CAMP MCCUMBER. Overnight Camp. Camp Dates: Session I: July 8-July 14, 2018 Session II: July 29- August 4, 2018 Expedition Camp Theme

Transcription

1 CAMP MCCUMBER Overnight Camp Going into 3rd -9th Grade Camp Dates: Session I: July 8-July 14, 2018 Session II: July 29- August 4, 2018 Expedition Camp Theme

2 2018 OVERNIGHT CAMP YMCA Camp McCumber Registration Form Complete one registration packet per camper. Return to: Shasta Family YMCA, 1155 N. Court St, Redding, CA Camper s Name: First. Last... Date of Birth.../... /.. Gender Male Female Home Address:... City. State... Zip.... Family School Attending. Grade in Fall Years at Camp... Cabinmate Request.. (Must be within one year of age and request must be mutual. Requests are not guaranteed.) All individuals including parents or legal guardian picking up a child must be listed on the form below. Campers will not be released to anyone regardless of relationship or legal status unless their name can be verified by our staff. Anyone picking up a child must present a current form of a PHOTO ID EVERY TIME matching their name and date of birth as it appears on this pick up list. We at YMCA Camp McCumber take our responsibility for the welfare of your child very seriously. In the event of an emergency we will contact those listed below. Parent/Guardian 1:.... DOB.. Cell Phone. Work Phone Parent/Guardian 2:... DOB.. Cell Phone. Work Phone Relationship to Camper Relationship to Camper. Emergency Contacts and Authorized Pick-Up Persons: (In addition to parents/guardians) *Use this area to list the individual(s) we may contact in an emergency and/or you authorize to pick up your camper at the end of camp session in the event that you are unable to do so. Name... Relationship to Camper... Contact Phone..... Alternative Phone... Name... Relationship to Camper... Contact Phone Alternative Phone

3 HOW TO REGISTER: DROP OFF/MAIL Completed registration packet to: Shasta Family YMCA 1155 N. Court St Redding, CA For specific program details, call , or visit TRADITIONAL 1-WEEK OVERNIGHT CAMP Entering grades 3-9 By May 31 Y Facility Member: $415 Community Member: $425 After May 31 Y Facility Member: $440 Community Member: $450 7/8 7/14 7/29 8/4 COUNSELOR IN TRAINING Entering grades TRADITIONAL 1-WEEK OVERNIGHT CAMP By May 31 Y Facility Member: $395 Community Member: $405 After May 31 Y Facility Member: $420 Community Member: $430 7/7 7/14 7/28 8/4 SHIRT SIZE (PLEASE CIRCLE ONE) YOUTH: S M L ADULT: S M L XL 2X 3X Payment: A $50 non-refundable/non-transferable deposit will reserve your space for each camp. I agree to pay the balance of camp fees on or before July 1, Cancellations: We will refund program fees for cancellations made 30 days prior to the start of the camp session. Expectation: I understand that my child must comply with the camps rules and standards of conduct and that the organization may terminate my child s participation in the camp program if he/she does not maintain these standards. Photo/Video Release: I hereby consent to and authorize the use and reproduction by the YMCA, or anyone authorized by the YMCA, to any photographs/videos taken of my child without compensation to me. These photographs/videos will be property of the YMCA.,rsonal articles. Lost/Stolen Property: Shasta Family YMCA is not responsible for lost, stolen, or damaged personal articles. Medical Release I grant the Shasta Family YMCA and its agents full authority to take whatever actions they deem necessary regarding my child s health and safety, and I fully release the Shasta Family YMCA from any liability in connection there within. In the event of an emergency, I understand that prudent attempts will be made to contact the undersigned immediately. I understand the camp fees do not include health and accident insurance and I will be responsible for all charges incurred for prompt medical treatment. Risk Waiver: I understand and acknowledge that my camper may participate in a variety of activities. I hereby release and discharge, and agree to indemnify and hold harmless the Shasta Family YMCA and its directors, members, employees, and volunteers against all claims, demands, and causes of actions whatsoever, either in law or equity, relating to or arising from the participation, medical treatment, recommendation, transportation or administration, or any lack thereof. Signature. Date. What I Owe: Camp Fee (from above) $... Extras $10 Camp Store (optional) Donation to help send a kid to camp $... Total (add all applicable) $... Method of Payment Check Enclosed Amount $... Charge My Credit Card Type: Visa MC Discover $50 non-refundable/non-transferable deposit. I understand and authorize that my credit card will be used to pay any outstanding balance on July 1. For full balance of fees $... Card Number.... Expiration Date.... Security Code. Name on Card... Signature.. Date....

