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2017 CAMP Registration Packet

HATBORO YMCA

PHILADELPHIA FREEDOM VALLEY YMCA

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Camp Registration Procedures

1. The camp registration packet contains the following pages:

• Page 2 Registration procedures

• Page 3 Registration Form

• Page 4 Emergency Contact Form

• Page 5 Authorization for Emergency Hospital or Medical Treatment

• Page 6 Fee Agreement

• Page 7 Authorization Form

• Page 8 Parent Checklist

• Page 9 Getting to Know You Form

• Page10 Medical Form

• Page11 Request for Modification

• Page 12 Diabetes Medical Management Plan

• Page 13 Non Discrimination Policy

• Page 14 EFT Schedule

2. The entire camp registration packet must be completed in full at the time of

registration. Completed medical forms are due before the first day your child attends

camp.

3. Camp weeks may be dropped, switched, and or added up until May 31st. After June 1st a

drop/switch/add form must be filled out and turned into the Camp Director or Camp

Registrar for approval and processing.

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Shirt Size (circle one) CS CM CL AS AM AL AXL Member #: _______________________

Allergies

*Please place an "X" in the box for the particular camp weeks that you would like to register your child.

*The shaded areas are the weeks that the camp is NOT offered.

*A $25 non-refundable deposit per week is due to secure your child's spot on the roster.

*Deposits will be applied to camp fees.

*Please note - camp weeks are subject to change

Traditional Ages Camp Fee Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk6 Wk 7 Wk 8 Wk 9 Wk 10 Wk 11 Wk 12

Camps Time 6/12- 6/19- 6/26- 7/3 - 7/10 - 7/17 7/24 7/31 8/7 8/14 8/21 8/28

6/16 6/23 6/30 7/7 7/14 7/21 7/28 8/4 8/11 8/18 8/25 9/1

Camp Small Feet * 3-5 9:00am-4:00pm FP $240 / Prog. $270

Camp Pioneers 6-7 9:00am-4:00pm FP $240 / Prog. $270

Camp Explorers 8-9 9:00am-4:00pm FP $240 / Prog. $270

Camp Pathfinders 10-12 9:00am-4:00pm FP $240 / Prog. $270

Trailblazers 12-14 9:00am-4:00pm FP $240 / Prog. $270

Leaders in Training 14-16 9:00am-4:00pm FP $140 / Prog. $160

Specialty Camps

Art Camp 6-12 9:00am-4:00pm FP $260 / Prog. $285

Archery Camp 8-12 9:00am-4:00pm FP $260 / Prog. $285

Brain Buster & Science Camp 7-12 9:00am-4:00pm FP $260 / Prog. $285

Cake Design Camp 6-12 9:00am-4:00pm FP $260 / Prog. $285

Cheerleading Camp 6-9 9:00am-4:00pm FP $260 / Prog. $285

CSI Camp 8-12 9:00am-4:00pm FP $260 / Prog. $285

Dance Camp 6-10 9:00am-4:00pm FP $260 / Prog. $285

Fitness Frenzy Camp 9-13 9:00am-4:00pm FP $260 / Prog. $285

Fishing and Hiking Camp 9-13 9:00am-4:00pm FP $260 / Prog. $285

Fun Week 6-12 9:00am-4:00pm FP $240 / Prog. $270

Future Broadway Stars Camp 6-9 9:00am-4:00pm FP $260 / Prog. $285

Gymnastics Camp 6-14 9:00am-4:00pm FP $270 / Prog. $325

Preschool Gymnastic 1/2 Day Camp* 3-5 9:00am-12:00pmFP $105 / Prog. $130

1/2 Gymnastics Day Camp* 6-9 9:00am-12:00pmFP $105 / Prog. $130

Master Chef Camp 6-12 9:00am-4:00pm FP $260 / Prog. $285

Nature & Photography Camp 8-12 9:00am-4:00pm FP $260 / Prog. $285

Sewing and Textiles Camp 9-13 9:00am-4:00pm FP $260 / Prog. $285

Sports 9-12 9:00am-4:00pm FP $240 / Prog. $270

Sports Jr. 6-8 9:00am-4:00pm FP $240 / Prog. $270

Teen Theater Camp 11-16 9:00am-4:00pm FP $260 / Prog. $285

Theater Camp 8-12 9:00am-4:00pm FP $260 / Prog. $285

Trip Adventure Camp 8-16 9:00am-4:00pm FP $345 / Prog. $400

Sports Travel Camp 6-12 9:00am-4:00pm FP $345 / Prog. $400

Trip Camp 8-16 9:00am-4:00pm FP $345 / Prog. $400

Extended care is included in camp fee.

