CROSS ISLAND YMCA Summer Camp 2013

CROSS ISLAND YMCA Summer Camp 2013

Is your child ready for a summer of growth and adventure? YMCA SUMMER CAMP The Cross Island YMCA is about to embark on yet another fun and exciting summer of camp. Welcome to all of our returning and new campers to our 2013 Day Camp Program. Y Summer Camp uses hands-on learning through indoor and outdoor educational activities. Thank you for choosing our summer day camp for your child. We look forward to getting to know your son or daughter! Sincerely, Tyronza Murray Senior Program Director Cross Island YMCA Winter & Spring 2013 ymca 2 Cross Island YMCA Summer camp 2013 Like us! www.facebook.com/crossis Like us! www.facebook.com/crossislandymca

WELCOME TO YMCA SUMMER CAMP Through programs like YMCA Day and Sleepaway Camp, we nurture your child s sense of selfconfidence and introduce them to positive, fun experiences that build leadership and social skills. Well-trained, qualified staff serve as positive role models for campers. Y Day Camp enhances camper s self-confidence, self-esteem and leadership skills through structured (and fun!) activities. Campers develop a true understanding of diversity in an atmosphere of acceptance and approval of the uniqueness of others. Campers are encouraged to be creative, expressive and learn new skills. Summer learning activities offer fun way for campers to read and learn over the summer months. All YMCA Day Camps are licensed by the NYC Department of Health and Accredited by the American Camping Association (ACA). YMCA Summer Camp helps campers ages 2-12 years old and teens ages 13-17 years old grow mentally and physically by participating in challenging activities in both small and large group settings under the supervision of a caring and well trained staff. SUMMER LEARNING To succeed in school and life, children and young adults need ongoing opportunities to learn and practice essential skills. This is especially true during the summer months when children lose much of what they learn during the school year. YMCA of Greater New York Day Camps provide high-quality summer learning initiatives that give children a variety of ways to improve reading and math skills and explore music, drama, art and sports. Through fun, themed curriculum that incorporates key academic components, children will practice and further their academic skills, learn to plan and create projects, learn teamwork and develop new skills. To inspire reading, our program will provide books recommended by the Department of Education for summer reading. OUR CAMP LOCATIONS The Cross Island YMCA Summer Day Camp operates out of Cross Island YMCA and PS 33. We also use offsite facilities such as local parks to conduct Day Camp. CONTACT US DAY CAMP OPEN HOUSES Saturday, March 2 10am-4pm Saturday, April 27 10am-4pm Saturday, May 18 10am-4pm For more information or have questions, please contact: Dana Feinberg, Executive Director 718-551-9306; dfeinberg@ymcanyc.org Tyronza Murray, Sr. Program Director 718-551-9320; tmurray@ymcanyc.org Marie Turenne, Camp Director 718-551-9336; mturenne@ymcanyc.org Shonnell Batson, Program Associate 718-551-9309, sabatson@ymcanyc.org Mandy Dihal, Program Coordinator 718-551-9334; mdihal@ymcanyc.org Shareé Vielot, Sports Coordinator 718-551-9337; svielot@ymcanyc.org Sunita Batra, Kinder Camp Director 718-551-9313; sbatra@ymcanyc.org jobscrossisland@ymcanyc.org or visit www.ymcanyc.org/careers 3 Cross Island YMCA Winter & Spring 2013 Like us! www.facebook.com/crossislandymca Visit us at www.ymcanyc.org/crossisland Cross Island YMCA Summer camp 2013 3

