YMCA CAMP LETTS DAY CAMP Main Office: or Fax: Health Center: Federal ID Number:

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1 YMCA CAMP LETTS DAY CAMP Main Office: or Fax: Health Center: Federal ID Number: (Please keep this sheet for your reference.) CAMPER DROP OFF/PICK UP Parents bringing their child/children to camp by car are requested to follow our 15mph speed limits on the camp road. We at Camp Letts take our responsibility for the welfare of your child very seriously. All individuals picking up a child must present a current PHOTO ID EVERYDAY matching their name as it appears on the approved pick-up list provided by the parent/guardian. (Form enclosed) CAMPER LUNCH/SNACKS You are required to provide a bag lunch each day and any snacks and drinks you wish your child to have at our designated snack times during the day. We will provide refrigeration and fresh drinking water throughout the day. CAMP DISCIPLINE It is agreed and understood that each camper will cooperate and accept all camp standards of behavior. Failure to adhere to these standards will result in discipline or immediate dismissal. These rules are in place for our staff and your campers to have a fulfilling experience at YMCA Camp Letts each summer. If you have questions or would like a copy of this policy, contact our Summer Camp Director, Trev Dalton at CAMP STORE You have the option of opening a store account for your camper to use while at camp. If your camper is attending more than one session and there is money still in their account at the end of the session, that balance will be carried over to the next session they are attending. This makes it easier for parents not to open an account each session. (Form enclosed) CANCELLATIONS The parent/guardian agrees and understands that in case of dismissal, homesickness or voluntary withdrawal, there will be no refund of camp fees. If it is deemed advisable by camp to send a camper home due to medical reasons, the parent must provide a doctor s note and request in writing a pro rate refund. There will be no refund on cancellations made within five days of expected arrival date. No refunds are given for cancellation of activities due to weather conditions. The YMCA reserves the right to refuse an applicant and to cancel any reservation. EQUIPMENT Please do not allow your campers to bring items of value to camp. We cannot be responsible for lost, misplaced, stolen or damaged items or money. Please mark all campers belongings with their name. Please remember cell phones and other electronic devices are not permitted on camp. (Over)

2 HEALTH FORM Each camper must have a completed health form on file before attending camp. This is a Maryland State law. (Form enclosed) PARENT/COUNSELOR CONFIDENTIAL FORM The information on this form aids our staff in understanding your child and your objectives in sending them to camp. Please complete it and mail to YMCA Camp Letts at least two weeks prior to your child s arrival. The information on this form remains confidential with your child s counselor. (Form enclosed) SPECIALTY DAY CAMP PROGRAMS Those campers participating in one of our specialty programs (Equestrian, Water Ski/Wake Boarding, Equestrian or Sailing) may need additional items brought to Camp for their special program. Please see our equipment list for those items. (Form enclosed) Listed below is the list of forms you will need to complete for your child s attendance at YMCA Camp Letts Day Camp Program. Please return them to Camp Letts two weeks before your child is to start camp. Authorization for Pick-up Equipment List Health Form Confidential Camper Information Waiver Form Camp Store (optional) EFT Payment Form (optional)

3 YMCA CAMP LETTS PICK-UP AUTHORIZATION All individuals including parent or legal guardian must be listed on the approved pick up list. Any one picking up a child must present a current form of a PHOTO ID matching their name as it appears on this pick-up list. If you (the parent/legal guardian) do not pick up your child, we want to make sure the person who does have your authorization. We at YMCA Camp Letts take our responsibility for the welfare of your child VERY seriously. Camper Name: Session No: I,, give permission for my child to be released from camp to the following adult(s): Name Relation to Child Day Time Telephone Number Parent/Guardian Signature Date: List any person(s) PROHIBITED from picking up your child: Name FOR CAMP USE ONLY I am picking up the above named child from YMCA Camp Letts and am assuming full responsibility for him/her. Name: Signature: Date:

4 YMCA CAMP LETTS DAY CAMPERS Suggested Clothing and Equipment Lists All Items should be labeled with your camper s name Campers should arrive at Camp wearing appropriate clothes for that day s weather conditions and any planned special activities. You will be informed at the beginning of each week of the one day special activity (example: pony rides) that may need extra items or clothing. DAILY ITEMS NEEDED Backpack Lunch and drink with camper s name clearly labeled Bathing Suit Towel for Swimming Comb or Brush Hat or Cap Raincoat or Poncho for rainy days Sunglasses Sunscreen (waterproof) Water Bottle Water Shoes (sandals or sneakers that can get wet) ADD ON PROGRAM REQUIRED ITEMS Equestrian Specialty Program MUST HAVES Pair of long pants (jeans, breeches, jods, etc.) No shorts for riding. Heeled shoes with a ½ heel* and must be closed toe and closed heel. *No tennis shoes, sneakers, mountain boots, construction boots or snow boots are permitted due to rider safety. Paintball Specialty Program MUST HAVES Pair of jeans Long sleeve shirt Waterski/Wakeboard and Sailing Specialty Program RECOMMENDED BUT NOT MUST HAVES Ski gloves Rash Vest or Wetsuit Sailing gloves (Sailing Specialty Program) Please do not bring valuables such as expensive cameras, jewelry, tape players, video games, or headphones, etc. NO CAMPERS ARE ALLOWED TO HAVE A CELL PHONE WITH THEM WHILE IN CAMP.

