av SF 2 | 2011 REGISTRATION FORM YMCA OVERNIGHT CAMPS - CAMP MARSTON ¢ RAINTREE RANCH ¢ CAMP SURF P.O, Box 2440, Julian, CA 92036 (T) 760.765.0642 (F) 760. ).785.0183 (E) camp@ymca.org (W) http://camp.ymca.org i ee at RRC “Camper Name: 7 “Date OF Birt Boy 0°Gir ‘Home Phone: “Malling Adaross: eT ear eer eee a Parent ¢ Name: ‘Work Phone: (__. colt (_), arent 2 Name: Work Phone: (__ ott (_), “Family Emall Address (We are sending papertess confirmation this yar ‘atwrnate! Emergency Contact Na Cabin Mato Request: How Dia You Hear About Our Camps? © BrochuroFlyer © Retorral E Return Camper Websit ty Phone: atm run a ea Capon ina bea ta Sother YMCA © Magazine Why 3 Prices? We offer a 3-orod pricing program based en the needs of familie. I ls cempletely confidential and inno way affects the quality of ihe experience each chid receives. Pree Tha lowest cost, funded by donations fo the greatest extent. Price B's pata sponsored by Contributed funds. Brice C - Represents the actual cost of camp operations (wear & teer and depreciation). Please circle session and price. Ff Comp Marston Seesion 1 Session4 | Session ] Session 6 Session 8 | Spasion9 Eslerevtesis | Srieat | ctoewn | exces | Sovend | Sater | Siac | aoe | Scone | Sot FR ES ounisinoors Senons | omen | Smvine | soont | Smamne | cosine | soma? ] comma | comma Be 2 a eee eee < BES coder train Sse ae Taaean Ff Emerg raion to saya Som age s1670 CAMP WARSTON PRICES! A-#805 B-faRs ©. #008 Fal Raintree Ranch sessions | Sessin2 | Session | Sosson4 | sessins | Sessine | Session? | sessond | Seasing pissy | Sat [ASR | SSS | MS | SPS | Sat | Sar | Sea | ee pi Pegasus CIT jession: 7 Session 5 sion 7 Session 8 Egy Erg Sates 10.1 angel sions: | Sanaa staigs | agri Fe] oe Sal : sr 38 | oe FA Posesue ur Sesen Sanna Siena Seana Boj] Ere Sates 0-2 Seer 98 Se Gy re) tog RAINTREE RANCH PRICES! A-9545 B-f595 ¢- 4045 SURF Mariners Sensons | soon | stoma | sursins | somims | senmno | somin? | comme | comin PS Encraosess | Sieh | svat: | Sass? | Sasi | Re | Sees |.2seeye| Spey | Ait fis z SURFWatemmon | Suamai | sama | Soma | comma | coame | cmime | soma | amine | mmo | ENGratesess | inves | dnaectis | “Sosa? | Saiteie | Soper | Sistas | asta. | Sips | Ais fas = SURF Beachcombers | Session t ‘Session 213 ee ‘Session 6/7 ‘Session 89 z intresowsiee™ | Socio | Siietie SerRgs me Ss SOUL Sure Sonia conn a Tone Ena oo See SR = CAMP SURF PRES: 4 WEEK: A-045 8 S505 C-¥olE TWEEK Boacheombor = SOUL:A- #1050 B-#TI80 C- $1200 TRANSPORTATION? PAYMENTIREEUND POLICY Camps Mareton & Raintree Ranch: —p- ToCamp- a Wil Provide Gum 1 Sus From Camp- a Wil Provide Own a Bus (Bus Servico from 8508 Fria’s Rd, San Diogo, 92110; Sundays at 1pm) Camp Surt: 2 Wil Provide Own 1 Arpecrain Shute Service ($50 fee) HOLDOVER BETWEEN SESSIONS? Bus Fee is $35 ‘way or roundtrip We ole o “hol” campers over the weekend in between consecuthe registered sessions for FREE. Dovs not apply betwoon Camp Surf and ‘oho Mountain Camps in Juan, Yes {100/veek non-refundable deposits requce to reserve camp sessions) ‘Rogistration forme submited without minimum deposit wil not bo ‘ccoptod. fer June 1, 2011 refunds willbe fue, fl payments Faqued AND reaisvation remains open based on space avabatle NT INFORMATION Check enclosed, Please charge my: «Cre Card Debit Card 3 Vita GMC a Discover ty ANEX 1 For $10ahveek non efncable depost ony, OR {For fll balan of fees (required ater June ts!) cand Wo Cardhatder: Exp Date: ENCES SealerYMCA Camper HEALTH HisTory ForM - 2011 * DO NOT MAIL * PLEASE BRING THIS FORM WITH YOU ON CHECK-IN DAY. Adee Parent Guard 1 Binh de Age Sex ro 7 Tame iy State: is Phone Name Work Catt: Parent/Guardian 2: Name Work ot awily Kail Adee Phone cat emergency Contact: Name Teamunization History Ae all nuivatons up to date? Yes oNo Date of las fears shoe &F known) Medical Information Family physician: Medical insurance canter Medical Information pastor prosent (please check). IF YES for asterisk * items, must have a Doctor's A Caenly under De eate® Bes aN6 Hen defecr/isease® Vex No Receat hospitlization* Yes No Asthma BYeraNo Seizes aYeraNo /Dinbetee* aYeraNo For each Yes, please explain Phone: Date of