DAY CAMP All Day Camps include swimming lessons, field trips to various museums and events, and projects that explore our weekly themes. Kinder Camp (Ages 2 5.8) SEssion I - IV Rates: See page 10 Our primary goal is for each child to develop a positive self-image. The staff is made up of carefully selected teachers and assistant teachers. They provide guidance and supervision so that each child can achieve selfconfidence and awareness. Our camp offers air-conditioned classrooms, outdoor playground, picnic area, indoor pool and gym. Children participate in a wide variety of activities, including arts & crafts, swim (3 years & up), gym, music, and organized games. Each week will feature a special theme, and each session will have a trip to the zoo, children s museum or park. All activities are geared to meet individual needs, abilities, and interests. Kinder camp CONTACT INFORMATION Sunita Batra at 718-551-9313; sbatra@ymcanyc.org Youth CAMP (Ages 5.9 12) SEssion I - IV Member Rates: $400 per session Program Member Rates: $410 per session Campers participate in a wide range of sports, instructional swimming, mini trips, arts and crafts, weekly themed days, environmental science and more. To facilitate academic success our recreational reading component is designed to help kids sharpen their reading skills throughout the summer months. Campers are paired with others within 2 years of their age range. team sports CAMP (Ages 5.9 12) SEssion I - IV Member Rates: $450 per session Program Member Rates: $460 per session Baseball, Basketball, Soccer and Flag Football. Campers will learn basic fundamentals and rules for each of the sports. Each day of the week our staff will focus on one of the four sports. Our goal is to expose the children to a variety of sports. Camper should bring proper equipment for each sport. BASKETBALL CAMP (Ages 5.9 12) SEssion I - IV Member Rates: $450 per session Program Member Rates: $460 per session Classes are based on appropriate age and level of play. All ability levels are welcomed. Offensive and defensive skills and team concepts develop the most complete basketball player possible. Cross Island YMCA Winter & Spring 2013 ymca 4 Cross Island YMCA Summer camp 2013 GYMNASTICS CAMP (Ages 5.9 12) SEssion I - IV Member Rates: $450 per session Program Member Rates: $460 per session Drills and skills in all Olympic events, following a progressive program. Dance, conditioning, stretching and performance tips will focus on fun for gymnasts of every level. The last day exhibition will give gymnasts an opportunity to show their new skills. TENNIS CAMP (Ages 5.9 12) SEssion I - IV Member Rates: $450 per session Program Member Rates: $460 per session The Tennis Camp offers drills and activities carefully designed for different developmental levels so each camper will have a successful learning experience. The camp will focus on positioning, court layout and rules and regulations. The campers will also learn about the basic fore-hand and back hand strokes and compete in both singles and doubles activities. Campers must bring a racket and a sun visor or hat. PERFORMANCE Arts or music camp (Ages 5.9 12) SEssion I - IV Member Rates: $450 per session Program Member Rates: $460 per session Performance Arts Camp participants experience a wonderful summer of dance, drama, music & art. Campers will learn the basics of choreography from lyrical to hip-hop. In addition, campers will learn the fundamentals of acting, character study, improvisation exercises, and even try script writing. Create, Play, have Fun! Music Camp will start or continue a love for musical instruments. Your child will be in a rock band, write a song, and perform. Each camp showcases their new skills and performs for their families at the end of the session. Crafts CAMP (Ages 5.9 12) SEssion I - IV Member Rates: $450 per session Program Member Rates: $460 per session Crafts campers experience a vast array of creative arts, including sculpture, painting, collaging, scrapbooking, drawing, and more. This project based camp will give young artists hands on experience trying new mediums. Campers will make different art projects weekly, learn new skills, and develop lasting friendships in Crafts Camp! Like us! www.facebook.com/crossis Like us! www.facebook.com/crossislandymca

Teen CAMP (Ages 13 15) SEssion I - IV Member Rates: $400 per session Program Member Rates: $410 per session Teen Camp balances scheduled and optional activities for older boys and girls. Campers participate in a wide range of sports, instructional swimming, mini trips, arts and crafts, weekly themed days, environmental science and more. Teen Camp will have three major components: sports and recreation, visual and performing arts, and leadership training. All activities, trips, and additional programming will be an outgrowth of these three components. Teen SPORTS CAMP (Ages 13 15) SEssion I - Iii Member Rates: $450 per session Program Member Rates: $460 per session Our progressive curriculum enhances various sports skills and fundamentals. Campers will learn the different rules of each game while practicing their techniques in mini games. In addition, they will learn about team work, sportsmanship, and motivating each other to succeed. The camp will also focus on teaching fitness and healthy lifestyles. COUNSELOR IN TRAINING (Ages 16-17) SEssion I - Iii Member Rates: $250 per session Program Member Rates: $260 per session Our Counselor In Training (CIT) program is for tomorrow s leaders. Teens who are involved in this amazing program gain job readiness skills and work experience during the summer working along with experienced staff. CITs l receive training in program safety and a Community Service Award. The program will provide hands-on learning allowing teens to slowly work into responsible roles leading children. Staff will assist teens in developing their communication and organization skills. CIT candidates will be interviewed by our Camp Director. LISA BETH GERSTMAN CAMP FOR CHILDREN WITH PHYSICAL CHALLENGES (Ages 6 14) SEssion A - B Rates: $700 per 3 week session The Cross Island YMCA is extremely proud to offer The Lisa Beth Gerstman YMCA Summer Day Camp program serving children with physical and developmental challenges in an integrated setting. Every child deserves the opportunity to participate in a safe, caring, and fun learning environment. Our goal is to develop each child s spirit, mind, and body through quality driven programs. This special camp is made possible through the generous support of the Lisa Beth Gerstman Foundation. Its donation has offset the expenses of equipment, transportation and staffing required to serve youngsters with special needs. All children will receive wheelchair accessible transportation, one-on-one swimming instruction, adaptive physical activities and equipment. A nurse is also present both onsite and on field trips outside of the Y for children who require special care like catheterization and/or medication administration. LBG DAY CAMP SESSION Monday - Friday 9:00am - 4:00pm Session A July 8 - July 26 Session B July 29 - August 16 LBG CONTACT INFORMATION Jean Dattner at 718-551-9325, jdattner@ymcanyc.org Dianne DiPeri at 718-551-9319, ddiperi@ymcanyc.org INCLUSION CAMP (Ages 5.9 14) SEssion I - IV Rates: $700 per session A special summer experience awaits those enrolled in the inclusion explorer camp. This camp brings an inclusive recreational experience to children with disabilities. This unique camp gives children with special needs the same experience as other campers. Children with disabilities and their peers who are typically developing come together to participate in recreational activities such as swimming, arts and crafts, educational activities, reading, physical fitness and more. Camp counselors will serve as shadows one counselor to every 2 campers. 5 Cross Island YMCA Winter & Spring 2013 Like us! www.facebook.com/crossislandymca Visit us at www.ymcanyc.org/crossisland Cross Island YMCA Summer camp 2013 5