5 YMCA CAMP LETTS DAY CAMP HEALTH FORM CAMPER S NAME BIRTH DATE SEX AGE PARENT or GUARDIAN PHONE HOME ADDRESS If parent is not available, in an emergency notify: Name/Relation PHONE Area/Number PARENT'S AUTHORIZATION--The health history is correct so far as I know and the person herein described has permission to engage in all described camp activities on and off premises. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the Camp to hospitalize, secure proper treatment for and to order injection and/or anesthesia and/or surgery for my child as named above. PARENT/GUARDIANS SIGNATURE DATE Please mark this box if you DO NOT wish to permit camp staff to apply Sunscreen to your camper. Please note: By marking this box your camper may be limited in their daily activities. HEALTH HISTORY FOR CHILD To be completed by parent. 1. Does your child have any significant allergies? Hay Fever Bee Stings Insects Poison Ivy Foods Others Medicines _ If yes, what are they? 2. Do they take any medicines regularly? Yes No MEDICATIONS BEING TAKEN AT CAMP- This section MUST be signed off by the prescribing physician. Please list ALL medications (including over the counter or nonprescription drugs) taken routinely. Please note over the counter or nonprescription medication dosages that exceed the recommended dosages per the manufacturer MUST be signed off by a physician or will not be administered. No prescription medication will be given that is not in its properly labeled prescription bottle-no EXCEPTIONS! Prescriptions must be in the original packaging/bottle that identifies the camper s name, the prescribing physician, the name of the medication, the dosage, route, and times of administration, prescription date, expiration date, and conditions for storage. Camp administration times are after breakfast, lunch, dinner, and at bedtime. No other medication schedule can be accommodated due to the nature of the camp activities schedule. Campers must be able to self-administer all inhaler and Epipen medications. Campers are responsible for reporting to the Health Center for medications. Reasonable attempts will be made to locate the camper; missed doses will be administered at the discretion of the Wellness Center Director and within state guidelines for medication administration. (OVER)

6 MEDICATION DOSAGE TIMES (PRN?) RECEIVED AT CAMP (Initial) I certify that these medications have been prescribed for the above listed individual: Signature of Authorized Prescriber Date 3. Have they been exposed to any communicable disease to which they may be at risk for developing during their camp stay? If so, when 4. Are there any health reasons which would limit your child's ability to participate in any activities? 5. Date of last tetanus shot 6. Is your child covered by a Family Medical/Hospital Insurance Yes No Is pre-authorization required before treatment? Yes No Carrier Policy/Group Number PHOTOCOPY OF THE FRONT AND BACK OF INSURANCE CARD MUST BE ATTACHED TO THIS FORM NAME OF FAMILY PHYSICIAN PHONE Please note that all medical expenses incurred because of your child's illness/injury while at camp are the parents/guardians responsibility. The camp does not submit medical insurance forms for your child. 7. Is your child attending a Maryland School? Yes Name of School No* * Please provide a complete vaccination record

7 YMCA CAMP LETTS DAY CAMP CONFIDENTIAL CAMPER INFORMATION FORM This form MUST be completed by parent/guardian and returned to camp two weeks before your child is to attend camp. We have designed this form to develop communication between you and your child's counselor. We can know what your child's needs and desires are for their stay at Camp Letts. Please complete this form carefully. Please use the back of this form, if needed for more information that will help us give your child a better experience. Camper's Name Male/Female Session(s) Age Birth date Grade Next Fall Brother/Sister(s) Ages Who does camper live with? Relationship Address Home Phone Work Phone Cell Phone Address Are there any problems that may confront your child while at camp? How did you hear about Camp Letts? Duties and responsibilities at home: How does your child get along with children of the same age? Name your child's interests and hobbies: Adjectives that describe your child: List two objectives you have for sending your child to YMCA Camp Letts Please provide any other information you feel may put us in a better position to understand your child/children and her/his needs.

8 YMCA OF METROPOLITAN WASHINGTON CAMP LETTS ( YMCA CAMP LETTS ) PARTICIPANT WAIVER FORM Camper s Name ACKNOWLEDGEMENT I expressly acknowledge that there are certain dangers, risks, illnesses and personal injuries inherent in participating in the YMCA s programs, events, classes, and/or other activities, which may result from unavoidable accidents or injuries, athletic activities, sports programs/classes, the use of any equipment, exercise, or other activities or from my or my minor child(ren) s or ward(s) physical condition. I understand that the YMCA and its employees, agents, counselors, teachers, trainers, representatives, successors and assigns assume no responsibility for loss, damage, illness or injury to person or property that I or my minor child(ren) or ward(s), if applicable, may sustain as a result of my or their physical condition or resulting from my or their participation in any activities, programs, events, classes, the use or non-use of any equipment, exercise, horseback riding, archery, field trips, waterfront and pool activities, canoeing/boating, campfires, hiking, high ropes and other challenge courses, or any other activities, classes, events, or programs at and/or sponsored by the YMCA. I expressly acknowledge, on behalf of myself and my minor child(ren) and ward(s), heirs and executors, that I voluntarily assume the sole risk for any and all dangers, illnesses and personal injuries that may result from my or my minor child(ren) s or ward(s) participation in any events/activities/programs/classes while at the YMCA and/or sponsored by the YMCA. I also acknowledge that the YMCA often uses photographs, videotapes, television programs, motion pictures, tape recordings, or other similar media for promotional purposes. I hereby consent to the use of my and/or my minor child(ren) s or ward(s) name(s) and/or likeness(es) in such materials to be exhibited and used for advertising, trade purposes, solicitation of patronage, promotional purposes, or other similar purposes, even if my and/or my minor child(ren) s or ward(s) name(s) and/or likeness(es) are an integral part of such photograph, videotape, television program, motion picture, tape recording, or other similar media. RELEASE Camp Session In consideration of the YMCA allowing me and/or my minor child(ren) or ward(s) to attend and/or participate in any programs, events, classes, or other activities at the YMCA and/or sponsored by the YMCA, I hereby, for myself, my minor child(ren) or ward(s), heirs, and executors, waive, release and forever discharge the YMCA and its employees, agents, counselors, teachers, trainers, representatives, successors and assigns, from and against any and all rights and claims for any loss, damage, illness or injuries to person or property sustained as a result of my attendance and/or participation in any such programs, events, classes, and other activities, whether or not such loss, damage or injury results from the negligence of the YMCA and its employees, agents, or representatives or from some other cause. My agreement to release the YMCA does not include any loss, damage or injury that results from the YMCA's gross negligence or willful, wanton, or reckless misconduct. I further waive any and all rights to inspect or approve the photograph, videotape, television program, motion picture, tape recording or other use of my and/or my minor child(ren) s or ward(s) name(s) and/or likeness(es), including any written article, script, caption or other writing that may accompany such use of my and/or my minor child(ren) s or ward(s) name(s) and/or likeness(es). I (OVER)

9 hereby, for myself, my minor child(ren) or ward(s), heirs, and executors, waive, release and forever discharge the YMCA and its employees, agents, counselors, teachers, trainers, representatives, successors and assigns, from and against any and all liability, claims, losses, costs, expenses or damages for libel, slander, invasion of privacy, conversion, defamation, appropriation of likeness or any other claim based on the use of my and/or my minor child(ren) s or ward(s) name(s) and/or likeness(es) in any such materials. INDEMNIFICATION I hereby represent and warrant to the YMCA that I have the authority to execute this Participant Waiver Form on behalf of myself and/or on behalf of my minor child(ren) or ward(s) as parent, guardian and/or next friend, if applicable. In the event of any misrepresentation or breach of the foregoing warranty by me, or in the event that I, my minor child(ren) or ward(s), or any other person nevertheless asserts any claim against the YMCA arising out of my or my minor child(ren) s or ward(s) participation in any program, event, class or other activity as set forth herein, I agree to indemnify, hold harmless and defend the YMCA from and against any and all liability, claims, losses, costs, expenses or damages resulting therefrom, including, but not limited to, claims of loss, damage, illness or injury to person or property whether or not such loss, damage, illness or injury results from the negligence of the YMCA or from some other cause. ACCEPTANCE I expressly acknowledge and agree to the terms and conditions set forth on this Participant Waiver Form. Signature of Participant or Parent/Guardian of Participant(s) under the Age of 18 Date Address and Telephone Number of Participant or Parent/Guardian of Participant(s) Name(s) and Age(s) of Participant(s) under the Address(es) and Telephone Number(s) Age of 18, If Any of Participant(s) under the Age of 18 Name of Emergency Contact Person for Participant(s) Telephone Number for Emergency Contact Person for Participant(s) Y /1/11 7:23 AM 2

10 YMCA CAMP LETTS DAY CAMP STORE FORM CAMP STORE POLICY The Camp store will be open to our summer day campers each day. The store will also be open on check-in and closing days during summer Camp. A $10 minimum is required to open an account. This amount should be added to your camp fee balance and paid prior to your child s arrival at Camp. Please do not add any additional money to your camper s account after Wednesday. This account is used to purchase items from our store only. Campers are unable to withdraw money from this account. Any remaining money in their accounts at the end of Camp will be donated to our Caring for Community Campaign, unless your child is attending more than one session. This Campaign helps children who without this assistance could not afford to attend YMCA Camp Letts. REMINDER: All purchases will be deducted from your camper s account. Any remaining monies at the end/last of your child s camp sessions will be donated to our Caring for Community Campaign. This account is for store purchases only. The store can not give any money out of this account. Please be informed that if you want your camper to have cash with them, you will need to give it to them. The Camp is Not Responsible for lost, misplaced or stolen money left with campers CARING FOR COMMUNITIES The Caring for Community Campaign is developed by YMCA Camp Letts to raise money through donations to send needy children to Camp. Our goal this year is $180,000. Your donation of any unused store money from your child s account will help us reach this goal. Simply sign the bottom of this form, which acknowledges that the remaining money in your child s account will automatically be put into this program. We appreciate your kindness and generosity. Over the past 100+ years we were able to send thousands of children to Camp Letts that otherwise would have never experienced our wonderful program or seen our beautiful facility. I acknowledge that the remainder of my child s store account will be donated to the YMCA Camp Letts Caring for Community Campaign. Camper Name: Session: Parent Name: Signature: Date:

11 EFT PAYMENT AUTHORIZATION FORM YMCA of Metropolitan Washington YMCA Camp Letts Day Camp 2014 PLEASE SELECT THE DESIRED PAYMENT OPTION: OPTION 1 Pay camp fees in full at the time of registration OPTION 2 Pay a deposit per camp at time of registration, and remit payment for the balance through (EFT) draft based on selected camps. See payment schedule below. Camp Schedule Day Camp Dates Draft Date Session 1 June May 26 Session 2 June 30 July 4 June 10 Session 3 July 7 11 June 10 Session 4 July June 26 Session 5 July June 26 Session 6 July 28 August 1 July 10 Session 7 August 4 8 July 10 Session 8 August July 26 Session 9 August July 26 Camper s Name Session Amount CREDIT CARD AUTHORIZATION PLEASE COMPLETE PAYMENT AUTHORIZATION BELOW (Please Check Method of Payment) AMEX MC VISA DISCOVER DRAFTS WILL OCCUR ON APPROXIMATELY THE 10 th or THE 26 th. INITIALS I authorize the YMCA to charge my credit card for camp payments. I understand that I must provide written notice of cancellation. If at any time there is to be a change, deletion, or cancellation of my child s camp enrollment, it is to be submitted in writing to the YMCA branch where camp was purchased two weeks prior to the date of my credit card draft in order to discontinue the debit. PRINT NAME AS IT APPEARS ON CARD CREDIT CARD DRAFT COMPANY CREDIT CARD NUMBER EXP. DATE SIGNATURE OF CARD HOLDER BILLING ADDRESS OF CARDHOLDER: CITY: STATE: ZIP - BANK DRAFT AUTHORIZATION DRAFTS WILL OCCUR ON APPROXIMATELY THE 10 th or THE 26 th. INITIALS I authorize my bank to honor pre-authorized drafts drawn by the YMCA on my account for camp payments. I understand that my EFT drafts will occur automatically until I provide written notice to the YMCA two weeks prior to the date of my bank draft payment. When the bank honors the draft by charging my account, such drafts constitute my receipt for the payment. Should any draft not be honored by said bank when received by them, it is understood that the payment is to be made by me in the amount of said payment, plus a service charge. If at any time there is to be a change, deletion, or cancellation of my child s camp enrollment, it is to be submitted in writing to the YMCA branch where camp was purchased two weeks prior to the date of my draft in order to discontinue the debit. A voided check is required with all electronic funds transfer (EFT) applications. NAME OF BANK ACCOUNT NUMBER TRANSIT/ROUTING NUMBER (OVER) PLEASE PRINT NAME SIGNATURE OF ACCT. HOLDER DATE

12 We are excited to announce that we are now offering Electronic Funds Transfer (EFT) as our preferred payment option for your YMCA Summer Camp Registration. We are glad to be able to bring you this technology to make your life a little easier. No more checks to write or trips to the Business Office during your busy day. How does the EFT process work? There are only three steps: 1. First, complete the Electronic Funds Transfer Authorization Form included in your Summer Camp registration packet. 2. Second, place a minimal deposit on each session for each child. 3. Third, the balance will be drafted at the date specified on the EFT Form. It s that simple. How does EFT benefit you? Paying by EFT saves you time and who couldn t use a little more time? Paying by EFT relieves you from having to remember to make payments and who doesn t need one less headache? Paying by EFT can save you money by avoiding bank check processing or transaction usage fees. Paying by EFT is an efficient use of technology. It is simple and easy. (OVER)