YMCA ELKWATER OVERNIGHT CAMP REGISTRATION 2017

YMCA HIGH ROPES CAMP 2017

All information will be treated in the strictest confidence (FOIP)

MEMBER ONLY

Please provide a photo of your child
(at the end of camp year you may request the photo back)
Child Name
First Last / Male 
Female  / Age at Camp
Birth date
| MM | DD | YYYY / Address (residing)
Apt # Street / City / Gender
Prov. / Postal Code
Parent’s e-mail: / Current Swimming Level:
Legal Custody / Parent’s/Guardian’s Name / Home Phone / Work Phone / Business Name / Other or Cell #


If Parent/Guardian is not available in an emergency, notify: (THIS WILL BE CONSIDERED AN AUTHORIZED RELEASE ALSO)
Name: ______Relationship: ______Phone:______

AUTHORIZATION OF RELEASE (LEGAL Parent/Guardian may only change the Authorizations)

I hereby authorize the following people to pick up my child at the YMCA:

1. Name: ______Relationship______Phone: ______

2. Name: ______Relationship______Phone: ______

3. Name: ______Relationship______Phone: ______

Are there any people who are NOT to pick up your child? ______Reason:______

I hereby authorize my child to arrive and depart from the YMCA on his/her own accord (Must be nine or older to be authorized)

Health Information
Is the camper on any medication?
 YES  NO
Medication:______
What are the effects of the Medication?
______
Does your child need this or other medication during camp hours?
 Yes  No
If yes, please fill out Medical Release Form obtained from the front desk.
Does the Camper have any allergies?
 Food:______
 Drugs:______
 Insect Bites /Animals: ______/ Health Information
Does your child have any of the following?
Asthma Ear Infections Diabetes Epilepsy  Bed Wetting  Other
Explain:______
Carries an Epi-pen:
 Yes  No
Wears Medical Alert bracelet
 Yes  No
For:______
Dietary Restrictions
Lactose Intolerant
Vegetarian
Peanut Butter
Gluten
Other
Explain:______/ Health Information
Does your child have any of the following behaviour disorders?
ADD ADHD ODD FASD Other Explain:______
______
Advise about habits, physical, emotional or needs:
______
______
______
______
______
______/ Health Information
Doctor Information
Family Doctor Name: ______
Doctor Phone #: ______
Is your child under any form of treatment for an illness, condition or injury?
 YES  NO
Explain:______
______

Signature:______Date: ______

*I give permission to sunscreen, take promo-photos, offsite trips, and all other policies outlined on the 3rd page