SLEEPAWAY CAMP The New York YMCA Camp is located 86 miles from NYC on a 1,150 acre property. Activities offered at New York YMCA Camp are Summer Sleepaway Camp, Specialized Summer Sports Camps (Gymnastics, Volleyball and Judo), Day Camp for Hudson Valley residents, Greenkill Outdoor Education Center, and customizable Retreat Groups or Special Retreat Weekends (Women s Wellness Weekend, Men s Adventure Weekend, Family Camp). Summer Sleepaway Camp (June 30 th August 23 rd ) Have an unforgettable summer at New York s YMCA Camp! Our camp is for boys and girls ages 6-16 from all over the world. There are two villages, McAlister (Ages 6-12) and Talcott (12-15), that are located on our 1,150 acre property for Summer Sleepaway Camp. Just a sample of activities that we offer are swimming lessons, a wide variety of sports, arts and crafts, outdoor living skills, our new media program, canoeing, and our ropes courses. We also offer specialty programs that include water skiing, horseback riding, and rafting trips.we are 86 Miles outside of NYC and we are a safe, inclusive, and diverse camp community. We are a place where children can develop friendships, lifelong skills, and cherished memories. Sports Camps Gymnastics (June 23 rd July 5 th ) We offer world class training for dedicated and determined gymnasts from around the world. Our focus is to support each gymnast while learning new skills and improving existing ones. Every gymnast has the opportunity to train closely with our world-class coaches. Our facilities include 16,000 sq feet of training space, 6 vault stations, 12 beam stations, 4 sets of competition bars, 2 full floor exercises, and more. Volleyball (July 14 th August 9 th ) We offer progressive training techniques for all skill levels, position specific training, and video training with personal feedback. We also offer plyometric and weight training opportunities for qualified campers. Our facilities include 6 indoor courts with all new sport court, 5 outdoor grass courts, a training room, certified athletic trainers, and medical attention available 24/7. Judo (August 11 th August 17 th ) We offer world class training for athletes from around the world. During daily practice and evening Randori, our coaches evaluate skills to develop an individualized, appropriate training program for every camper. Our focus is to support each child and adult to learn new skills and to perfect their existing ones. Cross Island YMCA Winter & Spring 2013 ymca 6 Cross Island YMCA Summer camp 2013 Like us! www.facebook.com/crossis Like us! www.facebook.com/crossislandymca

Day Camp - (Hudson Valley) (July 1 st August 23 rd ) All camp activities are progressive and designed to allow each child to see the growth of skills they learn in a fun and safe environment. Younger campers are lead through adventurous and fun activities, while older campers have a choice in the activities they participate in throughout the day. Outdoor ADVENTURE (June 30 th August 23 rd ) Safe, sensational travel adventures for ages 10 to 15. Experience outdoor adventure activities during one and two week camping trips in the NE and SE regions. YEAR-ROUND PROGRAMS Outdoor Education (September June) The Greenkill Outdoor Education Center provides safe and educational programs for students through a holistic approach that tailors each trip to a school s specific needs. Our professional staff focuses on the needs of students and encourages learning in the natural environment. Winter Family Camp and Summer family Camp (Winter - Feb. 15 th 18 th Summer - Aug 30 th Sept 2 nd ) Enjoy a wonderful themed weekend during the winter, the summer, or both filled with family fun. Sleepaway camp open houses at NEW YORK YMCA CAMP March 24 April 14 May 5 June 2 1:00-4:00 pm Transportation is available from NYC For more information on any of these activities please call 877-30-CAMPS or visit our website at www.nyycamp.org 7 Cross Island YMCA Winter & Spring 2013 Like us! www.facebook.com/crossislandymca Visit us at www.ymcanyc.org/crossisland Cross Island YMCA Summer camp 2013 7

