LONG ISLAND CITY YMCA SUMMER CAMP 2016 REGISTRATION FORM Branch: Long Island City

Camp Type: Summer Day Camp 2016

Camp Site: Branch & Off-Site Location

PARTICIPANT INFO Child’s Name ___________________________________________________________________________________________________ Age ____________________________________________ D.O.B. _______________________________________________________ Gender ______________________________ Grade in September 2016 _______________________________ School _____________________________________________________________________________________________ Mailing Address ________________________________________________________________________________________________________________ ____ Apt.# _______________________ City ______________________________________________________________________________ State ___________________________________ Zip ____________________________________ Home Phone (________) _____________________________________________________ Email Address _____________________________________________________________________ My child will:

Be picked upWalk home (Only 10 yrs. or older, please sign bottom of page 2)

T-Shirt Size

Child:

S

M

L XL

Adult: S 

M

L

XL 

PARENT/GUARDIAN INFO Name of Parent/Guardian registering child ___________________________________________________ Home Phone (_______)_____________________________________ Work Phone (_____) ___________________________________ Cell Phone (_____) _____________________________________ Email _________________________________________ Name of Parent/Guardian _____________________________________________ Home Phone (_______)______________________________________ Work Phone (_____) ___________________________________ Cell Phone (_____) _____________________________________ Email _________________________________________

EMERGENCY CONTACT INFO Please list two (2) contacts not already listed on this form, to be used if the parents/guardians cannot be reached

Name ___________________________________________________________________ Relation ________________________________ Home Phone (_____)_________________________ Work Phone (_____) ___________________________________________________ Cell Phone (_____) ____________________________________________________ Name ___________________________________________________________________ Relation ________________________________ Home Phone (_____)_________________________ Work Phone (_____) ___________________________________________________ Cell Phone (_____) ____________________________________________________

PHYSICIAN INFO *Additional medical form from physician required Name ________________________________________________________________________________ Telephone Number (_______)______________________________________________ Address ____________________________________________________________________ City ________________________________ State _________________ Zip ___________________

AUTHORIZATION / CONSENT EMERGENCY AUTHORIZATION: I understand that in the event of an emergency affecting my child while participating in a YMCA program, a designated employee of the YMCA will attempt to contact me and inform me as soon as possible. In the event I cannot be reached, I hereby give permission for my child to be treated or hospitalized by a licensed physician or hospital selected by the YMCA. __________________________________________________________________________________________ Parent/Guardian Name

___________________________________________________________________________________ Parent/Guardian Signature

___________________________________________________________________________________________ Participant Signature

____________________________________________________________________________________ Date

LONG ISLAND CITY YMCA SUMMER CAMP 2016 REGISTRATION FORM PERMISSION FORM I hereby grant permission for my child to use all equipment and participate in all activities of the Long Island City YMCA. I hereby grant permission for my child to leave the Long Island City YMCA premises, under proper supervision of Long Island City YMCA staff, for neighborhood walks, park activities and field trips. It is my understanding that these trips will be taken over the camp session without further consent from me. ______________________________________________________________________________________ Child’s Name

__________________________________________________________________________ Camp Type

_______________________________________________________________________________________ Parent/Guardian Signature

___________________________________________________________________________ Date

AUTHORIZED PICK-UP FORM The following individuals are 18 years old or older and are allowed to pick up my child from the Long Island City YMCA Programs:

NAME

RELATIONSHIP

PHONE NUMBER

I understand that no one else will be allowed to pick up my child unless I notify the Long Island City YMCA in advance and in writing. This person will also be asked for their photo ID for verification. ________________________________________________________________________________________________ Parent/Guardian Signature

___________________________________________________________ Date

Contact Telephone Number: ____________________________________________________________

UNESCORTED DISMISSAL AUTHORIZATION My child is ten years of age or older and may go home without an escort at the end of the day.

____________________________________________________________________________________________________________ Parent/Guardian Signature

Contact Telephone No.: _____________________________________________________________________________

________________________________________________ Date

2016 LONG ISLAND CITY YMCA SUMMER CAMP FEE SCHEDULE * Session dates DO NOT include Saturday and Sunday. *

Early Childhood Early Childhood Camp Camp to 5 AgesAges 2 to2 5

 SESSION Session I Session II Session III Session IV

Junior Day Camp

  NONMEMBER DATES MEMBER NON-MEMBER DATES $520.00 $485.00 July July15 15 $520.00 July 5 5- -July $570.00 $530.00 July 18 - July 29 $570.00 July 18 - July 29 $570.00 $530.00 August 1 - August 12 $570.00 August - August $570.00 $530.00 August115 - August12 26

MEMBER

$485.00 $530.00 $530.00 $530.00

$570.00

Ages 6 to 8



August 15 - August 26

NON-MEMBER

MEMBER

SESSION Session I Session II Session III Session IV

$450.00 $500.00 $500.00 $500.00

Day Camp SESSION Session I Session II Session III Session IV

Ages 9 to 11  NON-MEMBER

 MEMBER

$432.00 $480.00 $480.00 $480.00

$477.00 $530.00 $530.00 $530.00

DATES

$495.00 $550.00 $550.00 $550.00

July 5 - July 15 July 18 - July 29 August 1 - August 12 August 15 - August 26

Middle Camp DATES

 MEMBER

SESSION Session I Session II Session III Session IV

July 5 - July 15 July 18 - July 29 August 1 - August 12 August 15 - August 26

$432.00 $480.00 $480.00 $480.00

Ages 12 to 14  NON-MEMBER

$477.00 $530.00 $530.00 $530.00

DATES

July 5 - July 15 July 18 - July 29 August 1 - August 12 August 15 - August 26

Extended Camp Hours SESSION AM Session PM Session AM/PM Combo

Ages 2 to 14 FEE $80.00 $80.00 $150.00

(Check Session)

1

2

TIME 7:30 - 9:00 am 5:00 - 6:00 pm 7:30 - 6:00 pm 3

4



Camp Fees EXTENDED FEES

DEPOSIT/ DISCOUNTS

+

AM/PM _____________ -

_____________

=

_____________

______________ _

+

AM/PM _____________ -

_____________

=

_____________

Session III

______________ _

+

AM/PM _____________ -

_____________

=

_____________

Session IV

______________ _

+

AM/PM _____________ -

_____________

=

_____________

Session Total ______________ _

+

Total _____________ -

Total _____________

=

Grand Total _____________

SESSION

FEE

Session I

______________ _

Session II

SESSION TOTAL

Payment Information Check

Credit Card

Bank Draft

Money Order

Credit Card # __________________________________________________________________________________ Bank Name: __________________________________________________________ __________________________________________

Exp. Date: ____________________________________________________

Account #: ___________________________________________________

Routing #:

Authorized Signature: __________________________________________________________________________________________________________________

PARENT AGREEMENT I, the undersigned, give permission for my child to participate in the camp for the days he/she attends. I am aware that a completed medical form signed by a physician is required before my child may begin camp. In addition, I am fully aware that to reserve a space, I must make a deposit of $50 per two-week session and submit a registration form. I am fully aware that should my child change camp sessions after the start of original session there is a $25 change fee. I fully understand that refunds/ credits will be given at the discretion of the Camp Director after submission of the refund/credit form. I fully understand and approve of my child being photographed for Long Island City YMCA publicity. Lastly, I fully understand that my child is responsible for his/her possessions. I have read, signed, and agreed to the registration requirements. Signature of Parent/Guardian:_________________________________________________________ Date: ________________

There is a non-refundable $50.00 deposit per session per child which is applied to session fee.

YMCA OF GREATER NEW YORK SUMMER CAMP REGISTRATION FORM STANDARD RELEASE FORM From time to time, the YMCA of Greater New York (the “YMCA”) takes pictures or records videos of members and non-members participating in YMCA programs, using its facilities, or attending one of its special events. Additionally, the YMCA may permit members of the media (the “Media”) to take such pictures or record such videos in order to promote the YMCA’s charitable mission and for other journalistic purposes. The individual person named below is signing this Release for the purposes of allowing the YMCA and the Media to use one or more such photographs, video recordings, and/or sound recordings (collectively, “Recordings”) of such person for any purpose consistent with the YMCA’s charitable mission, which includes, but is not limited to, the YMCA or the Media publishing such Recordings in newspapers, web sites, and other print or electronic publications, on television, or on the radio. By signing this Release, such person acknowledges that he or she has freely consented to be photographed, filmed, or otherwise recorded and has signed this Release of his or her own free will. If the person named below is under age 18, a parent or guardian of such person must sign on such person’s behalf. 1.

I agree that I am willing to be photographed, filmed, or otherwise recorded by the YMCA, its contractors, and the Media, either individually or as part of a group Recording, which may include my image, likeness, and/or voice. further agree that my name may be used to identify me as a subject of any Recordings featuring my image, likeness, and/or voice.

2.

I understand that the YMCA will own all rights in the Recordings of me that the YMCA or a YMCA contractor takes or records (“YMCA Recordings”), and that the YMCA will have the exclusive right to use, or allow others to use, such YMCA Recordings in any medium for any purpose consistent with the YMCA’s charitable mission as determined by the YMCA.

3.

I understand that the Media will own all rights in the Recordings of me that the Media takes or records (“Media Recordings”), and that the Media will have the exclusive right to use, or allow others to use, such Media Recordings in any medium for any lawful purpose.

4.

I understand that I am waiving any and all rights that may preclude the YMCA’s or the Media’s use of the Recordings as described above.

5.