4 A Letter To My Counselor: For First Time Campers Dear Counselor, My name is (first and last) I like to be called. and at camp I will be years old. In the fall I am entering grade at.school. I live with my. When I am not in school I like to.. My favorite things are (food, books, movies, colors, etc.). I am excited about camp this summer because I am MOST excited about this camp activity. I am a little nervous about I would like a cabin leader who is. The last time I spent a night away from home I felt. Sincerely,..

5 A Letter to My Counselor: For Returning Campers Dear Counselor, My name is (first and last) I like to be called. and at camp I will be years old. In the Fall I am entering grade at School. My favorite activity at camp last year was. I have decided to return to camp because.. Last year my counselor s name was The highlight at Camp McCumber 2017 for me was. This year at camp I m most looking forward to My favorite campfire song is... My camp nickname is Sincerely,..

6 ALLERGY INFORMATION Please check one box: No known allergies Has allergies (please describe below) What is the camper allergic to? What is the typical reaction? What treatment is needed? Please attach additional information/pages if necessary MEDICATION INFORMATION Check the applicable statement below: My camper WILL NOT bring/take medication, vitamins, or supplements while attending camp. My camper WILL bring/take medication, vitamins, or supplements while attending camp. *Medication Administration Authorization Form is required. DIETARY INFORMATION No food restrictions Eats vegetarian diet Lactose Intolerant Glucose Intolerant Other (please specify below) Notes about camper s diet:.. MENTAL, EMOTIONAL, AND SOCIAL INFORMATION Please check YES or NO for each statement YES NO Please check YES or NO for each statement YES NO 1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (ADHD)? 4. In the past 12 months, seen a professional to address mental/emotional concerns? 2. Ever been treated for emotional/behavior difficulties? 5. Had significant life event that continues to affect the camper s life? (history of abuse, death of a loved one, family change, adoption, foster care, new siblings, etc.) 3. Ever been treated for an eating disorder? 6. Are there any issues that we should be aware of in order to help make this a positive experience? Explain yes answers in the space below: CONSENT FOR EMERGENCY MEDICAL TREATMENT As the parent or guardian, I hereby give consent to the Shasta Family YMCA to obtain all emergency medical or dental care as prescribed by a duly licensed and authorized health care provider, osteopath, or dentist for my child. This may be given under whatever conditions are necessary to preserve the life, limb, or well-being of the child named above. I hereby understand that the Medication Administration Authorization portion MUST be signed by the prescribing physician. I further understand that NO prescription and/or non-prescription will be administered unless the Medication Administration Authorization form is signed by the prescribing physician and medication is correctly packaged/labelled as described in the Parent Handbook. Parent/Guardian Signature:

7 Camper Last Name: Camper First Name I. CAMP OPERATOR This form must be completed fully in order for youth camp operators and staff members to administer the required medication or for the camper to self-administer medication. A new medication administration form must be completed at the beginning of each camp season, for each medication, and each time there is a change in dosage or time of administration of a medication. Prescription medication must be in container labeled by the pharmacist or prescriber. Non-prescription medication must be in the original container with the instructions for use. Nonprescription medication includes vitamins, homeopathic, and herbal medicines. An adult must bring the medication to camp and give the medication to the camp nurse. Youth Camp Name: YMCA Camp McCumber Camp Address: Deer Flat Rd, Shingletown, CA II. CAMP INFORMATION Camper Name: Condition for which medication is being administered: III. PRESCRIBER S AUTHORIZATION Date of Birth: Emergency Medication: YES NO Medication Name: Dose Route: Time/Frequency of Medication: If PRN, frequency: If PRN, for what symptoms: Known side effects to child: Medication shall be administered: (not to exceed one year) Prescriber s Name/Title: Telephone: Address: From: Fax: To: This space may be used for prescribers address stamp. City: State: Zip: Prescriber s signature, or signature stamp (Parent cannot sign): IV. PARENT/GUARDIAN AUTHORIZATION I request the authorized youth camp operator/staff to administer the medication or supervise the camper in self administration if authorized as prescribed by the above prescriber. I certify that I have legal authority to consent to medical treatment for the child named above, including the administration of medication at the facility. I understand that at the end of the authorized period, an adult must pick up the medication, otherwise it will be discarded. I authorize camp personnel to communicate with the prescriber as allowed by HIPAA. Parent/Guardian Signature: Cell Phone: Home Phone: Work Phone: V. AUTHORIZATION FOR SELF ADMINISTRATION ANF SELF CARRY I consent that the child named above is able to self administer the medication listed. I authorize self administration of the above listed medication for the child named above under the supervision of an authorized youth camp operator/staff member. The child named above may carry emergency medication if indicated below. Prescriber s Signature: Self Carry Emergency Medication: Yes No Not an Emergency Med: Prescriber s Signature: Self Carry Emergency Medication: Yes No Not an Emergency Med: