FROM THE OCEAN TO THE LAKE

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1 FROM THE OCEAN TO THE LAKE Channel Islands YMCA Sleepaway Camp 2018 Registration Packet YMCA CAMP FOX: School Age Camp Junior High Camp YALP (Youth and Leadership Program) YMCA SEQUOIA LAKE CAMP: Youth Camp Teen Camp CIT (Counselor in Training) CHANNEL ISLANDS YMCA serving Santa Barbara and Ventura counties

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3 CHANNEL ISLANDS YMCA SLEEPAWAY CAMP (One packet is required per camper) Campers Name: Camp Name: Grade (Fall 18): YMCA Branch Registered Through: T Shirt Size (please circle): Youth M Youth L Adult S Adult M Adult L Adult XL Adult XXL I would like to request to room with a friend: Yes No If yes, whom: Cabin Requests must be turned in at time of registration and are not guaranteed. Are you involved in the Rags/Leathers Program: Yes No If yes, please list Rag or Leather level: CAMP FOX CAMP SESSION/DATES SCHOOL AGE CAMP: June (Entering Grades 3-6) JUNIOR HIGH CAMP June (Entering Grades 6-9) YALP CAMP Youth and Leadership Program June (Entering Grades 9-12) *There is an application process for this program. FACILITY/ PROGRAM MEMBER COMMUNITY FEE $630 $670 $630 $670 $630 $670 $100 deposit due at time of registration. Balance due by 5/30/2018. Parent and Camper Rally on 6/7/2018 at 6:00pm CAMP SEQUOIA YOUTH CAMP JULY 29 August 3 (Entering Grades 3-7) TEEN CAMP JULY 29 August 3 (Entering Grades 8-12) CIT CAMP Counselor In Training JULY 29 August 3 (Entering Grade 12) $600 $635 $600 $635 $600 $635 $50 deposit due at time of registration. Balance due 7/16/2018. Parent and Camper Rally on 7/18/2018 at 6:30pm. *I understand that final payments for all camps are due as indicated above. Failure to complete payment on time will result in loss of registration and deposit. *I understand that a $50 deposit/child is due upon registration for Camp Sequoia and a $100 deposit/child for Camp Fox. *Scholarships are available upon completion of the Open Doors application and proof of income. All scholarships are based on income, and availability of scholarship funds. Scholarships are processed on a first come first serve basis. Parent Signature Date

4 EMERGENCY/HEALTH INFORMATION HISTORY FORM General Information (Please print) Child s Name: Age M F Grade in Sept 2018 Address: City Zip Home Phone: School: Birthday: / / Adult #1 Name: Birthday: / / Work Phone: Cell Phone Address: Adult #2 Name: Birthday: / / Work Phone Cell Phone : Address: Child lives with Relationship Thank you for agreeing to receive our periodic communications. We never share or sell addresses Please attach copies of any legal documentation regarding non-custodial parents Health Information Has your child had any serious or severe illnesses or accidents in the last 3 years? Yes No If yes, explain Does the child take any medication during the day? Yes No If yes, Medication Release Form is required* Please list medications: Food Allergies? Yes No If yes, explain: Environmental Allergies? Yes No If yes, explain: Medication Allergies? Yes No If yes, explain: Special needs or fears? Yes No If yes, explain: Physician: Phone: Dentist : Phone: Insurance Co: Group #: *Medication Release Form can be found at the Welcome Center Emergency Contacts/ Authorized Pick-Up (In addition to Parents) Name: Phone: Relationship: Name: Phone: Relationship: Name: Phone: Relationship: Name: Phone: Relationship: I hereby give permission to Channel Islands YMCA and it s employees and volunteers to release any and all of the above health history to any medical personnel rendering emergency medical aid or treatment to my child. Parent's or Legal Guardian s Signature: Date: 5

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6 Walking Fieldtrip permission, Consent to Treatment and Release, Child s Health Statement, Photographic Release, and Insurance Disclaimer Child s Name (Please Print) PERMISSION FOR FIELDTRIPS, WALKING FIELDTRIPS, WALKING EXCURSIONS, AND USE OF PUBLIC PARK FACILITIES I hereby give consent to the Channel Islands YMCA and its designated leaders to take the above named child on walking trips in the neighborhood, public park facilities, special excursions to places of interest in YMCA vans, buses, commercial vehicles, public transportation, or rented vans or buses, with the understanding that such trips are under supervision of authorized personnel of the YMCA and that all possible precautions are taken to insure the health and safety of my child. Initial CONSENT FOR EMERGENCY MEDICAL TREATMENT As the parent [ ], domestic partner [ ], or authorized representative [ ], I hereby give consent to Channel Islands YMCA to obtain all emergency medical or dental care prescribed by a duly licensed physician (M.D) Osteopath (D.O.) or Dentist (D.D.S.) for the child named above. This care may be given under whatever conditions are necessary to preserve the life, limb or well being of a child named above. Initial CHILD S HEALTH STATEMENT I, the undersigned parent/legal guardian, understand that at a YMCA Camp Program and Child Care Program, physical activity is a regular part of the program. To the best of my knowledge, my child is in excellent physical health and needs no restrictions (except what is listed on the Emergency/Health Information Form) from strenuous physical activity. If I have any questions regarding my child s health, I understand that it is my obligation to seek professional medical advice and to inform the Channel Islands YMCA of any restrictions on my child s activities. Initial PHOTOGRAPHIC RELEASE In exchange for good and valuable consideration, the adequacy of which is hereby acknowledged, I hereby give Channel Islands YMCA, its volunteers, employees and any other person and entity acting with its permission the right to take, copyright, use, and publish any photographs or video of the above named child for the purpose of any YMCA advertising, promotion, or other purpose consistent with the YMCA mission. I agree that any such photograph or video is the property of the Channel Islands YMCA, and I hereby waive all rights thereto. I further waive any right to inspect or approve any printed or electronic material that may be used in conjunction with the photographs or video, or to approve the use to which the photographs or video may be applied. Initial INSURANCE DISCLAIMER The Channel Islands YMCA does not carry health or accident insurance on its members or participants. All expenses incurred in the treatment of illness, injuries or accidents will be the responsibility of the participant s parents or guardians. Initial 7

7 PARTICIPANT SWIM ABILITY ASSESSMENT FOR MINOR : The YMCA program may include aquatic activities at a pool, beach or other location with water. Your initial below authorizes your child to participate in swimming activities. Please check the box below with the description that most closely fits the participant. Type I: Does not know how to swim or is uncomfortable or nervous around water. Cannot put their face in the water, hold their breath, right themselves or float. Type 2: Can hold their breath, fully submerge their head under water, right themselves, float unsupported for five (5) seconds, flutter kick and can turn over from front and back. Is uncomfortable in water over their head and is unable to propel themselves beyond ten (10) yards. Type 3: Comfortable in deep water, can demonstrate basic swimming stroke techniques with controlled breathing, can propel themselves twenty five (25) meters and tread water for two minutes. Type 4: Comfortable in deep water, can demonstrate advanced swimming stroke techniques with controlled breathing, can continuously propel themselves for a minimum of 100 meters, tread water for four (4) minutes and swim fifteen (15) meters under water. Initial: PERMISSION FOR AUTHORIZING USE OF SUNSCREEN: I understand that providers now must have written permission from parents authorizing use of sunscreen and identifying the Sunscreen Brand and Sun Protection Factor (SPF) to be used on children. The Channel Islands YMCA is trying to avoid the possibility of an allergic reaction. I hereby give consent to the Channel Islands YMCA and its designated leaders to apply sunscreen, which I have provided for my child during the YMCA program. The staff may use the brand provided by the Channel Islands YMCA in the event my child does not have their own sunscreen. Sunscreen provided by parent: (brand) SPF: I understand that I am required to provide my sunscreen for my child and I authorize the YMCA Staff to directly apply the sunscreen to my child. Initial: CODE OF CONDUCT FOR ALL PARTICIPANTS: By Submitting this application, you, for yourself or on behalf of your minor child, agree to abide by the policies and conditions of the Channel Islands YMCA Association "Code of Conduct. The Code of Conduct can be found at the front service center of your local YMCA. Initial: MANDATED REPORTING: I understand that the YMCA staff is mandated by state law to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation. Initial: I HAVE READ AND AGREE TO THE ABOVE INFORMATION: Parent or Legal Guardian s Signature Date 8 Printed Name September 2009

8 CHANNEL ISLANDS YMCA Branches: Camarillo Lompoc Montecito -Santa Barbara Stuart C. Gildred Ventura - Youth and Family Services PARENT STATEMENT OF UNDERSTANDING The following information is important for the safety and protection of your child. Please read the information, sign this form and return it to the YMCA. I understand that YMCA staff are not allowed to babysit or transport children at any time outside of the YMCA program. Immediate disciplinary action will be taken by the YMCA toward staff and volunteers if a violation is discovered. I understand that I am not to leave my child at the YMCA or program site unless a YMCA staff or volunteer is there to receive and supervise my child. I understand that my child will not be allowed to leave the program with an unauthorized person. Any person authorized to pick up my child must either be listed with the YMCA or other arrangements must be made by calling the YMCA office to inform them of a change. I understand that should a person arrive to pick up my child who appears to be under the influence of drugs or alcohol, for the child's safety, staff may have no recourse but to contact the police. Please do not put staff in a position where they have to make this judgment call. I understand that the YMCA is mandated, by state law, to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation. Parent or Legal Guardian s Signature Date 11

9 Medication Release Camper s First Name Last Name DOB Age Reason for camper needing medication: I give my permission to the Channel Islands YMCA and its designated leaders to dispense medication to my son/daughter (child name). As the legal guardian/parent/caregiver of the camp participant, I hereby agree to assume the risks associated with improperly packaged and marked medication. In consideration for the acceptance by Channel Islands YMCA of the Participant in the camp and related camp activities, the undersigned do hereby release, forever discharge and waive any claims, causes of action, demands, debts, lawsuits and liabilities which may arise against CIYMCA and its officers, directors, employees, agents and representatives, and other camp related persons acting with permission of CIYMCA (collectively its "Agents"), directly or indirectly, for injury to Participant's person, during his/her involvement with or activities at camp and in particular related to claims for personal injury or death resulting from the Participant being administered medication that was improperly packaged or marked (collectively a "Loss"); and the undersigned further do agree and covenant to indemnify and hold harmless, and not to sue, ESN and their Agents from and against any Loss on account of any action which may be brought against any of them by the undersigned, or any person on behalf of the undersigned or the Participant for the purpose of enforcing or collecting any Loss. Parent or Guardian Authorized Signature Parent or Guardian Printed Name Date Parent Guardian Phone Number 9

10 Supplemental Medication Packet Camper s Name: IMPORTANT: You will be required to bring along the original bottles/containers with the detailed, printed, prescription information. Prescription medication must be dispensed according with physician s current orders. It must be prescribed for the child who is to receive the medication. Those with no prescribed medication must still have a Medication Sheet on file. Please be aware that the nurse on duty must see every camper regardless of their medical or medication issues. An extra day s supply of medication, in the original prescription bottles, must be brought to camp in case of an emergency. With the change of routine, added stress, change of diet, etc., all PRN s (medication as needed seizure medication, epi-pens, pain medications, asthma inhalers, etc.) medications that the camper takes must be brought to camp also. All medications will be turned in during the camper s check in time. Medication Name Dosage Morning Afternoon Evening Night/Bedtime My Camper has no Medications 10

11 CHANNEL ISLANDS YMCA LETTER TO MY COUNSELOR CAMPERS NAME: NICK NAME: This letter will be given to your child s counselor and used to help us provide the best possible experience for your child. If the Health Care Staff should be aware of these needs please include them on the Health History Form. Please take time to write this letter. The more we know about your child before he or she arrives at camp, the better we can prepare for their experience. We know you are busy and have a lot to do, especially in preparation for camp. Please make this a priority. Find some time to sit with your child and talk about their upcoming camp experience. He or she can even help you write this letter. Once completed, mail it to us at the address listed on this form. Please complete entire letter. Dear Counselor, This will be s year at an overnight camp and year at Sequoia Lake OR Camp Fox. I want them to go to camp because While at camp, I hope that my child will My child is looking forward to Is worried about most unhappy when is enthusiastic about is be afraid of is allergic to likes to eat does not like to eat My camper is at personal hygiene (brushing teeth, changing dirty clothes, hand washing, etc.), and is at taking care of personal belongings. My child gets along with other children who My child has the following responsibilities at home Please pay special attention to Thank you for taking care of my child while at camp. I know my child will have a great time. Be safe and have fun... Sincerely, Parent/Guardian s Signature 12

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15 THIS PORTION ONLY TO BE FILLED OUT BY CAMPERS ATTENDING CAMP SEQUOIA. YMCA Camp Sequoia Lake Store Deposit Form Camper Name (first & last): Spending Money We recommend $20 to $75 in spending money per session. It can be used to purchase snacks and items at the camp store. The camp store offers beverages, souvenirs, apparel, snacks, and the opportunity for a camper to practice money management. Carbonated sodas are not available in the camp store. Each camper s account works on a debit system. Purchases are deducted from your child s store deposit daily by the Camp Director. CASH AND CHECKS WILL NOT BE ACCEPTED. Ways to make a store deposit Provide credit/debit card or EFT information and set a spending limit. We ll charge your card/account at the end of the camp session for the exact amount your child spent (at or below the limit you set.) Indicate your choice here: Charge this card at the end of the camp session: Name on card Card # Exp (mm/yy) Card code Billing zip code Charge this Bank Account at the end of camp: Name on Account: Routing Number: Account Number: I prefer my child not have credit at the camp store. My child s spending limit is $. Authorized signature Here are SAMPLES of items/prices in the Camp Store. This is only an example and not an inclusive list. Souvenirs Snacks Drinks Camp Sweatshirts - $20 Granola Bars - $1 Fruit juice - $2 Sunglasses - $5 Fishing Pole - $20 Chips - $1 Ice Cream - $2 Candy Bar - $1 Gatorade - $2 Bottled water - $1 Pre-order the following items to ensure your child gets his/hers! Camp Sweatshirt $20 Size (Circle): YM YL S M L XL $ Fishing Pole $20 Disposable camera $5 $ $ Total:$ Any pre-order totals are not included in the spending limit noted above.

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