Parent Signature:______Parent Printed Name:______Date:______

YMCA CAMP ELKWATER AND HIGH ROPES2017 Family YMCA of Medicine Hat AUTORIZATION
Ages 8 to 14 years
FEE / After April 30th
Member / 1st child $310.00
2nd child $300.00
3rd child $290.00
Non Member / 1st child $340.00
2nd child $330.00
3rd child $320.00
Week 1:July 10- 14: R#______
Camp Total: $______
 Cash  Debit  Credit Card  Cheque Staff Initial_____
Week 2: July 17-21: R#______
Camp Total: $______
 Cash  Debit  Credit Card  Cheque Staff Initial_____
Week 3:July 31-August 4: R#______
Camp Total: $______
 Cash  Debit  Credit Card  Cheque Staff Initial____
 Week 4 - High Ropes Camp: August 8 - August 11: R#______
Camp Total: $______
 Cash  Debit  Credit Card  Cheque Staff Initial_____
Week 5: August 14-August 18: R#______
Camp Total: $______
 Cash  Debit  Credit Card  Cheque Staff Initial_____
/ Please Initial all boxes
The Family YMCAof Medicine Hat will not assume responsibility for anything that happens asa result of false information given
Iamaware that the Family YMCAof Medicine Hat Association will not assume responsibility for children in transition toand from the program. YMCA Staff will mark attendance when children arriveand depart, it is the parent/guardianresponsibility to sign inand sign out their children with government issued photo ID, ready to present
I give the Family YMCA of Medicine Hat Staff permission:
To engage in emergency medical assistance (First Aid/CPR) and/orcallfor emergency careof ambulance, fire, or police for any child. And authorize the Camp Director and his/her designate to authorize onmy behalf all procedures, including admission to hospital and necessary treatment therein, injections, anesthesia
Togivemedicationtomychild giventhattheparent/guardianhavefilledoutthepropermedicalinformationsheetandthemedicationisinitsoriginal container
Totakemy childoff-sitefor programactivitiesandtours.Thisincludeswalks,bus,andothertransportation
Tohavesunscreen/insectrepellentappliedtomychildwhennecessary
Ensureyouhavesignedpermissiononthebottomofthefrontpage
Toterminatecarewhenachildrefusestocooperate,doesnotfollowourcodeofconduct,mayinjurethemselves,orphysicallyoremotionallyinjureothercampersregisteredwiththeprogram.IalsoagreethatIwillmeetwiththeDirectortodiscuss behaviorproblemsifsorequested.
Totakephotosofmy childfor useoftheFamilyYMCAofMedicineHataspromotionalandmarketingmaterial.
Ihavereadandagreetoalltermsandconditionsinthe ParentGuide,includingtheHealthSafety:RiskAwarenessforParticipants/FamiliesatYMCACampElkwater

Help provide life changing camp
experiences for other children in need.
I would like to donate $______,
to send a child to camp.
For Office Use Only:  FCS  JS  other
Subsidy Amount: $______/ week / child
 Pre  Post
Authorization Signature: ______
REGISTRATION PROCEDURES
  • It is veryimportantthatregistration isdonetheThursdayorearlierbeforetheweekofcampbegins as it isverydifficult tosetup our groups,orderfood supplies,set up campsleeping arrangements,andothercamplogistics.Please completeone registration formperchild.
  • Payment can bemadeby Debit,Visa,MasterCard,Debit,cheque,orcash. Charges for NSFchequeswill be
$30.00perNSFcheque.
  • Registrationsareacceptedona firstcomefirstservebasis.Incompleteregistrationswillnotbeprocesseduntilmissing information iscompleted (phoneor in person).

REFUNDS AND CANCELLATIONS
It is the policy of the Medicine Hat Family YMCA that refunds are not given unless:
a)There is a medical or physical reason and note from doctor that states why the child cannot attend day camp for the specified dates.
b)You are moving to another city (proof must be presented)
Refunds or credits will not be issued in instances where the camper is removed from the camp program at the choice or request of the camper or camper’s parent(s) / guardian(s) or is dismissed from camp for contravention of camp guidelines or the camp code of conduct for behavior.
There will be a $10.00 non-refundable administration charge to all camp refunds
A photocopy of the original receipt and doctor’s note must accompany the application for refund
There may be certain or special circumstances where CREDITS are given, however they must be approved by the front desk manager and the Youth Director.
CODE OF CONDUCT
Developing and understanding of, and responsibility for individual potential and abilities include accepting responsibility for individual actions. While under the leadership of skilled staff, the activities that your child will engage in as a participant at the YMCA Day Camps may involve risk – risk in choices made and any physical activity undertaken by the participant. As a condition of being allowed to participate in a Medicine Hat YMCA camp programs, you warrant that the participant is in good physical and mental health and that the participant shall not consume any substances which would impair the participant’s senses at any time during the program. A participant’s possession or consumption of alcohol, tobacco products, illegal or harmful substances will result in immediate dismissal from the program. You agree that no refunds or credits will be granted for participants dismissed from the camp for possession or consumption of these substances.
You agree that intentional participant behavior that puts the camp or others at physical or emotional risk will result in immediate dismissal from the program at the discretion of the YMCA Director responsible. Expenses incurred because of program dismissal will be the responsibility of the participant/parent/guardian. That your child uphold the values of respect, responsibility, caring and honesty everyday the attend camp.