA Summer Day Camp Social Contract As a participant in the YMCA Summer Day Camp Program, you have an opportunity to interact with a variety of people. You will have the chance to exercise independence without parental authority. It also means increased personal responsibility representing your town, the YMCA, and most importantly, yourself. This behavior contract is designed to allow you the greatest opportunity while outlining your most important responsibility to insure a fun time! The YMCA focuses on its 4 core values, which are Caring, Honesty, Respect and Responsibly. Read over the numbered rules below very carefully with your child. Please make sure your child understands these guidelines, and the expectations and consequences associated with them. Once you and your child have read this Social Contract, please sign your name, have your child sign his or her name, date it and return it. 1. In keeping with the YMCA mission and 4 core values, appropriate behavior is expected of all participants in the YMCA Summer Day Camp. Behavior that conflicts with essential YMCA values will be addressed in a manner appropriate to the disruptive behavior, and is at the discretion of the YMCA staff and Site Director. 2. The use or possession of alcohol, tobacco, weapons, or any controlled substance by any program participant will result in their dismissal from ALL YMCA programs. 3. Unauthorized use or theft of property, damage or theft to program vehicles or equipment on site or on any site visited, can lead to dismissal from ALL YMCA programs. 4. The YMCA has zero tolerance for fighting or any type of violence. Such behavior will result in DISMISSAL from ALL YMCA programs and/or SUSPENSION from programs. I have read this Social Contract with my child. Participant name: ______________________ YMCA of Newark & Vicinity • 600 Broad Street • Newark, New Jersey 07102 Voice: (973) 624-8900 • fax: (973) 624-3024 • Website: www.newarkymca.org Parent/Guardian’s Signature: ___________________________ (B) Date: ___________ PARENTAL AUTHORIZATION AND CONSENT FORM Child’s last name: _____________ First Name: _______________ Authorization to release child: Unless otherwise authorized by you in writing, no one, except you or your spouse may pick up your child from the program. List below the names of any persons you authorize your child to be released to: (Please print) ________________________________________________________ ________________________________________________________ If you ever wish for your child to be released to an individual whose name is not listed on this form, you must notify us in writing at least 24 hours in advance. The notice should include the name of the individual, his/her relationship to the child, and your signature. Authorization Contacts for Emergency Care: List below the names of persons who should be contacted in case of an emergency or if your child must be removed form the center and parents cannot be reached: Name: ______________ Relationship: _________________________ Address: _______________________ Phone: ______________ Name: _______________ Relationship: ________________________ Address: _______________________ Phone: ______________ EMERGENCY CARE CONSENT Physician: ___________________ Phone: _____________ Hospital of choice: ________________________________________________________ { } Emergency authorization: I hereby give permission to the medical personnel, selected by the director, to order x-rays, routine tests, and /or treatment for my child in the event that I cannot be reached in an emergency. I also hereby give permission to the physician, selected by the director, to hospitalize, secure proper treatment, and/or order injection and/or anesthesia, and/or surgery for my child as named above. This form may be photocopied. { } Field trip consent: I hereby give consent for my child to take part in field trips or excursions under proper supervision. { } Photo/video consent: I hereby give consent for my child’s picture to be taken by Child Care staff or area media personnel for occasional publicity needs. YMCA of Newark & Vicinity • 600 Broad Street • Newark, New Jersey 07102 Voice: (973) 624-8900 • fax: (973) 624-3024 • Website: www.newarkymca.org I have read and will agree to the above authorization and consent statements. Parent/guardian Signature: ___________________ Date: ______ (C) YOUTH HEALTH HISTORY FORM Child’s Information: Last Name: __________________ First Name: ______________________ { } Male { } Female Age: ___ Date of Birth: _______ Home address: _________________________________________________ City ______________________ State ___________ Zip _____________ Emergency Contact Information: Parent’s name: _________________________________________________ Home phone: _________________Work Phone: _______________ Emergency contact name: _____________________ Phone: _____________ Health Information: Physician’s Name: _______________________________________________ Address: ______________________________________________________ Phone: __________________________________ Does your child carry health insurance? { } yes { } no Carrier name: __________________________________________________ Please circle all applicable and provide date of occurrence: Rubella _____ Poliomyelitis Diphtheria _____ Tetanus Heart Defect/disease _____ Chicken Pox Convulsions _____ Measles Attention Deficit Disorder _____ Asthma Polio _____ Ear infections Hay Fever _____ German measles Clotting disorder _____ Pertusis Mononucleosis _____ Poison Ivy Hypertension _____ Mumps _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ List any allergies to food or medication: ______________________________ List any other diseases or ailments your child may have: ________________ ______________________________________________________________ Please describe any incidents in which your child required hospitalization in the last year: ______________________________________________________________ My child usually plays :{ } Alone { } with children in his/her own age group { } With older children { } with younger children Please check any words or phrases which describe you child: Obedient □ Affectionate □ Easily discourage □ Craves attention □ Shy □ Confident □ Cooperative □ Moody □ YMCA of Newark & Vicinity • 600 Broad Street • Newark, New Jersey 07102 Voice: (973) 624-8900 • fax: (973) 624-3024 • Website: www.newarkymca.org Highly sensitive □ Talkative □ Impulsive □ Serious □ Friendly □ Hyper □ Enjoys learning □ What particular concerns/fears does your child have (e.g. dark, animals, being alone, etc.)? ______________________________________________________________ (D) Please Select Session Attending & Shirt Size Camp Sessions Session # 1 June 30 – July 11 Session # 2 July 14 - 25 Session # 3 July 28 – Aug 8 Session # 4 Aug 11 – 22 (No Camp July 4) Name of Child: ________________________________ Please Circle Your Child’s T - SHIRT SIZES Small (6-8) Adult S Medium (10-12) Adult M Large (12-14) Adult L Adult XL For Statistical Purposes Only *This information will ONLY be used by the Newark YMCA to attain additional funding, scholarships or subsidies to enable more children to experience summer day camp. Please put a check next to your response. Thank you. EEOC Language Hispanic ____ Caucasion _____ _____ African American _____ ______ Income Level Native 0 – 20,000 _____ 20,001 – 28,000 _____ English _____ Spanish 28,001 – 35,000 _____ French YMCA of Newark & Vicinity • 600 Broad Street • Newark, New Jersey 07102 Voice: (973) 624-8900 • fax: (973) 624-3024 • Website: www.newarkymca.org Sessio Aug 2 (Newar Asian _____ Portuguese___ Other _____ _______ 35,001 – 43,000 _____ 43,001 + _____ Other YMCA of Newark & Vicinity • 600 Broad Street • Newark, New Jersey 07102 Voice: (973) 624-8900 • fax: (973) 624-3024 • Website: www.newarkymca.org
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