EXPLORE, PLAY AND GROW SAFE ADVENTURES NEW FRIENDSHIPS A HEALTHY SUMMER Cross Island YMCA Winter & Spring 2013 ymca 8 Cross Island YMCA Summer camp 2013 Like us! www.facebook.com/crossis Like us! www.facebook.com/crossislandymca

2013 Summer Day Camp registration Cross Island Y CAMP registration form (all Ages) PARTICIPANT INFO Child s Name Age D.O.B M F Address Apt # City State Zip School Name Grade starting in Sept 2013 Y Member? Y N T-Shirt Size Child: XS S M L XL Adult: S M L XL 2XL PARENT/GUARDIAN INFO Guardian 1 Name Relation Work Tel # Mobile Tel # Home Tel # Email Guardian 2 Name Relation Work Tel # Mobile Tel # Home Tel # Email " AUTHORIZED PICK UP AND EMERGENCY CONTACT INFO At dismissal and/or in case of an emergency, the following people are authorized to pick up my child: 1. Parent/Guardian 1: Yes No 2. Parent/Guardian 2: Yes No 3. Name Relation Tel 4. Name Relation Tel 5. Name Relation Tel PARENT/GUARDIAN AGREEMENT I, the undersigned, give permission for my child to participate in all summer camp activities for the days he/she attends. I understand that no refunds or credits will be given for missed days under any circumstances. I understand that a completed medical form signed by the physician is required before my child may begin camp. In addition I am fully aware that all balances are due by the due date listed above before my child may begin camp. I also hereby give authority to YMCA staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible. In addition, in consideration of the good will, public service, and community aid provided by the YMCA of Greater New York, I hereby grant permission to the YMCA to use my child s name, to take and publish photographs, video of him/her which include his/her voice and image, in any media for YMCA purposes. I release all rights to such photographs and video. I acknowledge that the YMCA will be the sole owner of all rights arising out of their use for all purposes. I understand that I shall receive no compensation from their use from any source whatsoever. Parent/Guardian Signature Date 9 Cross Island YMCA Winter & Spring 2013 Like us! www.facebook.com/crossislandymca Visit us at www.ymcanyc.org/crossisland Cross Island YMCA Summer camp 2013 9