Before Care 7:00 AM - 9:00 AM After Care 4:00 PM - 6:00 PM

*Extended care is not available *

Please Check One

I would like more information about the EFT payment option.

I am aware of the EFT payment option but do not want it at this time.

PHILADELPHIA FREEDOM VALLEY YMCA - Hatboro Area Branch

Summer Day Camp 2017 - Camper Registration Form

CODE FOR BELOW FEES: FP=Full Privilege Member Prog.=Program Member

Child's Name: _________________________________ Sex M/F Age____ Birthdate___/___/______ Grade_____ (fall '17)

Street Address: _____________________________________________City_____________________State_______Zip_______________

Phone Number: ________________________________ Email:___________________________________________________

*All campers must have an active YMCA Full Privilege or Program Membership from registration through the camp Season

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Philadelphia Freedom Valley YMCA Authorization for

Emergency Hospital or Medical Treatment

All families are required to complete this form for each child. Children will not be permitted to attend field trips without a completed form.

In case of an emergency due to illness or accident, when it is thought advisable to have immediate medical attention for my child; I hereby authorize the Philadelphia Freedom Valley YMCA Summer Camp to send my child to the nearest hospital.

I agree to meet YMCA staff at the hospital as soon as possible after being notified.

I understand that I must bear all expenses involved, including those incurred to Transport my child to the hospital.

In the event of a minor injury, I authorize the Philadelphia Freedom Valley YMCA Summer Camp staff to administer minor first aid to my child.

Name of Child________________________________________________________

Parent/Guardian Signature______________________________________________

Date______________________ Relationship to Child_________________________

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Summer Camp Fee Agreement

Child’s Name

FEE AMOUNT PER WEEK Day Payment Made

2 weeks prior to camp session Services to be provided as part of care:

Swimming / Daily Activities / Field Trips (preschool campers do not go on trips)

Child’s Arrival Time Child’s Departure Time

Late Payment Fee $25.00 Late pick up fee $1.00 per minute

Extra Service to be provided at an additional fee if applicable

NOT APPLICABLE

Person(s) to Whom Child may be Released

NAME ADDRESS PHONE # (when child is in camp)

I, the parent/guardian: Care Provider

Received complete written program information at the time of enrollment {3270.121,3280.121,3290.121}

Agree to update the emergency contact/parental consent form information whenever changes occur or

every 6 months at a minimum. {3270.124, 3290.124}

Signature – Parent or Guardian Date

Signature – Operator Date

Date of Child’s Admission Date of Child’s Withdrawal

6 Month Periodic Review Date Parent’s Signature

55 PA CODE CHAPTERS 3270.123 & 181 (c); 3280.123 & 181 (C); 3290.123 & 181 (c)

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SUMMER DAY CAMP AUTHORIZATION FORM

Please sign all spaces and fill in your child’s name for those activities you authorize.

Transportation and Planned Field Trips/ Unscheduled Walking Trips

I, ________________________________, the parent/legal guardian of ____________________________, who is my minor child, hereby

give permission for my child to be transported to and from off-site locations and attend planned schedules

field trips. I agree that they may be transported by the YMCA Bus, rented van, or a private bus company on

said trips. I also give permission for my child to go for unscheduled walking trips.

Unscheduled Emergency Evacuation

I, ________________________________, the parent/legal guardian of ____________________________, who is my minor child, hereby

give permission for my child to be transported in the event of inclement weather or for the purpose of

emergency evacuation.

Photo Release

I, ________________________________, the parent/legal guardian of ____________________________, who is my minor child, hereby

give permission for my child’s image, photograph, or other reproduction to be taken without reimbursement for

the sole purpose of advertising YMCA programs.

Swimming

I, ________________________________, the parent/legal guardian of ____________________________, who is my minor child, hereby

give permission for my child to participate in recreational/instructional swimming as part of the YMCA Camp

Program. My child’s swimming ability is that of a (check one) ____ non swimmer or _______swimmer. I

understand that my child will be taking part in recreational swim time.

Lost or Broken Item

I, ________________________________, the parent/legal guardian of ____________________________, who is my minor child, hereby

give permission for my child hereby agree to be aware that toys, games, electronics, and or any other items of

value are not to be brought to YMCA camp programs. I am aware that the YMCA will not be held responsible

for lost, broken, or stolen items brought from home to camp.

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Summer Camp Parent Checklist Your weekly camp fee includes:

• the camp day from 9am – 4pm

• Extended care hours 6:30am – 9am and 4pm – 6pm • No extended hours available for Preschool Camps • Field trips (Preschool campers do not go on field trips) • Arts & Crafts, Swimming, Sports and Games

DAY CAMP POLICIES:

• A current YMCA Full or Program membership is required for every child in Day Camp.

• A $25 per week non-refundable deposit is required for all registrations. • Deposits are due at the time of registration. Deposits are applied to each weeks balance. • Balances are due Monday, two weeks prior to the camp start date (payment in full date). • Payment made after due date will incur a $25.00 late fee.

• Any child picked up after 6:05PM will receive a $1.00 late fee per minute, fees must be paid before they return to the camp program.

• A refund will be issued, excluding the deposit, if written cancelation is received prior to May 31, 2017. After June 1, 2017 refunds will be issued in the form of credit towards any YMCA program.

No credit will be granted for a cancellation requested less than 2 weeks prior to the start of the camp session.

• Campers may only be registered for one camp per week.

• Any changes to your child’s camp schedule must be submitted in writing two weeks prior to the change. The YMCA cannot guarantee the availability of your new selection.

• All medical forms MUST be on file at the YMCA before your child can begin summer camp. • I understand my child will only be released to those individuals listed on the emergency

contact/parental consent form. Valid photo identification – driver’s license must be presented at pick up.

• I understand that a custody order must be on file at the YMCA if one or more parent does not have

visitation rights. A custody order cannot be enforced if the YMCA does have a copy of the order. • All electronics, games, cell phones and any other item of value will not be brought to camp and I

understand the Philadelphia Freedom Valley YMCA and the branches will not be held responsible for lost, broken, or stolen items brought to camp.

• I received the Parent Handbook and give consent for all Philadelphia Freedom Valley YMCA policies and procedures.

No child will be admitted into camp until all paperwork is completed and returned to the

YMCA. I have read, understand and will abide by the above policies. I have retained a copy for

my records.

Parent Name Parent Signature Date

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Philadelphia Freedom Valley YMCA Getting to Know You Form

Participant’s Name:

Parents: We can work more effectively with your child at the YMCA this summer if we know as much about him/her as possible. Please help us by filling in the blanks and handing in with the registration packet. Feel free to make an appointment with the Program Director as well.

Well-liked nickname: Age at beginning of the program:

Birth Date:

Living with whom:

Others with whom your child resides:

Does your child require any modifications in YMCA policies, practices or procedures or auxiliary aids and services in order to allow your child to fully participate in our programs? M Yes M No

If yes, explain.

________________________________________________________________________________ (Our ADA Compliance Officer will follow up with you to discuss any requests.)

Does your child require the services of therapeutic support staff (TSS) while at the YMCA? M Yes M No

(If yes, an appointment must be made to meet with the Program Director prior to starting the program to review the YMCA TSS policy).

If your child has an IEP, would you like to provide a copy to the Program Director? (Provision of the IEP is up to the discretion of the parents/guardian.) M Yes M No

What areas of your child’s life would you hope to see developed by at the YMCA?

What do you consider his/her strengths and weaknesses?

Does your child have siblings attending YMCA programming at the same time?M Yes M No If yes, Name (s) & Age(s)

Please note any additional information the Program Director should know about your child to better serve your goals for your child. Such information may include, but is not limited to, information about your

child’s personality, disposition, social skills, and forms of behavior modification used at home as well as hobbies, interests and preferred activities etc.

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Philadelphia Freedom Valley YMCA

Request for Modifications/Auxiliary Aids and Services

Case Management Form

Section A – INITIAL REQUEST FOR MODIFICATION/AUXILIARY AIDS AND SERVICES

Prospective or Current Participant: ______________________________________

Gender: ________

Date of Birth: ___________________________

Program Registration for: __________________________________________________

Date Request Received: _____________________

Branch: _______________________________ Dept.:_____________________________

Person Making the Request (if not the prospective or current participant) and Relation to

Prospective or Current Participant:_______________________________________________

Parent/Guardian or Emergency Contact Name:

________________________________________

Address: _____________________________________________________________________

Home Phone:________________________ Cell Phone: ______________________________

Email(s):__________________________________________

Nature of Request for Modification to Policies, Practices or Procedures and/or for Auxiliary Aids

and Services:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

(If the request was submitted in writing, attach it to this form.)

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Philadelphia Freedom Valley YMCA Diabetes Medical Management Plan (DMMP)

Date of Plan: This plan is valid for the following period:____ - ______

Participant’s Name: Date of Birth:

Date of Diabetes Diagnosis: M type 1 M type 2 M Other

School/Program: Program Phone Number:

Grade: Program Director:

YMCA Program Nurse/Health Professional (if applicable):

Phone: ______

CONTACT INFORMATION

Mother/Guardian:

Address:

Telephone: Home Work Cell:

Email Address:

Father/Guardian: Address:

Telephone: Home Work Cell:

Email Address:

Participant's Physician/Health Care Provider: Address:

Telephone:

Email Address: Emergency Number:

Other Emergency Contacts:

Name: Relationship:

Telephone: Home Work Cell:

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` Nondiscrimination Policy The Philadelphia Freedom Valley YMCA (“YMCA” ) embraces values and beliefs which support and reflect the inclusion and appreciation of all individuals, regardless of race, color, physical or mental disability

(including use of a guide dog, hearing dog, or service dog), religion, creed, sex, pregnancy, childbirth or related medical conditions, sexual orientation or affectational orientation, gender identity or expression, national origin, ancestry, nationality, age, veteran status, uniform service member status, genetic information, atypical hereditary cellular or blood trait, marital status, domestic partnership status, civil

union status, familial status, or any other protected class under federal, state, or local law. We are proud to be an equal opportunity employer and provider of services to the community.

Nondiscrimination in the Provision of Services to Persons with Disabilities As a place of public accommodation, the YMCA is proud to serve a diverse community of individuals, including those with disabilities. The YMCA will work with prospective and current participants with disabilities, and/or their parents/guardians, to ensure that individuals with disabilities are offered full and

equal enjoyment to the YMCA’s goods, services, facilities, privileges, advantages and accommodations. The YMCA does not discriminate in the provision of services to individuals with disabilities, including children with diabetes, in any YMCA programs including, but not limited to, childcare, camps, before and after-school programs, classes and recreational programs. Accordingly, the YMCA will not exclude

individuals with disabilities from enrollment. The YMCA also will not impose or apply eligibility criteria that tend to screen out or screen out individuals with disabilities.

Prospective or current participants with disabilities, and/or their parents/guardians, may, at any time, request modifications to the YMCA’s policies, practices and procedures and/or request auxiliary aids or services. Reasonable modifications and auxiliary aids and services can be wide-ranging. A few examples include: working with children who have diabetes to administer the necessary care they need, allowing a

program participant to have a service animal, and providing sign language interpreters.

All requests for modifications or for auxiliary aids and services should be directed to the applicable

Program Director, the Branch ADA Compliance Officer or the Association Office ADA Compliance Officer. Program Directors may be reached in person or by calling the Branch’s main telephone number and asking for the Program Director. Contact information for Branch ADA Compliance Officers is located at https://philaymca.org under the “About Us” tab. The Association Office ADA Compliance Officer, Bertram

L. Lawson II, may be reached at blawson@philaymca.org or at 215.963.3731.

The YMCA will work with prospective or current participants in our programs, and/or their

parents/guardians, to promptly address all requests for modifications to the YMCA’s policies, practices and procedures and/or for auxiliary aids or services and to determine what reasonable modifications and/or auxiliary aids and services are available. Our goal is to ensure that all participants in our programs with disabilities have access to the full and equal enjoyment of all YMCA programs. Accordingly, the YMCA

conducts individualized assessments on the specific facts of each request and will not apply a general prohibition against providing particular types of reasonable modifications. The YMCA will make reasonable modifications for individuals with disabilities, including children with diabetes, unless the request for

modification amounts to a fundamental alteration of the applicable YMCA program. Similarly, the YMCA will provide auxiliary aids and services for individuals with disabilities, unless the request for the auxiliary aids or services creates an undue burden or amounts to a fundamental alteration of the applicable YMCA program.

The YMCA prohibits retaliation against any individual for exercising their rights to request and/or receive a modification to the YMCA’s policies, practices and procedures or auxiliary aids and services. The YMCA

further prohibits retaliation against any individual who in good faith participates in any investigation or proceeding related to a request for modification to the YMCA’s policies, practices and procedures or auxiliary aids and services.

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Payment Schedule Summer Camp 2017

Session

Beginning Date Session

Ending Date

Payment

(All payment

methods)

Due Date

6/12/17 6/16/17 5/29/17

6/19/17 6/23/17 6/5/17

6/26/17 6/30/17 6/12/17

7/3/17 7/7/17 6/19/17

7/10/17 7/14/17 6/26/17

7/17/17 7/21/17 7/3/17

7/24/17 7/28/17 7/10/17

7/31/17 8/4/17 7/17/17

8/7/17 8/11/17 7/24/17

8/14/17 8/18/17 7/31/17

8/21/17 8/25/17 8/7/17

8/28/17 9/1/17 8/14/17

Payments are due two weeks prior to your child’s camp session.

The YMCA accepts all major credit cards.

Pay for Y Summer Camps with Ease ….Use EFT! By taking advantage of this opportunity, you will have the ability to manage your

payments easier by signing up for EFT! When you sign up for EFT you are saving time and energy.

Online Account Management Register, make payments online, view balances paid and due

Visit www.philaymca.org for detailed information