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1 For Official Use Only: Branch: Camp Site: Camp Group: CHILD S FIRST & LAST NAME ADDRESS (Street Address, Apt#, City, Zip Code) DATE OF BIRTH (Month/Day/Year) CHILD S DISMISSAL [ ] BE PICKED UP [ ]WALK HOME (AGES 10 + UP ONLY) CHILD S GENDER [ ]MALE [ ]FEMALE CHILD S CURRENT GRADE []Kindergarten []1 st []2 nd []3 rd []4 th []5 th PARENT REGISTERING CHILD- FIRST & LAST NAME HOME PHONE CELL PHONE ADDRESS ETHNICITY? Please check one, this information is used for demographic analysis only. GUARDIAN & EMERGENCY CONTACTS 1 ST PARENT/GUARDIAN S NAME WORK & CELL PHONE NUMBERS 2 ND PARENT/GUARDIAN S NAME EMERGENCY CONTACT (THIS CANNOT BE THE PARENT) ADDRESS WORK & CELL PHONE NUMBERS ADDRESS RELATIONSHIP WORK & CELL PHONE NUMBERS American Indian/Alaskan Native Black or African American Hispanic/Latino Asian or Pacific Islander Caucasian/White Mix Other EMERGENCY RELEASE I give permission, in the event of an emergency, for first aid to be administered to my child. I understand that this may include transportation by ambulance to the nearest hospital and that every effort will be made to contact me. Parent/Guardian: Signature: Date: (Please Print) ALLERGIES & MEDICAL INFORMATION Allergies (medication, foods, etc.): Please List any medical problems, including diagnosis: Is your child currently on any medications, including inhalers? (Please Circle) Yes No If yes, name of medication: Will your child need to take any medication during camp hours? Yes No If yes, written permission must be submitted by the guardian allowing the child to self administer. YMCA cannot administer medications.

2 AUTHORIZED PICK UP (Must be over 18 years old) At dismissal, my child will: (Please check the one that applies) Be picked up by a parent or authorized adult. *Only adults over the age of 18 are authorized to pick up campers. Only adults listed below will be permitted to pick up your camper. Photo ID is always required when picking up campers. Go home without an escort. *Please note that any child going home without an escort must be at least 10 year of age Names and phone numbers of individuals authorized to pick your child up from camp. Individuals must be over 18 years old. 1 ST PERSON S NAME & RELATIONSHIP WORK & CELL PHONE NUMBERS 2 ND PERSON S NAME & RELATIONSHIP WORK & CELL PHONE NUMBERS 3 RD PERSON S NAME & RELATIONSHIP WORK & CELL PHONE NUMBERS PHOTO RELEASE From time to time, the YMCA of Greater New York (the YMCA ) takes pictures or records videos of members and nonmembers participating in YMCA programs, using its facilities, or attending one of its special events. Additionally, the YMCA may permit members of the media (the Media ) to take such pictures or record such videos in order to promote the YMCA s charitable mission and for other journalistic purposes. The individual person named below is signing this Release for the purposes of allowing the YMCA and the Media to use one or more such photographs, video recordings, and/or sound recordings (collectively, Recordings ) of such person for any purpose consistent with the YMCA s charitable mission, which includes, but is not limited to, the YMCA or the Media publishing such Recordings in newspapers, web sites, and other print or electronic publications, on television, or on the radio. By signing this Release, such person acknowledges that he or she has freely consented to be photographed, filmed, or otherwise recorded and has signed this Release of his or her own freewill. If the person named below is under age 18, a parent or guardian of such person must sign on such person s behalf. 1. I agree that I am willing to be photographed, filmed, or otherwise recorded by the YMCA, its contractors, and the Media, either individually or as part of a group Recording, which may include my image, likeness, and/or voice. I further agree that my name may be used to identify me as a subject of any Recordings featuring my image, likeness, and/or voice. 2. I understand that the YMCA will own all rights in the Recordings of me that the YMCA or a YMCA contractor takes or records ( YMCA Recordings ), and that the YMCA will have the exclusive right to use, or allow others to use, such YMCA Recordings in any medium for any purpose consistent with the YMCA s charitable mission as determined by the YMCA. 3. I understand that the Media will own all rights in the Recordings of me that the Media takes or records ( Media Recordings ), and that the Media will have the exclusive right to use, or allow others to use, such Media Recordings in any medium for any lawful purpose. 4. I understand that I am waiving any and all rights that may preclude the YMCA s or the Media s use of the Recordings as described above. 5. I acknowledge that neither the YMCA nor the Media has any obligation to use any Recordings of me or to use such Recordings for any particular purpose. 6. I understand that I will receive no monetary payment or other compensation in exchange for the rights to use recordings of me. Parent/Guardian: Signature: Date:

3 Mark with a X the camp(s) you would like to attend Chelsea Camp Ages 4-9 Session 1 July 1- July 12 (No Camp on July 4) Session 2 July 15 - July 26 Session 3 July 29 - August 9 Session 4 August 12 - August 23 Multi-Sports Camp Basketball Camp Soccer Camp Circus Arts Camp Ages 5-7 Science Camp Ages 5-8 Mixed Media Arts Camp Leaders Camp Ages Counselor in Training Ages AM Hours (8am-9am) PM Hours (5pm-6pm) Mark with a X the Extended Hours you would like to attend Session 1 Session 2 Session 3 Session 4 X-Small *Sorry, no Toddler sizes available T-Shirt Size Request *We cannot guarantee T-shirts size requests will be granted. We do however, try our best. Youth T-Shirt Sizes Small Medium Large X-Large Adult T-Shirt Sizes X-Small Small Medium Large X-Large