2013 Summer Day Camp Sessions and Fees Cross Island Y Youth & Teen CAMP OFFERINGS (Ages 5.9-17) PARTICIPANT INFO Child s Name Age Date of Birth Male Female Address Apt # City State Zip Home Phone Cell Phone CHECK ALL SESSIONS AND CIRCLE ALL PRICES THAT APPLY TO YOU Youth & Teen Camp Member Program Ages 5.9-8, 9-12 &13-15 Session I 7/01-7/12 $360 $370 Session II 7/15-7/26 $400 $410 Session III 7/29-8/9 $400 $410 Session IV 8/12-8/23 $400 $410 (9 Days) Session I $ Session II $ Session III $ Session IV $ Discounts $ Extended Hours (Rate multiplied by # of sessions) $ Transportation (Rate multiplied by # of sessions) $ Grand Total $ Specialty Camps Member Program Member Program Basketball Camp Ages 5.9-8 & 9-12 Crafts Camp Ages 5.9-8 & 9-12 Session I 7/01-7/12 $405 $415 Session I 7/01-7/12 $405 $415 Session II 7/15-7/26 $450 $460 Session II 7/15-7/26 $450 $460 Session III 7/29-8/9 $450 $460 Session III 7/29-8/9 $450 $460 Session IV 8/12-8/23 $450 $460 Session IV 8/12-8/23 $450 $460 Additional Services Team Sports Camp Ages 5.9-8 & 9-12 Performing Arts Camp Ages 5.9-8 &9-12 Extended Hours AM only PM only Both Session I 7/01-7/12 $405 $415 Session I 7/01-7/12 $405 $415 Session II 7/15-7/26 $450 $460 Session II 7/15-7/26 $450 $460 Sessions I, II, III, IV $100 $100 $200 Session III 7/29-8/9 $450 $460 Session III 7/29-8/9 $450 $460 Session IV 8/12-8/23 $450 $460 Session IV 8/12-8/23 $450 $460 Transportation (ages 6+ only) AM only PM only Both Gymnastics Camp Ages 5.9-8 & 9-12 Music Camp Ages 5.9-8 &9-12 Session I 7/01-7/12 $405 $415 Session I 7/01-7/12 $405 $415 Sessions I, II, III, IV $140 $140 $280 Session II 7/15-7/26 $450 $460 Session II 7/15-7/26 $450 $460 Session III 7/29-8/9 $450 $460 Session III 7/29-8/9 $450 $460 Fees Session IV 8/12-8/23 $450 $460 Session IV 8/12-8/23 $450 $460 Tennis Camp Ages 5.9-8 & 9-12 Teen Sports Camp Ages 13-15 Session I 7/01-7/12 $405 $415 Session I 7/01-7/12 $405 $415 Session II 7/15-7/26 $450 $460 Session II 7/15-7/26 $450 $460 Session III 7/29-8/9 $450 $460 Session III 7/29-8/9 $450 $460 Session IV 8/12-8/23 $450 $460 Counselors In Training Ages 16-17 Session I 7/01-7/12 $225 $235 Inclusion Camp Ages 5.9-8, 9-12 &13-14 Session II 7/15-7/26 $250 $260 Session I 7/01-7/12 $630 $630 Session III 7/29-8/9 $250 $260 Session II 7/15-7/26 $700 $700 Session III 7/29-8/9 $700 $700 Lisa Beth Gerstman Camp Ages 6-14 Session IV 8/12-8/23 $700 $700 Session A 7/8-7/26 $700 $700 Session B 7/29-8/16 $700 $700 A Program Member is an individual who participates only in specific programs and registers at Program Member rates with no further facility or membership privileges. Payment is due 30 days before participant attends camp. No camp will be held on July 4th. Session I/Week I rates are prorated. Sessions may be split. A non-refundable deposit of $100 per session is required at the time of registration. Accepted forms of payment are cash or credit card. Financial Aid is available to those that qualify. Forms are available at the Members Services Desk or online at ymcanyc.org. " Cross Island YMCA Winter & Spring 2013 ymca 10 Cross Island YMCA Summer camp 2013 Like us! www.facebook.com/crossis Like us! www.facebook.com/crossislandymca

2013 Summer Day Camp Sessions and Fees Cross Island Y Kinder CAMP OFFERINGS (Ages 2-5.8) PARTICIPANT INFO Child s Name Age Date of Birth Male Female Address Apt # City State Zip Home Phone Cell Phone CHECK ALL SESSIONS AND CIRCLE ALL PRICES THAT APPLY TO YOU " Toddler 2 to 3.4 years Half Day Full Day 5 Days (Monday Friday) Member Program Member Program Session I 7/01-7/12 $245 $255 $460 $470 Session II 7/15-7/26 $270 $280 $510 $520 Session III 7/29-8/9 $270 $280 $510 $520 Session IV 8/12-8/23 $270 $280 $510 $520 Additional Services Extended Hours Sessions I, II, III, IV AM only PM only Both 5 Days (Monday Friday) $100 $100 $200 3 Days (Mon, Wed, Fri) $70 $70 $140 2 Days (Tuesday-Thursday) $50 $50 $100 Fees Session I $ Session II $ Session III $ Session IV $ Discounts $ Extended Hours (Rate multiplied by # of sessions) $ Total Session Fee $ Grand Total $ PreSchool 3 to 4.5 years Half Day Full Day 5 Days (Monday Friday) Member Program Member Program Session I 7/01-7/12 $235 $245 $445 $455 Session II 7/15-7/26 $260 $270 $495 $505 Session III 7/29-8/9 $260 $270 $495 $505 Session IV 8/12-8/23 $260 $270 $495 $505 Toddler 2 to 3.4 years Half Day Full Day PreSchool 3 to 4.5 years Half Day Full Day 3 Days (Mon, Wed, Fri) Member Program Member Program 3 Days (Mon, Wed, Fri) Member Program Member Program Session I 7/01-7/12 $200 $210 $375 $385 Session I 7/01-7/12 $190 $200 $355 $365 Session II 7/15-7/26 $200 $210 $375 $385 Session II 7/15-7/26 $190 $200 $355 $365 Session III 7/29-8/9 $200 $210 $375 $385 Session III 7/29-8/9 $190 $200 $355 $365 Session IV 8/12-8/23 $200 $210 $375 $385 Session IV 8/12-8/23 $190 $200 $355 $365 Toddler 2 to 3.4 years Half Day Full Day 2 Days (Tuesday, Thursday) Member Program Member Program Session I 7/01-7/12 $160 $170 $300 $310 Session II 7/15-7/26 $160 $170 $300 $310 Session III 7/29-8/9 $160 $170 $300 $310 Session IV 8/12-8/23 $160 $170 $300 $310 PreSchool 3 to 4.5 years Half Day Full Day 2 Days (Tuesday, Thursday) Member Program Member Program Session I 7/01-7/12 $150 $160 $275 $285 Session II 7/15-7/26 $150 $160 $275 $285 Session III 7/29-8/9 $150 $160 $275 $285 Session IV 8/12-8/23 $150 $160 $275 $285 Early Childhood 4.5 to 5.8 years Full Day 5 Days (Monday Friday) Member Program Session I 7/01-7/12 $445 $455 Session II 7/15-7/26 $495 $505 Session III 7/29-8/9 $495 $505 Session IV 8/12-8/23 $495 $505 A Program Member is an individual who participates only in specific programs and registers at Program Member rates with no further facility or membership privileges. Payment is due 30 days before participant attends camp. No camp will be held on July 4th. Sessions may be split. A non-refundable deposit of $100 per session is required at the time of registration. Accepted forms of payment are cash or credit card. Financial Aid is available to those that qualify. Forms are available at the Members Services Desk or online at ymcanyc.org. 11 Cross Island YMCA Winter & Spring 2013 Like us! www.facebook.com/crossislandymca Visit us at www.ymcanyc.org/crossisland Cross Island YMCA Summer camp 2013 11

2013 Summer Day Camp MEDICAL Cross Island Y kinder CAMP Health exam form (Ages 2-5.8) CHILD & ADOLESCENT HEALTH EXAMINATION FORM NYC DEPARTMENT OF HEALTH & MENTAL HYGIENE DEPARTMENT OF EDUCATION Please Print Clearly Press Hard TO BE COMPLETED BY PARENT OR GUARDIAN Child s Last Name First Name Middle Name STUDENT ID NUMBER OSIS Child s Address Hispanic/Latino? Race (Check ALL that apply) American Indian Asian Black White Yes No Native Hawaiian/Pacific Islander Other City/Borough State Zip Code School/Center/Camp Name District Phone Numbers Number Home Health insurance Yes Parent/Guardian Last Name First Name Cell (including Medicaid)? No Foster Parent Work TO BE COMPLETED BY HEALTH CARE PROVIDER If yes to any item, please explain (attach addendum, if needed) Birth history (age 0-6 yrs) Does the child/adolescent have a past or present medical history of the following? Uncomplicated Premature: weeks gestation Asthma (check severity and attach MAF/Asthma Action Plan): Intermittent Mild Persistent Moderate Persistent Severe Persistent If persistent, check all current medication(s): Inhaled corticosteriod Other controller Quick relief med Oral steroid None Complicated by Attention Deficit Hyperactivity Disorder Orthopedic injury/disability Medications (attach MAF if in-school medication needed) Allergies None Epi pen prescribed Chronic or recurrent otitis media Seizure disorder None Yes (list below) Congenital or acquired heart disorder Speech, hearing, or visual impairment Drugs (list) Developmental/learning problem Tuberculosis (latent infection or disease) Diabetes (attach MAF) Other (specify) Foods (list) Dietary Restrictions None Yes (list below) Other (list) Explain all checked items above or on addendum PHYSICAL EXAMINATION General Appearance: Height cm ( %ile) Nl Abnl Nl Abnl Nl Abnl Nl Abnl Nl Abnl Weight kg ( %ile) HEENT Lymph nodes Abdomen Skin Psychosocial Development Dental Lungs Genitourinary Neurological Language BMI kg/m 2 ( %ile) Neck Cardiovascular Extremities Back/spine Behavioral Head Circumference (age 2 yrs) cm ( %ile) Describe abnormalities: Blood Pressure (age 3 yrs) / DEVELOPMENTAL (age 0-6 yrs) Within normal limits SCREENING TESTS Date Done Results Date Done Results If delay suspected, specify below Blood Lead Level (BLL) / / µg/dl Tuberculosis Only required for students entering intermediate/middle/junior or high school (required at age 1 yr and 2 yrs who have not previously attended any NYC public or private school Cognitive (e.g., play skills) and for those at risk) / / µg/dl PPD/Mantoux placed / / Induration mm Communication/Language Lead Risk Assessment At risk (do BLL) (annually, age 6 mo-6 yrs) / / Not at risk PPD/Mantoux read / / Neg Pos Hearing Interferon Test / / Neg Pos Social/Emotional Pure tone audiometry Normal OAE / / Abnormal Chest x-ray Nl Not (if PPD or Interferon positive) Abnl Indicated Adaptive/Self-Help / / Head Start Only Hemoglobin or g/dl Vision Acuity Right / Motor Hematocrit (age 9 12 mo) (required for new school entrants / / Left / / / % and children age 4 7 yrs) with glasses Strabismus No Yes IMMUNIZATIONS DATES CIR Number of Child Influenza / / / / / / Hep B / / / / / / / / MMR / / / / / / Rotavirus / / / / / / Varicella / / / / DTP/DTaP/DT / / / / / / Td / / / / / / Sex Female Male Date of Birth (Month/Day/Year ) / / " / / / / / / Hib / / / / / / / / PCV / / / / / / / / Polio / / / / / / / / RECOMMENDATIONS Full physical activity Full diet Tdap / / Hep A / / / / Meningococcal / / / / HPV / / / / / / Other, specify: / / ; / / ASSESSMENT Well Child (V20.2) Diagnoses/Problems (list) ICD-9 Code Restrictions (specify) Follow-up Needed No Yes, for Appt. date: / / Referral(s): None Early Intervention Special Education Dental Vision Other Health Care Provider Signature Date DOHMH PROVIDER / / ONLY I.D. Health Care Provider Name and Degree (print) Provider License No. and State TYPE OF EXAM: NAE Current NAE Prior Year(s) Facility Name National Provider Identifier (NPI) Comments Address City State Zip Telephone ( ) Fax ( ) Date Reviewed: / / REVIEWER: I.D. NUMBER CH-205 (5/08) Copies: White School/Child Care/Early Intervention/Camp, Canary Health Care Provider, Pink Parent/Guardian Cross Island YMCA Winter & Spring 2013 ymca 12 Cross Island YMCA Summer camp 2013 Like us! www.facebook.com/crossis Like us! www.facebook.com/crossislandymca

2013 Summer Day Camp MEDICAL Part 1 Cross Island Y Youth & Teen Health exam form (Ages 5.9-17) 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 / / M F CHILD'S LAST NAME FIRST NAME BIRTHDATE SEX Home Address: Parent or Guardian: Place of Employment: Father (Guardian) Mother (Guardian) In case of emergency, notify: Phone: Phone: Phone: Phone: Phone: If Parent, Guardian are not available in an emergency, notify: 1. Phone: or 2. Phone: 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 box if child has had afflictions, give appropriate dates) Allergies Rheumatic Fever Hay Fever " Seizures Diabetes Asthma Chicken Pox 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 Dr. Appliance worn (glasses, contacts, etc.) Medication taken Suggestion from Parent/Guardian Poison Ivy, etc. Insect Stings Penicillin Other Drugs Food 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 Tel.# Department of Health and Mental Hygiene The City of New York Bureau of Food Safety and Community Sanitation DCR 7 (Rev. 2/04) 13 Cross Island YMCA Winter & Spring 2013 Like us! www.facebook.com/crossislandymca Visit us at www.ymcanyc.org/crossisland Cross Island YMCA Summer camp 2013 13

2013 Summer Day Camp MEDICAL Part 2 Cross Island Y Youth & Teen PHYSICAL EXAMINATION (Ages 5.9-17) 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. DTaP, DTP, DT, Td Date Date Date Date Date Polio Date Date Date Date Date MMR Date Date Date Hemophilus Influenzae type b (Hib) Date Date Date Date Hepatitis B Date Date Date Date Varicella Date Date Pneumococcal Conjugate (PCV) Date Date Date Date Date Other Date Other Date Other Date MEDICAL EXAMINATION To be filled out by licensed physician. Examination is acceptable when performed no more than 12 months prior to arrival at camp. Code: S = Satisfactory X = Not Satisfactory (Explain) 0 = Not Examined General Appearance Genitalia Height Weight Blood Pressure Posture & Spine Throat - Tonsils Nose Teeth Abdomen Hernia Feet Lungs Skin Hgb. Test (Date) Urinalysis (Date) Eyes Vision w/glasses Extremities Heart Ears Hearing Neurological Findings Describe Abnormal Findings and/or Handicapping Conditions " Allergy: (Please specify) Recommendations and restrictions while in camp: Special Diet Special Medicine (dose, route of administration, when should it be administered) Is parent/guardian sending special medicine? Activity Restrictions Swimming Diving 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. EXAMINING PHYSICIAN (SIGNATURE) M.D. Telephone Address PHYSICIAN'S NAME (PLEASE PRINT) Date of Examination DCR 7 (Rev. 2/04) Cross Island YMCA Winter & Spring 2013 ymca 14 Cross Island YMCA Summer camp 2013 ZIP CODE Like us! www.facebook.com/crossis Like us! www.facebook.com/crossislandymca

