2018 SUMMER DAY CAMP REGISTRATION FORM CAMP HORIZONS: WEST CABARRUS BRANCH (Please Print) Today s Date: CAMPER INFORMATION Camper s Last First: Middle: Child s Code Word: Rising Grade (2018-19 School Year): Birth Date: Age: Sex: M F HEALTH CARE INFORMATION o I have enclosed a copy of the immunization records. o I will provide the immunization records in 2-3 business days. o Child participated in 17-18 YMCA After School-No records needed/ Name of Physician: Physician Phone #: Date of Last Physical Exam: Address: City: State: ZIP Code: Disability or Recurring Illness: Activities Limited by a Physician: Dietary Modifications/Food Allergies: Additional information about the camper that we should be aware of: PARENT/GUARDIAN INFORMATION Email is our preferred form of communication during Summer Camp. Please make sure that you provide the preferred/primary email address for your camper. Parent/Guardian Address (if different): Home Phone #: Cell Phone #: Email Address: Employer: Employer Phone #: Parent/Guardian Address (if different): Home Phone #: Cell Phone #: Email Address: Employer: Employer Phone #: AUTHORIZED PICK UP Persons other than parent/guardian authorized to pick up the camper. Must use the Code Word at pick up.
2018 PAYMENT INFORMATION Please initial each: Session deposits will be deducted from remaining weekly balances. Second child (sibling) discounts are deducted from the total weekly/session fee (not deposits) when enrolled in the same session. Weekly/session balances are due the Wednesday before the start date (Ex. Session 2 balances due by June 13.) In the event of past due balances, the Cannon Memorial YMCA reserves the right to refuse admittance to camp. Past due balances may incur service fees and may be sent to a collection agency if unpaid. Deposits for each session are non-refundable nor transferable between sessions. I will be signing up to get my account auto drafted for each session my camper attends, which will waive the $30 Administration Fee for each camper. Please initial those that apply: I would like to set my camp balance to auto draft from my account. If yes, please draft: I would like to set my smoothie balance to auto draft from my account. If yes, please draft: I would like to set my smoothie balance to auto draft from my account. If yes, please draft: I am accepting an Open Doors Scholarship. You Are Part of Something More DAY CAMP PAYMENT SCHEDULE SESSION DATE DUE ON OR BEFORE Session 1 June 11-15 June 6 Session 2 June 18-22 June 13 Session 3 June 25-29 June 20 Session 4 July 2-6* June 27 Session 5 July 9-13 July 5 Session 6 July 16-20 July 11 Session 7 July 23-27 July 18 Session 8 July 30-Aug 3 July 25 Session 9 Aug 6-10 August 1 Session 10 August 13-17 August 8 Session 11 August 20-24 August 15 *The YMCA will be closed on Wednesday, July 4 The Cannon Y ANNUAL SUPPORT CAMPAIGN directly supports the Y s Open Doors program, positively impacting community youth, families and active older adults regardless of their ability to pay. In 2017, the Open Doors program, supported by your gifts to the Y, reached over 2,600 individuals and over 500 families. Kids learn to swim in our pools and shoot a basket on our courts while building character and self-confidence. Single parents and others find a safe and affordable place for their kids to come after school and during the summer. Active older adults remain healthy and gain strength through targeted programming. When you give to the Y, you positively impact your community. I would like to donate to the ANNUAL SUPPORT CAMPAIGN today to help send a child to camp. Please select an amount: o $5 o $10 o $20 o $25 o $40 o $50 o $75 o $100
