YMCA OF SOUTHERN MAINE FINANCIAL ASSISTANCE APPLICATION

Transcription

1 YMCA OF SOUTHERN MAINE FINANCIAL ASSISTANCE APPLICATION CASCO BAY BRANCH 14 OLD S. FREEPORT RD. FREEPORT, ME FAX NORTHERN YORK COUNTY BRANCH 3 POMERLEAU ST BIDDEFORD, ME FAX I AM APPLYING FOR: PINELAND BRANCH 25 CAMPUS DRIVE NEW GLOUCESTER, ME FAX PORTLAND BRANCH 70 FOREST AVE. PORTLAND, ME FAX Membership Only Membership & Program Program Only (Program Name: ) TYPE OF MEMBERSHIP (IF APPLICABLE): New Renew Membership # Youth Program Youth Adult Single Adult with Family Family APPLICANT INFORMATION: Last Name: Address: City: State: Zip: Phone: Date of Birth: If under 18 years old, please print name of Parent/Guardian: Do you share expenses with anyone else in your household (ie. spouse, partner, roommate, family)? Yes No Total number of dependents living in your household: Are you a full-time student? Yes No If yes, where do you attend school? APPLICANT PAYMENT INFORMATION: For your reference, the full cost of our memberships are: Youth Program: $66/year Youth: $30/month Adult: $55/month Single Adult with Family: $67/month Family: $80/month One-Time Joiner s Fee: Youth: N/A Adult: $55 Single Adult with Family: $67 Family: $80 What amount do you feel you can pay for your membership per month and/or program? I can afford to pay $ per month toward a membership and $ towards joiner s fee I can afford to pay $ per session per week (child care and day camp) FOR OFFICE USE ONLY Application received: / / Application reviewed: / / Applicant notified: / / Annual Income: $ Percentage Member Qualifies for: % (to be entered into MemberST) Total Membership: $ Financial Assistance Amount: $ Member to Pay: $ Total Joiner s Fee: $ Financial Assistance Amount: $ Member to Pay: $ Total Program Fee: $ Financial Assistance Amount: $ Member to Pay: $ Amount Paid: $ Approval notes (with percentage) put into MemberST (yes/no): Notes: Staff Name: Staff Initials:

2 FINANCIAL ASSISTANCE APPLICATION The dollar amount of your portion of membership dues will be determined by the YMCA using a sliding scale that is based on your gross income (your pre-tax income), as well as your comments. All financial assistance applications are reviewed on an individual basis. Applications will be reviewed annually. EMPLOYMENT INFORMATION NOTE: If applying for a youth (membership or program), this information pertains to the parents/guardians of the youth applying. 1. Your Employer Work Phone Position Length of Employment Gross Monthly Income (NOTE: Please attach the last two paycheck stubs) $ Pay Period: Weekly Every Other Week Twice Per Month Monthly Other: 2. Spouse/Partner s Employer Work Phone Position Length of Employment Gross Monthly Income (NOTE: Please attach the last two paycheck stubs) $ Pay Period: Weekly Every Other Week Twice Per Month Monthly Other: INCOME/EXPENSE WORKSHEET PLEASE INCLUDE ALL HOUSEHOLD INCOME NOTE: If applying for a youth (membership or program), this information pertains to the parents/guardians of the youth applying. INCOME- PLEASE INCLUDE VERIFICATION OF ALL INCOME EXPENSES (Last two pay stubs and/or a statement of government funding, etc.) Your gross monthly income $ Monthly Rent/Mortgage/Taxes $ Spouse/Partner s monthly income $ Auto Loan $ Social Security/Disability $ Utilities $ Child Support $ Phone $ AFDC/TANF $ Food $ Food Stamps $ Other (please explain) $ Unemployment/Other $ Other (please explain) $ Total Monthly Income $ Total Monthly Expenses $ If you have no income, how are you meeting expenses? Are there any extenuating circumstances that we should know about when reviewing your paperwork? I verify that all information submitted is correct, complete, and accurate. If my situation changes, I agree to notify the YMCA within 30 days. If I submit false or inaccurate information, or fail to notify the YMCA within 30 days, I may be terminated from the financial assistance program. Signature Date Signature Date Of Parent/Guardian if applicant is under 18 years old INCOMPLETE FORMS WILL BE RETURNED TO THE APPLICANT APPLICATIONS ARE APPROVED FOR ONE YEAR. UNCLAIMED APPLICATIONS WILL BE KEPT ON FILE FOR SIX MONTHS.

3 2018 CAMPER REGISTRATON FORM YMCA OF SOUTHERN MAINE - DAY CAMPS Child s Last Name: Please note you must fill out a separate registration form for each child attending camp. Date of Birth: Age as of 7/1/2018: Grade Entering Fall 2018: Gender (identifies as:) Male Female Other Where did you hear about us? Press Herald Friends/Family YMCA Website /Facebook Online search The Sentry The Forecaster Journal Tribune Parent & Family Magazine Other: Ethnicity (this is used ONLY for statistical information for grants): White Asian African/African American Pacific Islander Latino/Hispanic Native American/Alaskan Native Multiracial Other: Prefer not to answer PARENT/GUARDIAN Last Name: Address: City: State: Zip: Best Phone to reach you: Relationship to Child: 2nd Best Phone: Employer: PARENT/GUARDIAN (Only if approved for pick up) Last Name: Address: City: State: Zip: Best Phone to reach you: 2nd Best Phone: Relationship to Child: Employer: With whom does this child live? Please list at least one NON-PARENT emergency contact: FIRST EMERGENCY CONTACT Best Phone *required: Relationship to Child: Last Name: SECOND EMERGENCY CONTACT Best Phone *required: Relationship to Child: Last Name: Other than those listed above, who is allowed to pick up your child? If you would like our staff to better understand specific family structures/agreements that could affect your child s drop-off, daily program, or pick-up, please list here in detail. 1

4 WAIVERS General Waiver (Required): I hereby, for myself, heirs, and executors waive and release all claims against the YMCA of Southern Maine for any danger my child may suffer or acquire during the YMCA Summer Camp Program. Parent/Guardian Signature: Date: Field Trip Transportation Liability Agreement: I give permission for the YMCA to take my child on field trips (bus or walking). I give my permission for my child to be transported by the appropriate YMCA of Southern Maine staff in a YMCA approved vehicle. I assume any and all liability for damages to or caused by my child in connection with the transportation services offered by the YMCA, except those caused by gross negligence or intentional act of the YMCA. I also understand that the YMCA will not be responsible for my child between the YMCA and his/her residence and vice versa. Parent/Guardian Signature: Date: Aquatic Permission Slip and Liability Agreement: I give permission for the YMCA of Southern Maine ( YMCA ) to provide scheduled, aquatic opportunities to my child. This permission covers any instructional and recreational activities conducted by the appropriate YMCA staff. I assume any and all liability for damages to or caused by my child in connection with the aquatic services provided by the YMCA, and unconditionally release the YMCA from any and all liability therefor or relating thereto, except those caused by the gross negligence or intentional wrongful act of the YMCA. Child s Name: Parent/Guardian Signature: Date: I decline. Signature: (Check here, sign and date if you do not wish to grant permission). Date: Camp Handbook Agreement: The Camp Handbook can be found on our website, or can be provided by the Camp Director or Membership Team at each Branch location. I hereby acknowledge receipt of the YMCA of Southern Maine s Camp Handbook. I understand that the policies and procedures may be changed at any time and I will receive notification if and when these changes occur. I have had explained to me any portions of the Camp Handbook about which I did not understand. I realize that by signing I agree to comply with the noted camp policies and procedures. Parent/Guardian Signature: Date: Printed Name: Camper's Name: Camp(s) Attending: Media waiver on next page 2