DATES & HOURS OF OPERATION Cross Island YMCA Summer Day Camp is an eight-week program that runs Monday to Friday, 9am - 4pm with optional morning, 7-9am and evening, 4-6pm extended hours. Session I Session II July 15 - July 26 Session III July 29 - August 9 Session IV August 12 - August 23 July 1 - July 12 (No Camp July 4th) REGISTRATION MADE EASY Follow instructions and fill out all enclosed registration packet forms making sure they are completed and signed. Register in person. Submit payment for your child s first session with additional deposits of $100 for each added session. This will hold your child s spot for the designated weeks of camp. Take advantage of the 10% Early Bird discount by registering on or before May 18. There will be a $25 (per change) transaction fee for any changes made with regard to camp or transportation after registration is completed. PARENT ORIENTATION Parent Orientation is mandatory. Parent or guardian must attend this mandatory meeting on one of the following dates: Friday, June 7 7pm 8pm Saturday, June 15 5pm 6pm Sunday, June 23 3pm 4pm Wednesday, June 26 7pm 8pm FINANCIAL ASSISTANCE The YMCA of Greater New York awards scholarships to campers based on a parent or a family s annual income. The scholarship applications must be submitted by May 18, 2013. GOVERNMENT & UNION VOUCHERS We accept ACD, HRA, TWU Local 100, and 1199 SEIU vouchers. You must have your confirmation letter with you at the time of registration. Submit your child s medical form completed with parent information and signature as well as the doctor s information, signature and stamp as soon as possible. It s a good idea to keep extra copies of the medical form for your records. Have 2 passport size photos of your child for submission The YMCA accepts all major credit cards or you may sign up for automatic billing to ensure payments are made on time with no late fees incurred. Transportation Transportation to and from the Cross Island YMCA is available only to campers in Youth & Teen or Specialty Camps (not Early Childhood Camp, contact directly) who attend regular hours (9am 4pm). We do not offer transportation for our extended hours campers. The registration deadline for transportation service is Friday, May 31. The Cross Island YMCA offers transportation within the following communities: Arverne Bayside Bellerose Cambria Heights Douglaston Elmont Far Rockaway Floral Park Flushing Forest Hills Fresh Meadows Glen Oaks Hempstead Hollis Jamaica Jamaica Estates Kew Gardens Laurelton Little Neck New Hyde Park Queens Village Rego Park Richmond Hill Rochdale Rosedale St. Albans Springfield Gardens Valley Stream West Hempstead REFUNDS AND CREDITS If your child cannot attend camp for a period of time paid, you may submit a request for credit along with documentation to the Camp Director. Credits can be used for camp or other programs throughout the year. Any refund requests will be submitted to the Camp Director and will be granted under the discretion of the Senior Program Director. All requests should be made prior to the start of the session. CAMP GEAR Each child will receive 2 shirts and a camp bag. Camp t-shirts must be worn every day and are distributed during the camper s first day of camp. Additional shirts may be purchased at $9 each. Swim caps will be given during the camper s first day of swimming. Swim gear consists of a towel, swimsuit, swim cap, a change of clothing, water shoes and a plastic bag (or other receptacle for wet swim gear). Franklin Square Ozone Park 15 Cross Island YMCA Winter & Spring 2013 Like us! www.facebook.com/crossislandymca Visit us at www.ymcanyc.org/crossisland Cross Island YMCA Summer camp 2013 15

CROSS ISLAND YMCA YMCA of GREATER NEW YORK 238-10 Hillside Ave. Bellerose, NY 11426 718-479-0505 www.ymcanyc.org/crossisland Facebook.com/CrossIslandYMCA Promotional Offers Early Bird Discounts 10% discount for participants who are registered by May 18 and have paid in full. Sibling Discounts 10% off each additional sibling. Discounts cannot be combined. Does not apply to New York YMCA Camp programs Non-Profit Organization U.S. Postage PAID Jamaica, NY Permit No. 671 VISIT YMCANYC.ORG/CAMP TO LEARN MORE!