2019 CAMP LAKEWOOD REGISTRATION FORM

Transcription

1 Page 1 Please print legibly. You may also register on-line at 1. CAMPER INFORMATION Last Name: First Name:_ M.I.: Nickname: Sex (check one): M F Birth date: Years at Camp Lakewood including Summer 2019: _ Home Address: City: State: Zip: School attended in : Grade: Is camper a YMCA Member? Yes No If Yes, which branch?_ (In order to receive member discount, you must enclose a copy of membership card or letter from YMCA branch as proof of membership.) How did you hear about Camp Lakewood? Referral Program (see page 9) Who referred you?: (Please provide camper s name) 2. PARENT/GUARDIAN INFORMATION How would you prefer to be sent the Parent Packet? (check one) Via (The packet will be sent to the 1st parent address.) Via postal mail 1st Parent/Guardian s Name: Relationship: Home #: (_) Work #: (_) Cell #: (_) If you would like to receive possible notifications via text, please list your phone network carrier: (ie. AT&T, Sprint, Verizon, etc.) 2nd Parent/Guardian s Name: Relationship: Home #: (_) Work #: (_) Cell #: (_) With whom does the child reside? 3. CABINMATE REQUEST Last Name: First Name: _ Only ONE cabinmate request is allowed. TO GUARANTEE the request, the campers must request each other, be within one year of age, be the same gender, and enrolled in the same program and session. NOTE: If there are 10 or 12 children who would all like to be together, ask about the possibility of booking an entire cabin. 4. BUS INFORMATION All buses pick-up and return campers to the South County YMCA in St. Louis. (Check one) Round Trip Bus - $70 Bus to Camp Only - $35 Bus from Camp Only - $35 No Bus 5. INCLUSION SERVICES (check all that apply) YMCA Camp Lakewood welcomes participation by children of all abilities. All children with any type of diagnosis and/or specialized documents will be referred to the Inclusion Services Department for assessment. For more information, contact YMCA Inclusion Services at Has your child been diagnosed with: ADD/ADHD OCD Cerebral Palsy Tourette s MR/D PDD Down s Syndrome Bi-Polar Disorder Rett s Syndrome Fragile X Autism ODD DD Asperger s Other:

2 5. INCLUSION SERVICES (Continued) Page 2 Are there any behavioral medications or psychological issues of which the camp should be aware? Yes No If yes, please describe: Are there any physical limitations that might hinder the camper s participation in camp events? Yes No If yes, please describe: Does your child have an IEP, Section 504 Student Accommodation Plan, or Behavior Management Plan? Yes No Does your child currently use YMCA Inclusion Services? Yes No If so, which branch? *Please note, you MUST submit a current IEP/BMP/Section 504 Student Accommodation Plan with this registration form and complete and return the Inclusion Information Forms before program participation is authorized. Forms must be received by the camp office at least four weeks prior to participation. Enrollment will NOT be considered final until all required processes have been met and reviewed. Although every effort is made to provide reasonable accommodations, there may be instances where a child s needs may exceed the parameters of the scope of our program. All camp forms are available to download at under For Parents. Note: Space is limited so the earlier paperwork can be turned in and processed, the better chances your camper has to come to camp. 6. ALLERGIES Does your child have any allergies? NO KNOWN ALLERGIES THIS CHILD IS ALLERGIC TO: Describe what the camper is allergic to and the reaction seen: 7. DIET Check those which apply. We can work effectively with most medically prescribed diets but cannot cater to individual food preferences. Please call if you have a question about diet. This camper eats a regular and varied diet This camper is lactose-intolerant of this type (select one): This camper uses a product like Lactaid and/or can self-manage the intolerance This camper needs lactose-free diet that includes no lactose in baked items (ie. breads, cookies, etc.) This camper is a vegetarian of this type (select one): Semi-vegetarian (no pork or beef) Pesco (no pork, beef or chicken) Lacto-ovo (no beef, pork, chicken, seafood or fish) Vegan (no meats, eggs or dairy) 8. MEDICATIONS (check all that apply) The medications listed below, stocked in the YMCA Camp Lakewood TLC, are used to manage illness or injury, and dispensed as directed by our medical protocols. Check all those which your camper should NOT be given: Acetaminophen Aleve Aloe Vera After Sun Benadryl Caladryl Calamine Lotion Chloraseptic Throat Spray Generic Cough Drops Generic Cough Syrup Ibuprofen Immodium AD Ivy Dry Maalox Multi-Symptom Cold Tabs Mylanta Nighttime Cold Formula Pepto Bismol Silvadene (burn creme) Sudafed Swimmer s Ear Tinactin Triple Antibiotic Cream Tums

3 9. HEALTH CONCERNS (check all that apply) This camper has NO chronic health concerns and is capable of full participation in this program Page 3 This camper has the following health concerns (select all that apply): Asthma/Wheezing/Shortness of Breath Headaches Sleepwalking Diabetes Menstrual Cramps Frequent Colds Frequent Ear Infections Bedwetting Seizures 10. PARTICIPANT AGREEMENT/ REFUND POLICY I verify to the best of my knowledge that everything on the registration is correct and the child is capable of such an experience. I recognize failure to disclose, falsification or deliberate omission of information will result in termination of services. I agree to pay the balance of the program fees by May 1. The deposit is not refundable or transferable under any circumstances. Fees are not refundable without a doctor s authorized medical reason (this excludes behavioral or psychological issues). No refunds will be issued unless cancellations are made at least four weeks prior to arrival. I understand that no refunds are given if a child leaves early because of homesickness or for disruptive behavior as determined by the Director. I grant permission for the camper to participate in all planned program activities including out-of-camp trips by van or bus, hiking or horseback riding, understanding that competent leadership is provided. In case of accident or illness, the YMCA is authorized to secure emergency medical treatment. Prudent attempts will be made to contact parents immediately. I understand the related expenses for this medical attention will be (my) the camper s responsibility. The YMCA is not responsible for lost, stolen or damaged personal articles. I also authorize the YMCA to have and use photographs and videos of the camper named on this registration for promotional purposes and web site session photos (if you do not wish your child to be photographed or videoed, please check the box below). I agree to waive any claims against the YMCA, its staff, and volunteers for injuries or damages that may result from the conduct of other persons including participants in YMCA programs. Parent/Guardian Signature:_ Date: I do not wish my child to be photographed or videoed. (Note: No pictures/videos of your child will appear when camp photos/videos are taken and uploaded. This includes the Daily Wave.) 11. SESSION CHOICE Other (describe): Provide information about supportive health care needed for each checked item: Please enroll camper in the following session (if enrolling in more than one session, please include both sessions & programs): Session #: Program: Session #: Program: If camper is attending consecutive sessions, will they be staying over between sessions? Yes No (If yes, please add $ ELECTIVE CHOICE (Optional) for each stay over) Advanced Arts & Crafts Elective : 1-4, 6-9 (optional for Main, East Camp, Jr. Rangers - ages 8-16)... $ 99 High Adventure Elective : 3, 8 (optional for East Camp only - ages 13-16)... $ 99 Horsemanship Elective : 1-4, 6-9 (optional for Main, East Camp, Jr. Rangers - ages 10-16)... Paintball Elective : 1-4, 6-9 (optional for East Camp - ages 12-16)... $200 SNAG (Starting New at Golf) : 1-4, 6-9 (optional for Main, East Camp, Jr. Rangers - ages 11-16)... $ ADDITIONAL PICK-UP AUTHORIZATION For safety and security reasons, we must know if someone other than the named person(s) in Section 2 (Parent/Guardian Info.) will be picking up your child from camp. If so, please indicate below. If no one is listed in this section only the person(s) listed in Section 2 of this registration form will be allowed to pick up the camper associated with this registration. No exceptions! Name (as it appears on driver s license) _ Relation: _ Name (as it appears on driver s license) _ Relation: _

