2018 L AKE COUNTY REGISTRATION FORM

21st CCLC SUMMER CAMPYMCA OF CENTRAL FLORIDA

STUDENT INFORMATION

First MI Last

Gender Boy Girl DOB Nickname

Address

City State Zip

Emergency Contact Relationship Phone

PARENT INFORMATION

Guardian Cell Phone

Employer Work Phone

Email Legal Guardian? YES NO

(initial)

(initial)

My student will be using YMCA sponsored bus ? YES NO

AUTHORIZATION TO REMOVE MY STUDENT (MUST PRESENT I.D. DAILY)

Name Relationship Phone

Name Relationship Phone

Non-Hispanic/Non-Latino

Hispanic/Latino

White

Asian

NativeHawaiinorotherPacificIslanders

Black or African American

American Indian/Alaska Native

ETHNICITY

SCHOOL

GRADE

STUDENT ID #

SALESFORCE#TO BE ENTERED BY YMCA STAFF

TO BE ENTERED BY PARENT/GUARDIAN

SIGN OUT PROCEDURESMy student has my permission to sign themselves out at 4:00 PM YES NO

I understand that my child must leave campus after signing out or they can be charged with trespassing.

I understand that this is not a “Drop-In” program and my student must adhere to the attendance policy. *Please see parent handbook.

Select Week(s) Camper will attend

June 4-7 June 25-28

June 11-14 July 9-12

June 18-21 July 16-19

WAIVER: I hereby state that I/ my child am physically and mentally capable of safe participation in the YMCA of Central Florida activities. I understand and expressly acknowledge that I release the YMCA of Central Florida and its staff along with Lake County Public Schools and their staff from all liability for any injury, loss or damage connected in any way to my child’s participation in the YMCA of Central Florida activities, whether on or off the YMCA’s premises. I also authorize the YMCA of Central Florida to obtain medical treatment for my child in the event of emergency.

(initial) I give my permission to the YMCA of Central Florida along with the Lake County Public Schools to use, without limitation orobligation,photographs,filmfootage,ortaperecordingwhichmayincludemychild’simageorvoiceforthepurposeofpromotingorinterpreting the YMCA of Central Florida’s programs.

(initial)Igivepermissionforallfieldtrips.

Participant Signature Date

Parent/ Guardian Signature Date

MEDICAL RELEASE & HISTORY Health Statement (to be completed by Parent/ Guardian and/ or Medical Doctor).

• Respiratory problems - Asthma, persistent cough, etc. YES NO

• Heart problems - High / low blood pressure, chest pain, etc. YES NO

• Kidney, stomach, gall bladder or liver problems YES NO

• Diabetes, hypoglycemia YES NO

• Recent fractures, illness, exposure to contagious disease, etc. YES NO

• Eye, ear, nose or throat problems - Skin disease YES NO

• Allergies - Bee stings, ant bites, plants, sun, food, penicillin, etc. YES NO

• Nervous disorders - Epilepsy, convulsions, dizziness, etc. YES NO

• Emotional disorders - Frequent anxiety, excessive fears, etc. YES NO

• Any hospitalization in the last two years? YES NO

• Do you have any physically limiting conditions? YES NO

• Do you currently take medication? YES NO

• Does your student have a 504 or Individualized Education plan? YES NO

• The participant WILL be bringing medication to programs and activities YES NO

Explanations

EMERGENCY MEDICAL TREATMENT: I understand that every effort will be made to contact the parent(s) or guardian(s) of student(s). If this is not possible, I hereby authorize the YMCA of Central Florida to obtain medical treatment.

Parent/Guardian Signature Daytime Phone

Family Physician/Clinic Location

Phone Insurance Company Policy #

ACCOMMODATION CLAUSE: The YMCA of Central Florida does not discriminate in admission or access to, or treatment or employment in its programs and activities, on the basis of race, color, religion, age, sex, national origin, marital status, disability, genetic information, sexual orientation, gender identity or expression, or any other reason prohibited by law. This holds true for all students who are interested in participating in any YMCA of Central Florida program.

The YMCA of Central Florida After School Program in Lake County is funded by a 21st Century CCLC Grant.

YMCA of Central Florida Mission Statement: The purpose of this Association is to improve the lives of all in Central Florida by connecting individuals, families and communities with opportunities based on Christian values that strengthen Spirit, Mind, and Body. Learn more at ymcacf.org.