YMCA CAMP PINEWOOD 2014 Summer Camp Registration

YMCA CAMP PINEWOOD 2014 Summer Camp Registration Send completed form to 4230 Obenauf Road, Twin Lake, MI 49457 Fax to 231.821.0487 Email to mmccarthy@ymcachicago.org Call our office at 231.821.2421 with any questions Camper Name: DOB: / / Gender: M F Age: Grade Entering in Fall 2014: Years at Camp Pinewood (including this year): Cabin Mate Request: How did you hear about us? (This camper must also request your camper. Limit 1 request. Campers must be within 1 grade of each other) (Please include name of YMCA/Person that you heard from) Parent/Guardian Contact #1: Relationship to Camper: Primary Contact Email: Phone #1: Phone #2: Phone #3: Address: City: State: Zip: Parent/Guardian Contact #2: Relationship to Camper: Contact #2 Email: Phone #1: Phone #2: Phone #3: Emergency Contact #3: Relationship to Camper: Emergency Contact Phone #1: Phone #2: Session Options *Please refer to our brochure or website for descriptions and age restrictions Session 1 June 22 28 [1 Week] Traditional Camp Pathfinders Trip Camp [1 Week] Counselor in Training II [3 Weeks] Session 2 June 29 July 12 [2 Week] 2 Week Traditional Camp Pioneer Unit 2A 1 Week Traditional Camp 6/29 7/5 Rangers: Entering K-3 rd grade 6/29 7/2 Session 3 July 13 July 26 [2 Week] 2 Week Traditional Camp Pioneer Unit Counselor in Training I 3A 1 Week Traditional Camp 7/13 7/19 Session 4 July 27 August 9 [2 Week] 2 Week Traditional Camp Leader in Training 4A 1 Week Traditional Camp 7/27 8/2 4B 1 Week Traditional Camp 8/3 8/9 Session 5 August 10 August 16 [1 Week] Traditional Camp Pathfinders Trip Camp [1 Week] Transportation Options YMCA Camp Pinewood reserves the right to change or cancel bus stops due to low enrollment from that location. Please identify your preferences below and we will confirm when payment is made. Bus Fee: $50 each way *Bus will not be available at the end of sessions 2A and 3A. Campers will need to be picked up from camp. How will your camper travel TO camp: Bus Drive Airport How will your camper travel FROM camp: Bus Drive Airport Bus Locations: Irving Park YMCA, Chicago, IL South Side YMCA, Chicago, IL Lattof YMCA, Des Plaines, IL Indian Boundary YMCA, Downers Grove, IL SEE REVERSE SIDE FOR MORE OPTIONS/DETAILS

Session Fees and Additional Options Session Fees Pricing is based on the number of weeks the camper attends *Additional fee for Stay Over, please see Stay Over Options Rate After Earlybird Discount 1 week $595 $545 2 weeks $995 $945 3 weeks $1490 $1390 4 weeks $1980 $1880 5 weeks $2460 $2310 6 weeks $2950 $2750 7 weeks $3430 $3180 8 weeks $3900 $3600 LIT/CIT 1&2 $995 $945 Rangers $395 $345 Stay Over Options $100/weekend Payment Information and Discounts Earlybird Deadline: March 25 Between sessions, activities on weekends vary; not included in multiweek fees, discounts unavailable A: June 28 June 29 B: July 12 July 13 C: July 26 July 27 D: August 9 August 10 *Please call our office to discuss other weekend options for your camper Additional Options TRADITIONAL CAMP ONLY Cost is IN ADDITION TO camp session fees One add on per session, please Horseback Riding $150 Sessions 1-5 Sailing Int./Adv. Lessons $150 Sessions 1-5, on-site Art - What s at Hand $150 Sessions 2-4, on-site Competitive Swim Camp $100 Sessions 2-3, on-site Calculate Your Total Session Fee (based on total # of weeks): Bus Fee ($50 each way): Add l Option (1 per session): Stay Over Weekend(s): Y-Membership Discount $50: Referral Discount: Is the Camper a member of a branch of the YMCA of Metropolitan Chicago? NO YES: # Payment Method: Credit/Debit Card Check #: (made out to YMCA Camp Pinewood) Name on Card: Signature: Card #: Exp. Date / Month Year Charge Full Fee Charge $100 Deposit Automatically Charge Balance of Fees 30 days prior to Camp Session Payment Plan (ends June 15, 2014; fees must be paid in full 30 days prior to Camp Session): + + + - - Name of friend: TOTAL: $ Please charge $ on the 1 st and/or 15 th of each month for the next months. PLEASE READ ALL OF THE FOLLOWING AND SIGN BELOW TO COMPLETE FORM: A $100 non-refundable deposit is required for each session and must follow this application. Please submit your deposit next. Any applications submitted without payment information is held, and not processed until a deposit/payment is received. Priority is given to registrations received and followed by deposit/payments. Applications followed by deposit/payment reserve a space in the session of their choice. Applications not followed by deposit/payment run the risk of having a session fill. Applications received within 30 days of the beginning of a session are required to pay the full fee at that time. All final payments for camp are due 30 days prior to your first session of camp. ** I GIVE THE CAMP PERMISSION TO CHARGE MY CREDIT CARD ON FILE FOR THE REMAINING BALANCE IF NOT PAID BY THIS DATE** Cancellation refunds will be given for the camp fee minus the deposit up until two weeks prior to arrival. After this time there are no refunds available. There will be no refunds when a child goes home early in case of disciplinary action or homesickness. I/We approve this application and certify that our child is in good health. I do hereby give permission to YMCA Camp Pinewood to transport the child named above off the camp property for the purpose of medical care or program activities as deemed appropriate by the Camp Director. I hereby authorize the Camp Health Officer to provide for and secure treatment of general health issues for the minor named above. I understand that my child may be dismissed from the program if their behavior or actions are not in keeping with camp goals and policies. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injection, anesthetic, or surgery for the child named above. The YMCA does not furnish accident/illness medical insurance. Medical expenses, including prescription drugs, will be the responsibility of the parents or guardians. The YMCA of Chicago has my permission to use photographs taken of my child while at camp for promotional purposes. Parent/Guardian Signature: Date: / / YMCA Camp Pinewood 4230 Obenauf Road, Twin Lake, MI 49457 Phone 231.821.2421 Fax 231.821.0487 www.camppinewood.com

CAMPER PICK-UP AUTHORIZATION FORM Please fill out a separate form for each camper. Transportation To Camp: Transportation From Camp: Please put DRIVING, STAYOVER, or the bus stop: (Lattof, Irving Park, South Side, Indian Boundary) Camper Name: Session # Please list the people authorized to pick up your child from camp or the bus, including yourself. Whoever picks your child up will be asked to present a photo ID for verification. Please list more than one (1) person in the event that you are not able to pick up your child on the day the session ends. 1. Authorized Adult Contact # ( ) 2. Authorized Adult Contact # ( ) 3. Authorized Adult Contact # ( ) 4. Authorized Adult Contact # ( ) Parent/Guardian name printed Signature Pick-up Signature: (Only sign this line at the time of PICK-UP) Date: ------------------------------------------------------------------------------------------------------------------ Do Not Cut Do Not Cut Do Not Cut Do Not Cut CAMPER STORE ACCOUNT FORM Please fill out a form for each camper. Credit Cards are the only acceptable form of payment. Campers have the opportunity to shop in the camp store for clothing, souvenirs, etc. Camp Pinewood will track your child s spending and charge your credit card at the conclusion of their session. A copy or your camper s store receipt with your credit card charge will be sent home with your camper. Camper Last Name First Name Session # Maximum $ amount that can be charged by your child $ (If not specified, we will allow your camper to spend up to a maximum of $75 for a 1 week session and $150 for a 2 week session) Cardholder Name (please print) Card Number Exp / Cardholder Signature WE DO NOT ACCEPT CA$H!

CAMPER INFORMATION FORM For our staff to be the most helpful to your child in his/her adjustment to camp life and direct his/her growth and development, we are asking that you complete the following form. This form is only shared with your camper s counselors and administrative staff and will be used in their best interest. Camper Name: Session(s): Name Camper likes to be called: Fav. Food: Brothers: Sisters: Has the camper been away from home before: YES NO Child lives with: Mother Father Guardian (specify): Does your child have any nighttime concerns (bedwetting, sleepwalking, nightmares, etc.): YES NO Explain: Any special needs we should be aware of? Any serious fears that your camper may have (Specify): Camper s major interests, hobbies and/or school activities? Is there any situation at home that may affect the child while at camp (ie. Recent death of family member/pet, moving, change in family structure, recent illness/injury)? How can we best support your child in regards to this? Describe the camper s social skills with his/her peers at school. Does the camper make friends easily? If your child shuts down at home, what are some techniques you use to help them open up? When a change of behavior is needed, what works best for you at home? (i.e. time out, activity restriction, etc.) Are there any camp activities in which you do not wish your child to participate? What are the top three (3) expectations your child has for his/her session at Camp Pinewood this summer? (1) (2) (3) Please list three (3) goals you have for your child at Camp Pinewood: (1) (2) (3) Parent Letter (Optional - please attach): Parents are requested to write a brief description of their child highlighting their personality and other information that would help the counselor in fulfilling his or her duties. Camper Letter (Optional, Yet Strongly Encouraged - please attach): Each camper is asked to write a note to his or her counselor before camp begins. In this way, our staff can read a little about his/her campers. Our counselors can then tailor the group activities and discussions and know more about each camper in his or her cabin group. Returning campers should be encouraged to complete this letter with some specific things they would like to do at camp this year including interests and experiences they hope to gain.