5 PHOTO/AUDIO VISUAL/NARRATIVE RELEASE Consent. With respect to my child/children named below I hereby give my consent for the National Council of Young Men s Christian Associations of the United States of America (YMCA of the USA), and/or the YMCA of Southern Maine (YMCA), YMCA of the USA, YMCA and collaborating third parties to make, reproduce, edit, broadcast or rebroadcast: video film or footage sound track recordings photo reproductions any narrative account of their experience My consent gives permission to use the above materials for publication, display, sale or exhibition in promotions, advertising, education and legitimate business uses. Use includes reproductions in any form and media, adaptations and/or revisions. I understand and agree there may be no compensation for this, and I will not make any claim for payment of any kind. I may, or may not be, identified in such reproductions; however, my child/children s will not be used to endorse any particular commercial products or commercial services. Should I wish to revoke this consent at any point in the future, I may do so, but I understand that images may already have been released to the public if such a revocation occurs after publication. Ownership, Confidentiality, and Shared Use. With respect to any of the above uses, I further agree: All uses shall belong to YMCA of the USA and YMCA and either may share them with others; There is no obligation of confidentiality YMCA of the USA, YMCA, and collaborating third parties will not be liable for any use or disclosure to a third party YMCA of the USA and YMCA shall exclusively own all known or later existing rights to the uses worldwide. YMCA of the USA and YMCA can use any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account for any purpose and without compensation to me. Release from Liability. I hereby release and discharge YMCA of the USA, YMCA and their related parties from any and all claims, actions, lawsuits or demands of any kind arising out of my consent, the use, or the shared use of the above materials. Name(s) of child/children (if applicable): Signature: Printed Name: Date: Address: I do not give consent. Signature: Date: Printed Name: 3

6 CAMP 2018 REGISTRATION Step 1: Choose your weeks - Check the boxes that correspond with the camp weeks for which you are registering. * Week of 7/2 is a 4-day week; closed 7/4. See week for pricing. ** Overnights: Must be registered for same week at camp. Total weeks/sessions my child will be attending this summer: Total Fees: $ In-Town Camp - Overnight at the Y! 5-12 $80 Camp Sokokis - Overnight at the Y! 9-12 $80 Otter Pond Camp - Overnight Camp Out!** 8-14 $80 OVERNIGHTS! ** Ages: * Total Weeks: Fee/Overnight: In-Town Camp Session 1 Session 2 Session 3 $380 Otter Pond Outdoor Adventure Camp Session 1 Session 2 Session 3 $380 Camp Pineland Session 1 Session 2 Session 3 $380 Camp Osprey Session 1 Session 2 Session 3 $380 Camp Sokokis Session 1 Session 2 Session 3 $380 LEADER IN TRAINING (LIT) Ages: * Total Weeks: Fee/Session: Outdoor Adventure Skills - Otter Pond $335 Outdoor Adventure Skills - Otter Pond 7-9 $335 Extreme OP Girls! - Otter Pond 8-13 $335 Dance Camp - Greater Portland Branch 5-8 $230 Theater Camp - Greater Portland branch 9-12 $230 Art Camp - Greater Portland branch 9-12 $230 Art Camp - Greater Portland branch 5-8 $190 $230 SPECIALTY CAMPS Ages: * Total Weeks: Fee/Week: In-Town Camp 5-12 $190 $230 Camp Longfellow: 1/2 day PM (1:30-5:30) 5-12 $140 $140 Camp Longfellow: 1/2 day AM (7:30-1:30) 5-12 $140 $140 Otter Pond Outdoor Adventure Camp 5-12 $190 $250 Camp Pineland 5-12 $190 $230 Camp Osprey 5-12 $190 $230 Camp Sokokis 5-12 $190 $230 DAY CAMPS Ages: * Total Weeks: Fee/Week*: JUNE JULY AUGUST Application Date: 4

7 CAMP 2018 REGISTRATION Step 2: Calculate camp fees 1. Carry your total camp fees listed on the bottom of page 4 to line 1 of the Fee Calcaluator below. 2. Complete the Fee Calculator below. (If you prefer, we can help you with this.) 3. Proceed to payment information on page 6. At the Y, we believe all kids should have the opportunity to discover who they are and what they can achive through programs like summer camp. That s why we are committed to serving everyone, regarless of ability to pay. If you have any questions about registering for camp or applying for the Y s financial assistance or Maine State subsidies, please call us. Fee Calculator 1. Total due for camp weeks (from page 4): $ Are you.. If yes, apply this adjustment a. Registering before 5/1? Early Bird ($10 x weeks) $ b. Registering for 7+ weeks before 6/1? Multi-week ($10 x weeks) $ c. Registering siblings before 6/1? Sibling ($10 x # of additional siblings x weeks) $ 2. Total Adjustments (add up lines a through c): $ 3. Total for Summer Camp 2018 (subtract line 2 from line 1): $ 4. Deposit due at registration ($50 per week x weeks) If receiving financial assistance, this amount $ will be adjusted at the same rate. This adjusted weekly deposit is still required in advance. 5. Total Remaining Balance Prior to Financial Assistance (subtract line 4 from line 3): $ YMCA Financial Assistance (Please complete Financial Assistance Application) To be ASPIRE or other State Subsidy (Please complete Subsidy Application) completed by the YMCA Adjusted Balance: Deposit is due at registration. Weekly balances are due in full the Wednesday prior to each week of camp through an automatic draft payment. If an automatic payment is not possible, please contact your Camp Director. Payment methods on next page 5

8 PAYMENT METHODS Weekly balances are due in full the Wednesday before camp starts through an automatic draft payment (credit card or checking account). If an automatic payment is not possible, please contact your Camp Director. We are dedicated to working with all families and will not turn a child away due to financial need. Payment schedules, options and financial assistance are available, please ask. Checks, credit card payments, and bank account drafts returned to us by the bank will incur a $20 fee. You must select one box. Registration cannot be completed (your spot will not be reserved) unless payment information is provided. I wish to pay my balance due in full. Total Balance Due: $ I have applied for Financial Assistance (the completed application is enclosed with this registration form). (NOTE: Billing information must be completed below. No payment will be made prior to your acceptance of your awarded fee.) The following must be completed if not paying in full. I authorize automatic payments for the amount due, as listed below: (NOTE: I understand I am responsible for payment and will be charged an additional $20 NSF charge if any payment is returned or fails to authorize.) Visa/MasterCard/American Express Charge Name on Credit Card: Card Number: CVC Number: Exp Date: Auto Draft from Bank Account Name on Account: Account Number: Routing Number: I am requesting a payment plan other than the week before camp. (NOTE: The Camp Director will be in touch to set this plan up.) If a State Agency or Independent Agency is assisting you with your child s camp fees, please fill out the Subsidy Forms and attach it to your camp registration packet. Signature: Date: CONTACT US In-Town & Longfellow Camp Bouranee Kim, Director 70 Forest Ave., Portland, ME bkim@ymcaofsouthernmaine.org Camp Osprey Nykole Cadigan, Director 14 Old S. Freeport Rd., Freeport, ME ncadigan@ymcaofsouthernmaine.org Camp Sokokis Danielle Cote, Director 3 Pomerleau St. Biddeford, ME dcote@ymcaofsouthernmaine.org Camp Pineland Jenny Mueller, Director 25 Campus Dr., Ste. 100, New Gloucester, ME jmueller@ymcaofsouthernmaine.org Otter Pond Outdoor Adventure Camp Liza Stratton, Director 25 Campus Dr., Ste. 100, New Gloucester, ME lstratton@ymcaofsouthernmaine.org In-session address: 71 Chadbourne Rd., Standish, ME 6