ACKNOWLEDGEMENTS AND WAIVERS Please Initial Each Statement: I understand the Administration Fee and deposits are non-refundable nor transferable. I understand that CANNON MEMORIAL YMCA assumes no responsibility for injuries or illnesses which my child may sustain as a result of his/her participation in athletic activities, sports programs, the use of any equipment, exercise or other activities. I expressly acknowledge that I assume the risk for any and all injuries and illnesses which may result from his/her participation in these activities. In consideration of the privilege of participating in summer camp, I hereby voluntarily release and discharge CANNON MEMORIAL YMCA and its agents, contact services, and employees from any and all claims of injury, illness, death, loss or damage which my child may suffer as a result of his/her participation in these activities. I agree to have my child examined prior to the first day of camp by a family physician stating he/she is free from communicable diseases and has not been exposed to such. In the event that I cannot be reached in an emergency, I hereby give my permission to the medical personnel selected by CANNON MEMORIAL YMCA to order X-rays, routine tests, treatments, to release any records necessary for insurance purposes, and to provide or arrange necessary related transportation for me or my child. I understand that no accident or medical insurance is carried on program participants. While CANNON MEMORIAL YMCA will make every effort to provide reasonable accommodations for mentally and physically challenged children, the YMCA will not accept children who are (1) a danger to themselves, (2) a danger to others, or (3) a disruption to the normal activities making it unreasonably difficult for other children to enjoy camp programs. Any of the above will be grounds for dismissal. A parent/guardian must discuss special conditions or circumstances involving their children with the Director prior to registration so that administration can make a determination if reasonable accommodations can be made. I hereby give permission to CANNON MEMORIAL YMCA without limitation or obligation, to use photographs, film footage or tape recordings which may include my child s image or voice for purposes of promotion or interpreting YMCA programs and release the YMCA from any claim of liability to that use. I give CANNON MEMORIAL YMCA permission for my child to leave the YMCA site, participate in authorized YMCA trips and to ride in authorized vehicles for the purpose of transportation in connection with the YMCA program. I understand that field trips will be scheduled in advance and parents will be notified of the details prior to departure. The information recorded on the registration form is correct to my knowledge and the child herein described has permission to engage in all prescribed activities, except as noted by a physician or myself. In its practices, the YMCA does not discriminate on the basis of race, creed and disability, national or ethnic origin. Parent/Guardian Signature: Date: SUNSCREEN PERMISSION FORM The West Cabarrus YMCA Summer Camp participants spend a great deal of time outdoors and are thereby exposed to the sun s harmful rays. Since it is our commitment to promote healthy living, we have made the following policies in this regard: All campers will wear sunscreen with an SPF of at least 15 on all exposed skin including lips, daily, even on cloudy days. Parents or legal guardians will be responsible for applying the first layer of sunscreen prior to morning drop off. Parents or legal guardians will be responsible for providing their children with enough sunscreen (spray sunscreen is preferred) to take with them for later applications. One container per child, please. Camp Staff will be responsible for ensuring thorough follow-up applications after one hour in the water, after two hours of activity in the sun (due to perspiration), and/or any other time as needed. Please note, your child will have the sunscreen applied for them by the Camp Staff if your child is 3-6 years of age. Ages 7 & up are responsible for their own application with supervision. Sunscreen application will be supervised by Camp Staff during the application process. All Camp Staff have completed Child Abuse Prevention Training and are trained on how to properly apply sunscreen to areas that are not covered by a bathing suit or clothing. Camp Staff will only apply sunscreen that is provided by the parent/legal guardian and will only apply spray sunscreen. I give permission to the West Cabarrus YMCA Camp Staff to apply spray sunscreen to my child as needed. I understand that the application of sunscreen to my child will comply with the policies of the West Cabarrus YMCA Camp Program. I do not give permission to the West Cabarrus YMCA Camp Staff to apply spray sunscreen to my child as needed and understand the risk associated with not having my child apply sunscreen during the day. I also understand the Cannon Memorial YMCA assumes no responsibility for injuries or illness that may be sustained as a result in not applying sunscreen. Parent/Guardian Signature: Date:
Total # of sessions = x Deposit $ Total Donation $ SESSION INFORMATION Camper s Last First Parent s Email: Allergies: Code Word: Shirt Size: Please mark the appropriate rising grade group: o Half Pints (Pre-K) o Dawn Seekers (K) o Rising Stars (1st) o Day Breakers (2nd) o Pathfinders (3rd-4th) o Trailblazers (5th-6th) Session 1 June 11-June 15 Session 2 June 18-June 22 Session 3 June 25-June 29 Session 4* July 2-July 6 Session 5 July 9-July 12 Session 6 July 16-July 20 Session 7 July 23-July 27 Session 8 July 30-Aug 3 Session 9 Aug 6-Aug 10 HALF PINT (Half Day) Pre-K 7am-1pm HALF PINT (Full Day) Pre-K TRADITIONAL CAMP Rising K-6th SPECIALTY CAMPS Grade Level Below o $165 All Sports Camp (K-6th) o $165 Art Camp (2nd-6th) o $165 Soccer Camp (K-3rd) o $165 Cooking Camp (2nd-6th) o $165 Football Camp (K-3rd) o $165 Outdoor Exp (2nd-6th) o $245 All Sports Camp (K-6th) o $245 Art Camp (2nd-6th) o $245 Soccer Camp (K-3rd) o $245 Cooking Camp (2nd-6th) o $245 Football Camp (K-3rd) o $245 Outdoor Exp (2nd-6th) *Optional on Friday camp balance *Optional on Friday $10/ week camp balance o $60 o $88 o $116 o $172 o $120 o $180 N/A N/A o $165 Basketball Camp (K-3rd) o $165 STEM Camp (2nd-6th) o $165 Soccer Camp (4th-6th) o $165 Art Camp (2nd-6th) o $165 Football Camp (4th-6th) o $165 STEM Camp (2nd-6th) o $165 Basketball Camp (4th-6th) o $165 Cooking Camp (2nd-6th) o $165 Volleyball Camp (2nd-6th) o $165 Kids Fit Camp (2nd-6th) o $245 Basketball Camp (K-3rd) o $245 STEM Camp (2nd-6th) o $245 Soccer Camp (4th-6th) o $245 Art Camp (2nd-6th) o $245 Football Camp (4th-6th) o $245 STEM Camp (2nd-6th) o $245 Basketball Camp (4th-6th) o $245 Cooking Camp (2nd-6th) o $245 Volleyball Camp (2nd-6th) o $245 Kids Fit Camp (2nd-6th) Session 10 Aug 13-Aug 17 N/A N/A Session 11 Aug 20-Aug 24 N/A N/A 2018 SUMMER CAMP REGISTRATION & DEPOSITS Administration Fee waived with auto draft FREE Administration Fee with no auto draft $30 TODAY'S TOTAL $ Edible Arrangements We offer $3 smoothies on Fridays. Payment is due the Wednesday before camp week with camp balance. (Ex: Session 1 smoothie is due Wednesday, June 6.) Friday Lunches We offer $10 lunches from local restaurants on Fridays. Payment is due the Wednesday before camp week with camp balance. (Ex: Session 1 lunch is due Wednesday, June 6.)
two weeks each. o $175 o $260 o $160 o $240 o $175 o $260 o $175 o $260 o $175 o $260 o $87.50 o $130 Total # of sessions = x Deposit $ Total Donation $ o $175 o $260 o $175 o $260 o $175 o $260 o $175 o $260 o $175 o $260 o $175 o $260 o $175 o $260 o $175 o $260 SESSION INFORMATION Camper s Last First Parent s Email: Allergies: Code Word: Shirt Size TEEN CAMPS: LEADERS IN TRAINING Rising 7th-10th Grade Sessions run for Session 1 and 2 June 11-June 22 Session 3 and 4 June 25-July 6* Session 5 and 6 July 9-July 20 Session 7 and 8 July 23-Aug 3 Session 9 and 10 Aug 6-Aug 17 Session 11 Aug 20-Aug 24 2018 SUMMER CAMP REGISTRATION & DEPOSITS Administration Fee waived with auto draft FREE Administration Fee with no auto draft $30 TODAY'S TOTAL 2018 SUMMER CAMP DISCOUNT For Staff Use Only Camp ODS Recipient % Staff Discount FT/PT Reciprocity Member Discount Sibling Discount (List sibling names) camp balance $ $10/week camp balance Week 1 Week 2 Week 1 Week 2 TEEN CAMPS: TEEN ADVENTURES Rising 7th-10th Grade SESSION DATES Ultimate Sports June 11-June 15 Leading 101 June 18-June 22 Teen Cooking June 25-June 29 Teen Explorers July 9-July 13 Camp 17:21 July 16-July20 Junior Lifeguard July 23-July27 Camp HIT July 30-Aug 3 Summer Traditions Aug 6-Aug 10 camp balance *Optional on Friday $10/week camp balance Edible Arrangements We offer $3 smoothies on Fridays. Payment is due the Wednesday before camp week with camp balance. (ex: Session 1 smoothie is due Wednesday, June 6.) Friday Lunches We offer $10 lunches from local restaurants on Fridays. Payment is due the Wednesday before camp week with camp balance. (ex: Session 1 lunch is due Wednesday, June 6.)