4 Page PAYMENT INFORMATION If registering prior to May 1, you may choose to pay the entire balance or a non-refundable deposit of $100 for each week requested to hold space. The deposit is applied to the total camp fee. If your deposit is paid by credit card, the balance will automatically be charged to your card on May 1. If the entire balance is not paid by May 1, the reservation may be cancelled and the deposit forfeited. If you are registering after May 1, the entire balance is due upon registration. Program Price (last page) $ _ Elective Fee-if applicable (page 3) $ _ Bus Fee-if applicable (page 1) $ _ Stay Over Between Fee-if applicable ($50) $ _ Donation to help send an underprivileged child to camp (optional) $ _ Multiple Child Discount-if applicable ($35 will be applied toward the balance for your 2nd, 3rd, etc. child) $ _ - YMCA Member Discount-if applicable ( $100 off sessions 1-3; $45 off sessions 4-10) $ _ - Total Amount Due $ _ Less Deposit Amount Enclosed ($100 for each week requested) $ _ TOTAL DUE (By May 1) $ _ Method of Payment: Check enclosed, payable to YMCA of the Ozarks. Please include driver s license number and camper s name on check. (A $25 charge will be applied for returned checks.) Visa MasterCard Discover AmEx Amount to be charged: $ Acct #: Exp.Date: _ Signature: _ 15. REGISTRATION INFORMATION Register in one of the following ways (you should receive a confirmation in 7-10 days): Register on-line at: registration form with credit card information to: camplakewood@gwrymca.org Mail registration form and deposit to: YMCA Camp Lakewood State Hwy AA Potosi, MO Fax registration form with credit card information to: Bring to your local Gateway Region YMCA (locations listed at Registrations are processed in the order received in the Camp Lakewood office. For information, call The Parent Packet with all necessary Camp Lakewood forms can be found online at www. camplakewood.org under Forms + Parent Information, as well as the packing/clothing lists. Branch Use: Date Received: Branch: Amount: Receipt #: _ Initials: Camp Use: Date Received: Check #: Amount: Session #: Initials:

5 2019 CAMP LAKEWOOD FEE SCHEDULE Fees listed do NOT include any member, referral, financial assistance and/or military discounts. Voluntary 3-tiered pricing program only where indicated (full, partial, subsidized). CAMP PROGRAMS Four Day TRADITIONAL PROGRAMS Mini-Camp (ages 6-8) Mini Raptor Camp (ages 9-10) Mini Pre-Teen Camp (ages 11-12) Main Camp (ages 8-12) East Camp Jr. Ranger Camp (ages 10-12) Canoeing Rangers High Adventure Rangers Hiking Rangers Rustic Engineering Rangers Survival Rangers NEW! Equestrian Camp Two week Explorer Camp (ages 11-12) Leaders-in- Training * Counselors-in- Training ** Elective Options Adv. Arts & Crafts (ages 8-16) Horsemanship (ages 10-16) EQUESTRIAN PROGRAM Ranch Camp One Week TRADITIONAL PROGRAMS ADVENTURE PROGRAMS Ozark Adventure Trip NEW! EQUESTRIAN PROGRAMS Equestrian Camp (ages 10-12) NEW! Two Week TRADITIONAL PROGRAM LEADERSHIP PROGRAM Four Week Session LEADERSHIP PROGRAM $1,350 $1,100 SNAG Golf (ages 11-16) $60 $60 $60 $60 $60 $60 $60 Paintball (ages 12-16) $200 $200 $200 $200 $200 $200 $200 High Adventure $1,100 $1,350 $900 $800 Counselor-in-Training participation doesn t guarantee acceptance as a counselor in following year(s). CIT s are selected through our application process. ** Must have completed Junior year in high school. ADDITIONAL ACTIVITIES $1,470 Full $1,370 Part $1,270 Sub Leader-in-Training focuses on own growth and is not a pre-cit program. * Must have completed Sophomore year in high school. Note: Some electives may have restrictions. Please see activity descriptions. ELECTIVES Camper can optionally participate in the below extra activities daily during their session; note age requirements $60 $200 Page 5