“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.):
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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
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Locations & Hours
Registration Fees
Camp Staff
Camp Meals
Camp Attire
Field Trips
II. Supervision & Safety
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Emergencies Phone Numbers
Weather Restrictions
Health Information
Sign-in/out Procedures
III Policies
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Policy on Release of children
Code of Conduct
Policy on the Management of Communicable Diseases
YMCA Summer Day Camp Staff
Attachments
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(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.
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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