4 Standard Conditions of Enrollment The camp assumes no responsibility for lost or stolen items. The camp reserves the right to terminate this contract at any time, if the camp deems it to be in the best interest of the camp to do so. The camper, parents and relatives agree to abide by the rules and regulations set by the camp for the health, safety and welfare of the camp. Every child must have a completed medical form in camp prior to their starting camp. No one will be permitted to start camp without form. Every child must submit 2 passport size photographs prior to camp. Copies are fine. I give permission to allow my child to attend all scheduled trips and out of camp activities under supervision of the camp staff. I allow for my child to be given professional medical treatment in case I or the emergency contact person cannot be reached. This camp is licensed by the NYC Department of Health and Mental Hygiene and is inspected twice yearly. The inspection reports are filed at the Bureau of Food Safety and Community Sanitation. Summer Camp takes place at PS 41. This includes drop-off and pick-up. I understand not all spaces in PS41 are air-conditioned. However, most are. I must enroll in extended hours if I plan to drop off early (8am-9am) or pick up late (5pm-6pm) Camps may be cancelled due to low enrollment. At least 2 weeks notice will be given, if a camp is cancelled. I understand my child will receive two camp T-shirts during their first week of camp. If I want to purchase additional T-shirts, I will do so at the Member Services desk at McBurney for $8 or 3 for $20. Please note: new T-shirts are issued each new session to new campers only. Campers should wear camp shirt every day. If my camper does not wear a camp shirt on trip days (Thursdays), I understand I will be charged $8 for a t-shirt to be given to my camper. I agree to all above listed conditions. By signing this contract I agree to all above listed conditions. Parent/Guardian s Name: Signature: Date: Refund Acknowledgement: I give permission for my child to participate in all program activities: I understand that NO REFUNDS will be given except for illness substantiated by a doctor s note or if camp activities are cancelled by the YMCA. Parent/Guardian Names: Signature: Date:

5 Child s Name Camp Group PHYSICAL EXAMINATION (To be filled out by Physician. Please note information on reverse side) The purpose of this health record is to provide the staff with pertinent information, which will help to serve the needs of this child in Day Camps and Afterschool and Youth Center programs. IMMUNIZATION HISTORY: This is a record of dates of basic immunization and most recent booster doses. Type Date Date Date Date Date DtaP, DTP or TD OPV/IPV MMR Hemophilus Influenza Type Hepatitis B Varicella Other (Specify): MEDICAL EXAMINATION: To be filled out by license physician Examination is acceptable when performed no more than 12 months prior to arrival at camp. Code: S = Satisfactory X = Not Satisfactory, Explain: O = Not examined General Appearance: Height: Weight: Blood Pressure: Hgb Test (Date): Urinalysis: Date: Posture & Spine: Eyes Vision W/ Glasses Extremities Heart Ears Hearing Feet: Lungs Skin Nose Teeth Abdomen Hernia Genitalia Neurological Findings Describe Abnormal Findings and/or Handicapped Conditions Has child ever received products containing horse serum? Allergy: (Please specify) Recommendations and restrictions while in After-school: Special Diet: Special Medicine (Name it) Is parent/guardian sending special medicine? Swimming Diving Activity Restrictions General Appraisal: I have examined the person herein described, reviewed his/her health history and it is my opinion that he/she is physically able to engage in Day Camp/Year Round Afterschool and Youth Center activities, except as noted above. MD Physician s Name (PLEASE PRINT) Examining Physician s Signature Telephone: Address: Date of Examination:

6 HEALTH RECORD FOR CHILDREN IN DAY CAMPS & AFTERSCHOOL & YOUTH CENTERS (This side to be filled in by Parent before presentation to Physician) NAME OF PROGRAM: Permit No. 85: / / Male Female Child s Last Name First Name Date of Birth Sex Home Address: Parent or Guardian: Place of Employment: Guardian 1: Guardian 2: In Case of Emergency, please notify: If Parent/Guardian are not available in an emergency, please notify: Important: Has this camper been exposed to any communicable disease during the three weeks prior to camp attendance. Yes No If yes, state type of exposure: HEALTH HISTORY: (Check and give approximate dates) Allergies Diseases Ear Infections Hay Fever Check Pox Rheumatic Fever Ivy Poisoning, etc. Measles Convulsion Insect Stings German Measles Diabetes Penicillin Mumps Behavior Other Drugs Other Contagious Illnesses Asthmas Other Past Illnesses: Operations or Serious Injuries (Dates): Hospitalization (Dates): Chronic or Recurring Illness: Any specific activities to be encouraged? Conditions that require activity to be restricted? Permission for all program activities unless otherwise noted by doctor: Appliance worn (glasses, contacts, etc.): Medication taken: Suggestion from Parent/Guardian: CONSENT FOR EMERGENCY MEDICAL TREATMENT I do hereby give authority to the Day Camp and Year Round Afterschool and Youth Center Program staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible. Relationship Signature Date Telephone No. Department of Health The City of New York Bureau of Inspections

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