lst physical exam: Policy and/or group #: ADD/ADHD Yer aNe Aisin bYecoNe Aspesper’s Syndrome Yes No Ledlvetting BYeraNa Sleeping Yer oNo Tubberelons nYeroNo srization completed (everte side) (Chicken Pox Yes ONo Measles Yes oNe German Measles cYes No Other dieses oe conditions DYes ON Allergies Hay feves pYesaNo | Bee stings BYexoNe | Penicillin Yer OND Oak/Ivy poisoning aYeraNa ‘espe beesting ki) —aYesoNo | Ocher drugs Yer No: Foods aVeraNo | Otherimacteor animals aYes aNo Any othot allergen? Yer aNo ‘Corrent medications t be continved at cum (dose /Fequency): Dietary restrictions? Yor No. ‘Any season to xestict full activity including swimming, long hikes, strenuous physical Ger aNo ‘Aay eucent mental, ne peychologiel conditions eoqiring special consideration or restctions? Cer No. Forench o/ Yee, please explain: ‘Non-Prescription Medications 1 authorize the following medications or penerc equivalent 10 be administered as needed Acetuminophos aes aNo Liydeoconizune BYernNo | Pepa Bisnol —YesNo | Benady? Yer No Choesseptic —aYes No Cough Drops Yes aNo | Thuprofen (dvi) oYesoNo | Cough Syrup Ver OND. Warerothabiigy Tonal try ee ears lor em Taste Calera Neal antes her Tribes orct/ penn ring a ‘astalygrdenip of he ve si ane ‘poison fe the mir tata in he RICA, {he and mental prepa pare a! feibiter dese inthe anunecrnet forthe progam: In conden ofl rincr keg eit enter arybanch of YMCA of San Dingo Canny AVM fe bration, oe of facts anl/orcaipment oe aro af the shone er ny pga Ion Beha of esl GF vcard cinch, ss spect ue by 1 lg ce cur hve hath ppt Thana the YMCA faci ad ogame, Gt Accept den ang eae oon or The pps inal volo ig is Alcimeat 2 Reese VACA, auditor cre, tmpiger ad wouter ence "Ree Signature of Parent or Guardian ropes oi oe death tn psn, wheter te by Rees or here nd whe toric fnor nse ny YHA birch 3. Lae ‘ute ne Reaes forays dames iy ot ‘kat hseed ave 1 winder tl ary elec aa cach of om ny tently, damage cnt hy ya i 0 ‘S58 mince prsence pon or ar the YMCA branes whether ened br the eggs of eke 4 [sur all apoyo, and kot bdiy ney deh or propery damage loco the neplgente of Rear rere. 5. ‘dotiehy athe the VACA seg athe Undergo eae with ape to ray en etn act, ech, eno sail ngs treatment a Inept ee wich domed ase bya ie cotsed nk general or spears of, iy hyn ced sgn ese ude the po tthe eda nlf any hop the esa Siege eaten verde the nfo Thelin ache gpa Vert chat the WRICA i at sepenal for ots nce oe tintin a pete yh ho he Sate Cao any pron Barco ed val, Pho Release iy prison the YRICA, Som Digs Counts oe my bi ite ihe ens in any of he YMCA etal Pasty and een etic LLaggage Sere tne tat any camp pacts telonprs moy be rch ote th ean proces for dey aol, weapon her Foden et Date Thi fr sie akTHIS SECTION TO BE COMPLETED IF CURRENTLY UNDER DOCTOR’S CARE OR *ASTERISK-HEALTH CONDITION IS. CHECKED ON FRONT OF THIS FORM. Note: \ Doctor's written authorization i only requite if the capes ha a history of Asthma, Hear Defect/Disease, Seiares, Diabetes, has ben see hospitalized, or is curently ander a Doctor's eae IPs, complete ris section. Health Examination by Licensed Physician Cis name Birth dae Sex Because of thir camper medical history, we lve eked that your waiton autbortzati YNCA Camp. Peake ese th held at either mountain (4300 fer elevation very active wih seni hiking, games, swimming, and eanp activities, Your care Toe provides prior to thei atendince 3 aceanront stings ‘he programs ae nsideatinn is appreciated, hve examined the eli named on dis Form within the past v0 years Date examined Ales examination and my review of his/her llth history i ny opinion eh dis person ie physically able to engage in camp activities, except as nated below Height, Weigh: Blood presse 7's he applicane unde the sats uf. physician for any conditions? © Yew & No Please explain: Any rpecific sts: toe encauna o limited by physician's cdlvice, ‘Any medially prescribed meal plan or distarysestrctions Any tncatmict or medications to be continued at camp (please give specific dosages) Ang allarios? (Hood, deg, plants, inscet, Aitonalbealth infomation: Licensed physician signature: Dats Adres Phone: Date of font completion: By