9 2018 DAY CAMP CHILD ACCOMODATIONS FORM YMCA OF SOUTHERN MAINE Child s Last Name: This form is used to assist us in providing the best possible experience for your child while s/he attends camp. Your signature on this form gives us permission to share this information with the counselors and staff who will be working with your child. Does your child have an Individualized Education Plan (I.E.P.) during the school year? YES NO Does your child have any behavioral or health concerns that you want us to be aware of? What is your recommendation for the best way for us to help your child? Are there any specific situations that trigger this concern in your child? What is typical and/or atypical behavior from your child? Please note, all of our participants must be able to participate safely in our programs. We do not provide one-on-one supervision and retain the discretion not to enroll or to remove a participant from our program if that participant is not able to participate safely in the program. Open communication is the best way to ensure a happy and safe summer for your child. Please contact your Camp Director with any questions. Signature of Parent/Guardian: Date: 1

10 2018 DAY CAMP HEALTH HISTORY FORM YMCA OF SOUTHERN MAINE Child s Last Name: HEALTH HISTORY Does your child have any chronic or recurring Illness? Please explain. Does your child have any reactions to insect bites/stings? (If any, how severe is the reaction?) Does your child have any allergies? Please explain. Are there any camp activities your child should be exempt from because of health reasons? Record of past medical treatment if any: Does your child have Epilepsy: Yes No o If yes, date of last seizure & severity Does your child have Diabetes: Yes No o If yes, does your child take medications or insulin? Does your child have Asthma: Yes No o If yes, does your child carry an inhaler?*** Yes No Does your child carry an epi-pen? *** Yes No o If yes, what for: Will your child be taking medications while attending camp? Yes No o If yes, an Authorization to Dispense Medication form is required. NOTE: Campers/parents MUST check-in ALL medications, epi-pens, inhalers, etc. (including over the counter medications) with the Camp Director, and proper paperwork for dispensing medications must be provided. ALL self-administered medications are to be handed to the staff leader in the campers group. The staff member

11 (after checking the medication in with the Camp Director), will carry the medication in their bag while with the camper, and will pass off the medication to other counselors should the camper switch groups. If your camper will be taking medications while at camp, please send a week s worth of medication. This will stay on campus in a double locked cabinet for the duration of the week, and the bottle will be sent home with the child (staff passing off to parents), on the last day of the week the camper will attend. If campers are attending multiple weeks, the medication will need to be re-stocked and sent in with the camper on Monday. Hospital Preference: HEALTH HISTORY FORM WAIVER This health history form is correct to the best of my knowledge, and my child herein described has permission to engage in all prescribed camp activities except as noted. I hereby give permission to the medical personnel selected by the camp director to order x-rays, routine tests, treatment, to release any records necessary for insurance purposes, and to provide or arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization for my child named above. My child s immunization records are attached. I understand the Y does not provide one-on-one supervision. I understand the Y retains discretion to remove a child if they are unable to safely participate. Parent/Guardian Signature: Date:

12 2018 DAY CAMP AUTHORIZATION TO DISPENSE MEDICATION YMCA OF SOUTHERN MAINE I hereby authorize the YMCA of Southern Maine to administer the following medication to: Child s Last Name: Prescribing Physician (when applicable): Name of medication: Dosage: When to give: Continue this medication until: NOTE: ALL MEDICATIONS MUST BE IN THE ORIGINAL CONTAINER CLEARLY LABELED WITH THE DOCTOR S NAME AND THE CHILD S NAME. I have given the first dosage on: Signature of parent/guardian: Date: RECORD OF MEDICATION The YMCA uses this to record the amount, date, time that the medication was given with staff initials. It is a reference for sharing information with the child s parent/guardian. NOTE: A new form must be used for each prescribed medication. DATE TIME AMOUNT IN /REMAINING AMOUNT GIVEN INTIALS DATE TIME AMOUNT IN /REMAINING AMOUNT GIVEN INITIALS