I acknowledge that neither the YMCA nor the Media has any obligation to use any Recordings of me or to use such Recordings for any particular purpose. s s Y Y

6.

re re a re C a re C

s m y a y a Fil w w d ad ied a o o r B r In B

I understand that I will receive no monetary payment or other compensation in exchange for the rights to use Recordings of me.

______________________________________________________________

____________________________________________________________________

Signature

Date

______________________________________________________________

____________________________________________________________________

Name (printed)

Name of Parent/Guardian

_____________________________________________________________________________________________

____________________________________________________________________

Mailing Address

Phone Number (optional)

HEALTH RECORD FOR CHILDREN IN DAY CAMPS & AFTERSCHOOL & YOUTH CENTERS (This side to be filled in by parent before presentation to physician)

NAME OF PROGRAM: Long Island City YMCA Summer Camp

Permit No.

/ CHILD’S LAST NAME

FIRST NAME

/

BIRTHDATE

Home Address:

Phone:

Parent or Guardian:

Phone:

Place of Employment:

Father (Guardian)

Phone:

Mother (Guardian)

Phone:

In case of emergency, notify:

M

F

SEX

Phone:

If Parent, Guardian are not available in an emergency, notify: Phone: or 2.

Phone:

Important: Has this camper been exposed to any communicable disease during the three weeks prior to camp attendance:

Yes

No

(If yes, state type of exposure:

)

HEALTH HISTORY: (Check, giving approximate dates) Ear Infections

Hay Fever

Chicken Pox

Rheumatic Fever

Ivy Poisoning, etc.

Measles

Convulsion

Insect Stings

German Measles

Diabetes

Penicillin

Mumps

Behavior

Other Drugs

Other Contagious Illnesses

Asthma Other Past Illnesses Operations or Serious Injuries (Dates) Hospitalization (Dates) Chronic or Recurring Illness Any specific activities to be encouraged? Conditions that require activity to be restricted? Permission for all program activities unless otherwise noted by Dr. Appliance worn (glasses, contacts, etc.) Medication taken Suggestion from Parent/Guardian *****CONSENT FOR EMERGENCY MEDICAL TREATMENT***** I do herby give authority to the Day Camp and Year Round Afterschool and Youth Center Program staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible.

Relationship Department of Health

Signature

Date The City of New York

Tele.# Bureau of Inspections

PHYSICAL EXAMINATION (To be filled out by Physician – please note information on reverse side)

The purpose of this health record is to provide the staff with pertinent information, which will help to serve the needs of this child in Day Camps and Afterschool and Youth Center Programs. IMMUNIZATION HISTORY – This is a record of dates of basic immunization and most recent booster doses. Date Date Date DpaP, DTP or TD Date Date Date Date Date Polio\ Date Date Date

MMR\

Hemophilus Influenzae type b Date Hepatitus B

Date Date

Date

Date

Varicella

Date

Date

Date Date

Date

Date

Date

Date

Date Date

Date

Date

Date

Date

Date

Date

Other

MEDICAL EXAMINATION – To be filled out by licensed physician Examination is acceptable when performed no more than 12 months prior to arrival at camp. Code: S = Satisfactory X = No Satisfactory (Explain) 0 = Not Examined General Appearance Height

Weight

Urinalysis (Date) Eyes___________ Ears___________

Blood Pressure

Hgb. Test (Date) Throat – Tonsils

Posture & Spine Vision____________ w/Glasses _____ __ Hearing_______ Feet_____

Nose

Teeth

Extremities _________ Heart Lungs________

Abdomen

Skin__ Hernia

Genitalia Neurological Findings Describe Abnormal Findings and/or Handicapping Conditions Has child ever received products containing horse serum? Allergy: (Please specify) Recommendations and restrictions while in camp. Special Diet Special Medicine (name it) Is parent/guardian sending special medicine? Swimming

Diving

Activity Restrictions

General Appraisal:

I have examined the person herein described, reviewed his/her health history and it is my opinion that he/she is physically able to engage in Day Camp/Year Round Afterschool and Youth Center activities, except as noted above. . EXAMINING PHYSICIAN (SIGNATURE) PHYSICIAN’S NAME (PLEASE PRINT)

Telephone

Address

Date of Examination ZIP CODE

LONG ISLAND CITY YMCA SUMMER CAMP 2016

Trip Consent Form

I do hereby give permission for my child _____________________ to participate in the trip portion of the Long Island City YMCA Summer Camp from 7/05/16 to 8/26/16.

Name: _________________________________ Signature: _________________________________ Relationship: ______________________________

Date: ____________ Telephone:_ _________________________________________________

LONG ISLAND CITY YMCA SUMMER CAMP 2016

Swim Consent Form

I do hereby give permission for my child ____________________________________ to participate in the swimming activities of the Long Island City YMCA Summer Camp from 7/05/16 to 8/26/16.

Name: _________________________________________________ Signature: _________________________________ Relationship: ______________________________

Date: ____________ Telephone: _________________________________________________