OFFICE USE ONLY
  _____ Received Camp
              Tee Shirt
  _____ Initials  

Click here to close window
Name: Birth Date:     Age:   
Address: Town:  Zip:   
Phone: Cell:  Grade Completed:
Mother's Name: Phone (H):   (W):
Father's Name: Phone (H):   (W):
Email Address: How did you hear about us?
CAMP DESIRED:   Session 1:
June 28 – July 16		   Session 2:
July 19 – August 6		   Session 3:
August 9 – August 27		  
Kiddie Kamp
(3-5 yrs)
Half Day Full Day
Youth Camp
(1st-6th)



Too Cool for Camp (7th-9th)
Grade
Transportation
Town Desired:
Sports Camp

Grade:
Extended Care
AM
PM
Both

Baseball Camps
7/26-7/30

MEDICAL INFORMATION: Allergies (please list):
  Medication

AUTHORIZED TO PICK UP (other than parent):

Name:

Phone:

Relationship:

Name:

Phone:

Relationship:

Name:

Phone:

Relationship:

UNAUTHORIZED TO PICK UP (Legal Documentation Required — please attach):

Name:

Phone:

Relationship:

TRANSPORTATION INSTRUCTIONS
Camper Pick Up Address (if different from home address)		  
Street:  

Zip:

  
Town:    
Any Special Directions:
 
Camper Drop Off Address (if different from home address)  
Street:

Zip:

 
Town:    
Any Special Directions:
 

PLEASE NOTE:
• All children that are 3 & 4 years old must have a car seat on the bus.
• Car seat must be provided by the parent/guardian.
• No Transportation available for Half Day Kiddie Kamp.

PERMISSION SLIPS: I,  give permission for my child to participate in all the Summer 2010 Camp activities planned for the days attended. I give permission for my child to leave the YMCA at Glen Cove building to participate in Rainy Day Activities (2nd grade & up). I understand that photographs taken during the camp season may be used for publication. I understand that I must have a completed medical form signed by a physician on file at the YMCA before the first day my child begins camp. I have read and will adhere to the policies outlined above.

Parent/Guardian Name:       Date:  


The undersigned being the parent or guardian of undersigned agrees to enroll said child in the Glen Cove YMCA Day Camp. Further the undersigned agrees to pay upon registration a $100 deposit per session in addition to the basic membership fee. The balance of each session is due by May 31st. I understand that if payment is not received within this time frame, the above named child will lose their placement in that camp session and forfeit their deposit.

I understand that health forms (as required by the New York State Department of Health) must be completed, signed and returned to the YMCA by May 31st. A physical is not required in order to attend camp. A current record of immunization and the health card signed and stamped by your child’s physician is required. The YMCA WILL NOT admit your child into camp without a current health form. There will be no exceptions. I understand that I will be notified if my child is seriously injured, has a suspected sprain or broken bone, fever, head injury or when deemed necessary by the YMCA first aid staff.

I understand that my child will not be allowed to leave the premises with an unauthorized person. Only those persons authorized by custodial parent or guardians will be permitted to leave the premises with my child. The YMCA will ask for identification before releasing my child. All requests for early release to a person other than those listed, must be made in writing and given to a camp director.
I understand that Hendrickson Bus company has been contracted by the YMCA to supply door-to-door bus transportation to and from the YMCA. I understand all comments will be addressed directly to Hendrickson, including bus route and length.

REFUND POLICY
A service charge of 25% will be issued before May 31st when any part of my child’s camp needs to be refunded. NO REFUNDS will be issued after May 31st. Should the YMCA determine that it cannot adequately meet the needs of your child, or that your child is behaving in a consistently uncontrollable manner, a credit or refund may not be granted.


CONDUCT POLICY
It is our intent that each child enjoys the activities planned by understanding that he/she is responsible for his/her actions. With prior knowledge of our basic rules of safety and good conduct, each child is made ware of how to exercise self-discipline that we are here to help him/her and to know that we want him/her to succeed. As in any group, activity, the inappropriate behavior of a few children can spoil the experience for the entire group. Therefore, the following conduct policies apply directly to each child and will be used in determining his/her eligibility to continue as a participant. In accordance with the severity of the infraction and the number of times an infraction occurs, a child may (a) lose privilege of participating in a specific activity, (b) be suspended from the program, or (c) terminated from the program for:

1. Repeatedly using foul language and/or being rude and discourteous to staff and/or peers.
2. Defacing YMCA property.
3. Bringing or using illegal substances; alcohol, drugs, cigarettes, weapons (as deemed by the staff of the YMCA) or unsafe personal sports equipment.
4. Stealing or defacing other children’s property.
5. Refusing to remain with his/her group, intentionally and repeatedly leaving his/her group activity.
6. Inappropriate physical contact: repeated hitting, biting, other physical altercations.

Intentionally or repeatedly going to unauthorized areas of the facility or leaving the premises without permission will result in the following actions: a search of the premises will be conducted; if the child is not found within 15 minutes, the police and parent/guardian will be notified and the child will not be allowed to return to camp. No refund will be given.
In the event that a camper has proven that he/she is unwilling to follow these policies, the parent/guardian will be notified and must meet a camp director in order to discuss the situation. A director will consider a possible suspension or termination. NO REFUNDS will be given.  It is our daily desire that every child enjoys his/her “Y” experience. It is for this reason that we have initiated policies we feel are fair, easily complied with and of benefit to everyone involved.

I certify that I have read and understood the information above.

Parent/Guardian Name:     Date: 

  

       

 OFFICE USE ONLY:    DATE: _____________________        PERSONNEL ON DUTY: ______________________
 Camp Fee: ________________________  Membership:  ____ BASIC ____ FAMILY ___ SUMMER
 Transportation : ___________________  
 Ext. Care: _________________________  
 Total: _____________________________  
 Deposit: __________________________  Membership Paid:   $ ___________________
 Balance: __________________________   Expires: ___________________