Camper Name: Session#: Date: Health History, Medication, and Examination Form (PAGE 1) ***Please complete this page fully for each camper*** Camper Birth Date: / / Age at Camp: Gender: Male Female Custodial Parent/Guardian: Home Phone: Home Address: Street Address City State Zip Work Phone: Cell Phone: Second Parent/Guardian/Emergency Contact Name: Home Address: Phone: Street Address City State Zip Work Phone: Cell Phone: If not available in an emergency, notify: Relationship: Home Phone: Work Phone: Cell Phone: Insurance Information Is the camper covered by Medical Insurance? Yes No Name of Policy Holder: Policy Holder Birthday: / / Carrier Name: Group #: Policy# Carrier Address/Phone: Street Address City/State/Zip/Phone Policy Holder Social Security Number or ID Number Important - The information below must be completed for attendance* I hereby give permission to the medical personnel selected by the Camp Director to provide routine health care; to administer medications; to order X-rays; routine tests; treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physicians selected by the Camp Director to secure and administer treatment, including hospitalization for the person named above. YMCA Camp Pinewood will make every attempt to notify you before making a doctor s appointment or an emergency room visit for your child while they are in our care. All minor medical needs will be cared for by the on-site Health Director without notification of parents. Parent/Guardian Signature: Date: *If for religious reason you cannot sign this, contact the camp for a waiver, which must be signed. Will the camper have any medication, prescription or non-prescription, over-the-counter drugs, inhalers, epipens, vitamins, minerals, herbs, and/or medical procedures needed or provided at camp: YES NO Does your camper have any Allergies: YES NO If YES to either, please fill out PAGE 2 of this form.

Camper Name: Session#: Date: Health History and Examination Form (PAGE 2) ***Please complete for each camper with any Medication and or Allergies*** Medication Procedures - Please list all medication prescription or non-prescription, over-the-counter drugs, inhalers, epi-pens, vitamins, minerals, herbs and or medical procedures taken regularly or as-needed basis by the camper. - Leave in the original container, pack enough to last the entire stay at camp. Make sure that all of the above listed and prescription drugs are in the original container that includes the physician name, medication name and dosage/administration instructions. - Put all medications into a sealed clear plastic bag labeled with the camper s name and take it to the check-in or the bus stop. Please DO NOT pack medications in your camper s luggage. This camper takes the following medications or needs the following medical procedures: Allergies/Medical Procedures: (please list any food, environmental, medication allergies or medical procedures) If space is needed for any other medication or procedures, please print a second copy of this page and attach.

Camper Name: Session#: Date: Health History and Examination Form (PAGE 3) ***Physician must complete for each camper if doctor signed physical is not attached*** Health Care Examination/Recommendations by Licensed Medical Personnel The Health Care Examination section must be completed by a licensed physician before attending camp. If the camper has had a doctor s examination within 24 months of their camp session, then that examination form may be attached in place of this page (may be obtained from child s school). Examination record must include information on current prescription and nonprescription drugs and medications, immunization status, physical limitations, allergies, and any special health and behavioral considerations. (Below is for Doctors Office Use Only) Camper Name: I examined the individual on / / (date) The applicant is under the care of a physician for the following conditions: Weight Blood Pressure Eyes Glasses Ears Nose Throat Skin Extremities Heart Lungs Abdomen Hernia Teeth Posture/Spine Other: Explanation of any checked: Females: Menstrual History Normal Special Considerations Recommendations and Restrictions at Camp: Treatment to be continued at camp: Medically-prescribed meal plan/dietary restrictions: Medication Allergies: Describe reaction and management/treatment: Food Allergies / Dietary Restrictions: Describe reaction and management/treatment: Other Allergies Describe reaction and management/treatment: Restrictions / Limitation of camp activities (e.g. what cannot be done, what adaptations are necessary, etc.): Has the camper had or have any recent illness, mental illness, injury or infectious disease? Yes No If yes, please explain: Health History (if any checked please put the date of the last record incident) Chicken Pox Ear Infections Migraines Mononucleosis Measles Nosebleeds Convulsions Surgeries German Measles Asthma Dizziness Heart Murmur Seizures Behavior Issues Mumps Diabetes Eating Disorders Diabetes Rheumatic Fever Other health or dental concerns or details of any of the above: Immunization History (Please list dates as accurately as possible) DPT Series Booster Tetanus Booster Hepatitis B Series Polio OPV (Sabin) Booster MMR Tuberculin Test Other (please list): I have examined the person described and have reviewed his/her health history. It is my opinion that the above named camper is physically able to engage in camp activities, except as noted. Physician Signature: Date: / / Name (Physician/Health Care Facility): Phone #: Address: