2018 Registration Form

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Edwina Dawson
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YMCA of Greater Saint John 191 Churchill Blvd Saint John NB, E2K 3E2 Telephone: (506) 693-9622 2018 Registration Form Must Include: o Payment for all weeks o Immunization Record o Completed Forms If

1 YMCA of Greater Saint John 191 Churchill Blvd Saint John NB, E2K 3E2 Telephone: (506) Registration Form Must Include: o Payment for all weeks o Immunization Record o Completed Forms If Required: o DAP form o Strong Communities application and proof of income form Before your camper can be registered, the Y must receive all parts of this registration form and must be accompanied by either a full cash payment or post-dated cheques. Please make cheques payable to the YMCA of Greater Saint John. All cheques must be dated 2 weeks prior to the start of each camp session. Camper must have completed Kindergarten in order to attend Y camps. Please complete one form per camper. Part 1/6 - Camper and Household Information Name Male Last Grade DOB dd/mm/yy Female Completed Mailing Address City Province Postal Code Parent/Guardian s Name Parent/Guardian s Name Cell # Home # Cell # Home # Place of Work Work # Place of Work Work # Address Marital Status Single Married Widowed Separated Divorced Address With whom has the child lived with most of the past year? Mother Father Both Guardian Other (specify) What languages are spoken at home? English French Other (specify) Emergency Contact: (different from parent/guardian) Name Relationship Home # Work # Cell # Emergency Contact: (different from parent/guardian) Name Relationship Home # Work # Cell Who has permission to pick up your child from camp: Did your child attend a Y Afterschool Program this year? Yes No Support Worker Information ( Camp) Complete if Applicable Is there anyone who does not have permission to pick up your child from camp? _ If so, which location? Does your child require a support worker at school? Yes No Has your child received funding support during the school year? Yes No If yes, through which department or organization is your funding provided? Please provide available contact information for relevant Social Worker/Case Manager Please note that YMCA funded Support Workers are limited. To ensure that we are able to offer Camp to as many participants as possible YMCA funded Support Workers are available to only those that do not have access to funding support through an alternate funding source. I understand that providing false information could result in cancellation of my registration. 1/5

2 Part 2/6 - Medical Information Medicare #: Expiry Date: Name of Family Physician: Phone: Address: Allergies Medication Allergies: Food Allergies: Other Allergies: Medical Treatment Name of Medication: Dosage: Instructions: Name of Medication: Dosage: Instructions: Emergency Treatment Please indicate any situation where emergency treatment and/or medication(s) might be required (i.e.: Epipen/ puffers/inhalers, Benadryl). Health Care Record Proof of immunization must be provided for each camper for the following: Diphtheria Tetanus Polio Rubella Varicella Meningococcal Mumps Measles Haemophilus Influenza Type B Pneumococcal Pertussis Medical History and Health Status Please indicate if your child has had any of the following: Medical History Yes No Health Status Yes No Measles Asthma Rubella Diabetes Mumps Eczema/Psoriasis Chicken Pox Epilepsy/Seizures Meningitis Other: Whooping Cough Please indicate any additional medical information that you feel is important for us to be aware of in order for us to help your camper make the most of their experience. Part 3/6 - Child Development Self Help Does your child need our help with the following self-help skills: Dressing/Undressing: Eating: Toileting: Handwashing: Other: Camp Experience Are there any hints/suggestions you could share with us to make your child s camp experience a positive one? Tell us a few things about your camper (interests, personality ) Is there anything else you would like to share with us about your child? 2/5

3 Part 4/6 Camp Selection - Highlight or circle your camps of choice. Please refer to the Day Camp Brochure for age restrictions. Week 1 Jun Urban iteracy Jr. Sr. Ball Hockey Junior Canoe Senior Archery Babysitting Jr. Sr. Yowza! Jr. Sr. STEM Forts and Sports Week 2 Jul 3-6 Jr. Sr. Gooey Inventions Junior Outdoor Survival Senior Fishing Golf $82 Jr. Sr. Race Jedi Training Jr. Sr. Race Enchanted Forrest $134 Safari Explorers Week 3 Jul 9-13 Race Jr. Sr. Gotta Catch Em All ** Junior Sport ** Senior Canoe Mountain Bike Jr. Sr. Jr. Sr. Y Comic Con Sweet and Sassy Gooey Inventions Week 4 Jul Canadian Ninja Warrior Jr. Sr. All Ball Sports Junior Iron Kids Senior Sports Senior Archery Jr. Sr. Derby Showdown Jr. Sr. Derby Showdown Wizards and Warlocks City Wide s Week 5 Week 6 Jul Jul 30-Aug 3 Bill McGuire Centre Early Learning Centre Forest Glen Community Centre Jr. Jr. Sr. Sr. Ultimate Challenge Glenn Carpenter Centre Junior Olympics Olympics (Track/Field) Olympics (Watersport) * Junior Fishing Sr. Outdoor Survival * Senior Iron Kids * Hatching Dragons Glenburn Millidgeville Community Centre Jr. Jr. Sr. Sr. The Great Canadian Ninja Escape Warrior Sweet and Sassy Quispamsis Community Centre (qplex) Jr. Jr. Sr. Sr. Canadian Ninja Warrior Graffiti Graphics Saint John Regional Y Movin and Groovin West Side (St. Mark s Church) Canadian Ninja Warriors Week 7 Aug 7-10 The Great Escape/Kayak Jr. Sr. Junior Outdoor Survival Mountain Bike Climbing $82 Jr. Sr. Y Comic Con Yowza! Jr. Sr. Beach Camp Roadrunners Week 8 Aug Jr. Sr. Super Hero vs. Super Villain Junior Sports Senior Archery Senior Canoe Jr. Sr. Y Stanley Cup Wizards and Warlocks Jr. Sr. Y Stanley Cup Gooey Inventions Week 9 Aug Jr. Sr. Gotta Catch Em All Junior Archery Senior Iron Kids Senior Outdoor Survival Day Camp $180 *** Jr. Sr. STEM Jr. Sr. Yowaza! The Great Escape Fitness Fun All Ball Sports Week 10 Aug Jr. Sr. Junior Canoe Senior Spots Babysitting Jr. Sr. Jr. Sr. Girls Empowered * Senior Under the Stars add-on available - $15.00 additional fee ** Junior Under the Stars add-on available - $15.00 additional fee *** Transportation Available from Regional Y and qplex - $20 additional fee 3/5

4 Part 5/6 Legal Waiver The following is a legal document. Please read it carefully and acknowledge that by signing you are giving up the right to sue the Greater Saint John YMCA Inc., its officers, agents, employees, Board of Directors, volunteers, participants and all other persons or entities acting on their behalf (hereinafter collectively referred to as Camp ). AUTHORIZATION In permitting my child to attend Camp, operated by the Saint John YMCA Inc., I, the undersigned, permit my child to participate in the full range of camp activities. I authorize the Camp Coordinator and his/her appointee in the event of an accident or illness affecting the above named camper to authorize on my behalf all procedures necessary therein, as he/she may deem essential for the care and well-being of said camper. In the event I cannot be reached, I hereby give permission to the physician selected by the Camp Coordinator to hospitalize, secure proper treatment, order injections, anesthesia or surgery for my child as named above. I give permission to take my child on outings, excursions and activities away from the facility, either on foot or in a vehicle providing the driver of said vehicle are properly insured for the carrying of passengers. I understand I will receive advance notice of these events. I give permission for my child to participate in swimming provided equipment is accessible and all required ratios and lifeguard certifications are adhered to. I have read and understand the information and policies in the day camp brochure and children s services manual and to the best of my knowledge, the information provided on this form is accurate. Parent or Guardian (print name): Signed: Date: INDEMNITY In consideration of (print camper s name) (hereinafter referred to as Camper ) being permitted by Camp to participate in its activities and to use its equipment and facilities, I agree to indemnify and hold harmless Camp from any and all claims, causes of action, actions or demands whatsoever which are in any way connected with such use or participation by Camper. Parent or Guardian (print name): Signed: Date: PUBLICATION & PRIVACY ACT I understand that the pictures taken at Camp may be used for promotional purposes. We collect, use and disclose personal data only in order to better meet your service needs, to ensure the safety of children in our care, for statistical purposes, to inform you about the YMCA program or service in which you are registered, and to satisfy government and regulatory obligations. You may also hear from us periodically about other YMCA programs, services and opportunities that may interest you. We do not share this information with any other party. Parent or Guardian (print name): Signed: Date: 4/5

5 Part 6/6 Payment Options Cheques Cash Would you like to help send a kid to camp? The Y s Strong Kids Campaign assists those who may have financial restraints in sending a child to camp. Every dollar helps. If you would like to help send a child to camp please check the box above and include a cheque for the amount of your choice. All donations over $10 will receive a charitable tax receipt. Day Care Assistance Program If you will be using the Day Care Assistance Program (DAP) during the summer please note: Parents MUST provide valid notification from Social Development for camp weeks selected Children will only be registered in programs during the approved period If assistance is ceased during program, parents/guardians will be responsible for payment All top up fees must be paid before registration will be accepted YMCA Payment, Withdrawal & Refund Policies NOTE: ALL FEES MUST BE PAID UPON REGISTRATION TO CONFIRM SPOT IN PROGRAM. Registration fees can be made by cash or cheque at each site or by credit card online. An address is required for receipt and confirmation of camp registration. Refunds may be requested for full weeks only if your child will not be attending. All refund requests must be made at least one week prior to the start date of camp and are subject to a $10.00 per week administrative fee. Cancellation requests are to be ed to our Registrar at t.benoit@saintjohny.com. We understand that plans may change from time of registration to when Day Camp begins. If changes are being made please do so through the Day Camp Registrar and we will be happy to find another week for you. Please note that multiple changes begin to incur a $10.00 administrative fee. Any returned cheques will be subject to a $25.00 administrative fee. Before your child can be registered into our Day Camp Program any money outstanding for other YMCA programs must be paid in full. Camp may be cancelled at any location if there are fewer than 15 registrants. I have read, understand and agree to abide by the policies listed above. Signed Date 5/5

2017 Registration Form

YMCA of Greater Saint John 191 Churchill Blvd Saint John NB, E2K 3E2 Telephone: (506) 693-9622 2017 Registration Form Must Include: o Payment for all weeks o Immunization Record o Completed Forms If required: