2013 Child Care Services Branch Youth Information Form

This youth information is effective for the 2013-2014 Summer Camp and Afterschool Programs. Childs Information Childs name___________________________________________________________________________ Address _____________________________________________________ City ____________________ Zip ___________ ___ Male ___Female Birth date _________________ Age (as of June 2013) _____ Ethnicity ______________________

School child attends during school year _________________________________Grade (as of Aug. 2013) ______________ If the Afterschool Program closes due to inclement weather, my child will: (Afterschool program use ONLY.) ___ Ride the school bus home ___ Picked up by a parent at school ___Attend YMCA Afterschool

Allergies (please be specific and note level of severity, etc.): ________________________________________________________________________________ Current Medications (please note all medications AND complete the Individualized Care Plan if medications will need to be administered at the Y program): __________________________________________________________________________________________________________________________________ Special Needs/Concerns/Differernces ___ YES ( If yes, please complete the attached Individualized Care Plan Form): ____ No What activities your child would enjoy while at Afterschool/Summer Camp:____________________________________________________________________ What are your expectations for the Afterschool/Summer Camp Program?______________________________________________________________________ Names and Ages of Siblings: __________________________________________________________________________________________________________ Swimming Ability (check one): ___ Non-Swimmer ___ Beginner ___ Intermediate ___Advanced Family Information (List both parents/guardians AND check the one parent/guardian completing this form to contact for payments and questions. ___ Parent/guardians name _________________________________________________________________ Employer ________________________________ E-mail address ____________________________________________________________(please provide the email address that we may use for contacting you) Home address _________________________________________________________________ City ________________________________ Zip _____________ Home # _______________________ Work # _______________________ ext. _______ Mobile # _______________________ Pager # ____________________ ___ Parent/guardians name _________________________________________________________________ Employer ________________________________ E-mail address ____________________________________________________________(please provide the email address that we may use for contacting you) Home address _________________________________________________________________ City ________________________________ Zip _____________ Home # _______________________ Work # _______________________ ext. _______ Mobile # _______________________ Pager # ____________________ Emergency Information(If you do not have a doctor/dentist, please list Buncombe County Health Department or another provider of your choice. All information is REQUIRED, including hospital name.) In case of emergency, please contact the following first: ____Mother/Guardian ___Father/Guardian Childs doctor ________________________________________________________________________Doctors phone # _______________________________ Childs dentist ________________________________________________________________________Dentists phone # ______________________________ Hospital preference ________________________________________________________________________________________________________________ Insurance company ________________________________________________________________________ Policy # _________________________________ Emergency Contact Information

When a parent/guardian is not available, I authorize these individuals to pick-up my child:

1. Name _________________________________________Relationship to child ____________________________ Home # _________________________ Work # _____________________ ext. ____ Mobile # __________________ Pager # ____________ 2. Name _________________________________________Relationship to child ____________________________ Home # _________________________ Work # _____________________ ext. ____ Mobile # __________________ Pager # ____________ 3. Name _________________________________________Relationship to child ____________________________ Home # _________________________ Work # _____________________ ext. ____ Mobile # __________________ Pager # ____________ 4. Name _________________________________________Relationship to child ____________________________ Home # _________________________ Work # _____________________ ext. ____ Mobile # __________________ Pager # ____________

YMCA of Western North Carolina

Child Care Services Branch Individualized Care Plan Form
This form will be utilized when a parent/guardian has indicated on the Youth Information Form that their child will be taking a prescription medication, requires special attention, has a special need or disability while participating in the YMCA program. _______________________________________________________________________________________________________

MEDICATION INFORMATION:
CHILDS NAME: ________________________________________________ CHILDS DATE OF BIRTH ___________________ Name of Prescription Medication to be taken at the YMCA:_____________________________________________________ Expiration Date: _____________ Time to Be Taken and Frequency: ______________________________________________ Dosage Amount: ____________Beginning Date: _______________________ Ending Date: ___________________________ Special Instructions:______________________________________________________________________________________ ______________________________________________________________________________________________________

Possible Reactions: ____________________________________________________________________________________ _____________________________________________________________________________________________________ Prescribing Provider: ____________________________________________ Phone: ________________________________ Pharmacy: ____________________________________________________ Phone: ________________________________ I give the YMCA staff authorization to give medicine noted above and to call the health care provider if needed. Parent/Guardian Signature: _________________________________________________________ Date: __________

SPECIAL NEEDS/CONCERNS/DIFFERENCES :
If you listed a medication on the previous sheet or checked yes to a special need, concern or difference, please explain so that our staff are familiar prior to your child attending program: ____________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________ If the YMCA staff and/or the parents/guardians feel it is necessary, a meeting will be scheduled in advance to discuss specific information. The YMCA program welcomes all children to the extent that it is reasonably able to do so. A child who requires measures that constitute a fundamental alteration to the program or other undue hardship, or a child that poses a direct threat to the health and safety of others, will not be able to participate in the program. All children, regardless of their circumstances, are subject to YMCA disciplinary procedures. _______________________________________________________________________________________________________ Office Use Only: ____YMCA is to contact family regarding admission into camp ____ Parent requests contact with YMCA staff prior to camp

CHILD CARE SERVICES YMCA ~ MOBILE ALERTS

As part of the registration process, we now require you to complete this form with updated information to ensure proper receipt of texts. ___ ___ I am new to the Ys mobile text alerts. I am already signed up for mobile alerts, however, I need to update my information. (Please complete only the sections you want to update.) I am already signed up for mobile alerts and do not need to update my information. Last Name: _________________________________________

___

First Name: _________________________________________

Address: _______________________________________________________ City: _____________________________________________ State: __________ Zip Code: ____________________ Email: __________________________________________________________ Mobile Phone #: ( ) _________ - ___________________ DOB (Month, Day, Year): __________________________ YES NO

Member of YMCA?: (Please circle)

_______________________________________________________________________________________________________________________ PLEASE SELECT AS MANY BOXES AS YOU NEED TO STAY INFORMED. REMEMBER, YOU MUST SIGN UP FOR THE AFTERSCHOOL & CAMP ALERTS. Facility Alerts: _____ _____ Asheville Hendersonville _____ _____ Child Care Services Reuter _____ _____ Corpening Woodfin

Afterschool & Camp Alerts: _____ _____ _____ _____ Explorer Camp _____ Adventure Camp _____ _____ Specialty Camps

Discovery Camp (Buncombe)

Discovery Camp (Hendersonville)

Afterschool Site (Please fill-in): _____________________________________________________ Schools Out Site (Please fill-in): ____________________________________________________

By signing below, I certify that I am over the age of 13 (Childrens Online Protection Act) and that I understand that by signing up for these alerts, standard message rates may apply depending on my wireless plan.

Signature: ___________________________________________________

Date: ______________________________________

Beaverdam Selection Form

Childs Name ___________________________________________________________________________ Camp Location ______________________________________________________________________
1. Select a Camp and place an X in the box under each session date needed.

A $20 deposit for each week of camp is required at the time of registration to reserve your childs spot, plus the one-time registration fee. The deposit and registration fees are nonrefundable/non-transferable. The deposit will be put towards the weekly fee.

Beaverdam Camps
Camp Name
Explorer Camp Explorer & Lego Camp PM Lego Camp Only PM (1 4 pm) Explorer & Porpoise Swim Camp Porpoise Swim Camp Only Explorer & Sports and Games Swim Camp Sports and Games Swim Camp Only Adventure Camp Mild Adventure Camp Wild Adventure Camp Wilderness Counselor-In-Training Kiddie Camp AM (8 am-11:45am Kiddie Camp PM (12:15pm-4pm) Kiddie Camp AM & PM (8 am 4pm)

Registration Fee
$50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family

Weekly Rate
$165 $225 $125 $225 $135 $225 $135 $185 $200 $395 $140 $82.50

Wk 1 6/4
$132 / 4 Days

Wk 2 6/10

Wk 3 6/17

Wk 4 6/24

Wk 5 7/1
$132/ 4 Days

Wk 6 7/8

Wk 7 7/15

Wk 8 7/22

Wk 9 7/29

Wk10 8/5

Wk11 8/12

Wk12 8/19

$ 148/ 4 Days $120 / 3 Days

$148/ 4 Days $160/ 4 Days

$112/ 4 Days $66/ 4 Days

$112/ 4 Days $66/ 4 Days

$82.50

$66 / 4 Days

$66/ 4 Days

$155

$124/ 4 Days

$124/ 4 Days

Black Mountain Selection Form

Childs Name _________________________________________________________________ Camp Location ____________________________________________________
1. Select a Camp and place an X in the box under each session date needed.

A $20 deposit for each week of camp is required at the time of registration to reserve your childs spot, plus the one-time registration fee. The deposit and registration fees are non-refundable/non-transferable. The deposit will be put towards the weekly fee. *Week 12 is contingent upon enrollment.*

Black Mountain
Camp Name Registration Fee Weekly Rate Wk 1 6/4
$124/ 4 Days

Wk 2 6/10

Wk 3 6/17

Wk 4 6/24

Wk 5 7/1
$124/ 4 Days

Wk 6 7/8

Wk 7 7/15

Wk 8 7/22

Wk 9 7/29

Wk10 8/5

Wk 11 8/12

Wk 12 8/19*
$62/ 2 Days*

Discovery Camp* Discovery & Art Camp AM Discovery & Art Camp PM Art Camp Only AM (9 am- 12pm) Art Camp Only PM (1pm-4pm)

$50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family

$155

$225

$225

$110

$110

** Subsidy Vouchers accepted for Discovery Camp Only**

Estes Selection Form

Childs Name _________________________________________________________________ Camp Location ____________________________________________________
1.Select a Camp and place an X in the box under each session date needed.

A $20 deposit for each week of camp is required at the time of registration to reserve your childs spot, plus the one-time registration fee. The deposit and registration fees are non-refundable/non-transferable. The deposit will be put towards the weekly fee. *Week 12 is contingent upon enrollment.*

Estes Camps
Camp Name Registration Fee $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family Weekly Rate Wk 1 6/4
$124/ 4 Days

Wk 2 6/10

Wk 3 6/17

Wk 4 6/24

Wk 5 7/1
$124/ 4 Days

Wk 6 7/8

Wk 7 7/15

Wk 8 7/22

Wk 9 7/29

Wk10 8/5

Wk 11 8/12

Wk 12 8/19*
$62/ 2 Days*

Discovery Camp * Discovery & Lego Camp PM Lego Camp Only PM (1 pm- 4 pm) Discovery & Porpoise Swim Camp Porpoise Swim Camp Only (8:30 am 12:30 pm) Discovery & Sports and Games Swim Camp Sports and Games Swim Camp Only (8:30 am- 12:30 pm) Kiddie Camp Am (8:15 am-11:45pm) Kiddie Camp PM (12:15 pm-4pm) Kiddie Camp AM & PM (8 am 4pm)

$155 $225 $125 $225 $135 $225 $135

$82.50

$66 / 4 Days

$66 / 4 Days

$82.50

$66/ 4 Days

$66 / 4 Days

$155

$124 4 Days

$124 4 Days

** Subsidy Vouchers accepted for Discovery Camp Only**/ Subsidy Vouchers not Accepted for Kiddie Camp 3

Hendersonville Selection Form

Childs Name _________________________________________________________________ Camp Location ____________________________________________________
1. Select a Camp and place an X in the box under each session date needed.

A $20 deposit for each week of camp is required at the time of registration to reserve your childs spot, plus the one-time registration fee. The deposit and registration fees are non-refundable/non-transferable. The deposit will be put towards the weekly fee.

Hendersonville Camps
Camp Name Registration Fee $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family Weekly Rate Wk 1 6/3 Wk 2 6/10 Wk 3 6/17 Wk 4 6/24 Wk 5 7/1
$124/ 4 Days

Wk 6 7/8

Wk 7 7/15

Wk 8 7/22

Wk 9 7/29

Wk10 8/5

Wk 11 8/12

Wk 12 8/19
$62/ 2 Days*

Discovery Camp * Discovery & Lego Camp AM Lego Camp Only AM (9 am 12 Pm) Discovery & Tennis Camp Tennis Camp Only (9 am- 12pm)

$155

$225 $125 $225 $110

** Subsidy Vouchers accepted for Discovery Camp Only**

Oakley Selection Form

Childs Name __________________________________________________________________ Camp Location ____________________________________________________
1.Select a Camp and place an X in the box under each session date needed.

A $20 deposit for each week of camp is required at the time of registration to reserve your childs spot, plus the one-time registration fee. The deposit and registration fees are nonrefundable/non-transferable. The deposit will be put towards the weekly fee. *Week 12 is contingent upon enrollment.*

Oakley Camps
Camp Name Registration Fee $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family Weekly Rate Wk 1 6/4
$124/ 4 Days

Wk 2 6/10

Wk 3 6/17

Wk 4 6/24

Wk 5 7/1
$124 4 Days

Wk 6 7/8

Wk 7 7/15

Wk 8 7/22

Wk 9 7/29

Wk10 8/5

Wk 11 8/12

Wk 12 8/19*
$62 2 Days

Discovery Camp *

$155

Discovery & Art Camp AM Discovery & Art Camp PM Art Camp Only AM (9 am- 12 pm) Art Camp Only PM (1 pm-4 pm) Discovery & Porpoise Swim Camp Porpoise Swim Camp Only (8:30am 12:30 pm) Discovery & Sports and Games Swim Camp Sports and Games Swim Camp Only (8:30 am 12:30 pm)

$225 $225 $110 $110 $225

$135

$225

$135

** Subsidy Vouchers accepted for Discovery Camp Only** 5

Sandhill Selection Form

Childs Name _________________________________________________________________ Camp Location ____________________________________________________
1.Select a Camp and place an X in the box under each session date needed.

A $20 deposit for each week of camp is required at the time of registration to reserve your childs spot, plus the one-time registration fee. The deposit and registration fees are non-refundable/non-transferable. The deposit will be put towards the weekly fee. *Week 12 is contingent upon enrollment.*

Sandhill Camps
Camp Name Registration Fee $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family Weekly Rate Wk 1 6/4
$124/ 4 Days

Wk 2 6/10

Wk 3 6/17

Wk 4 6/24

Wk 5 7/1
$124/ 4 Days

Wk 6 7/8

Wk 7 7/15

Wk 8 7/22

Wk 9 7/29

Wk10 8/5

Wk 11 8/12

Wk 12 8/19*
$62/ 2 Days*

Discovery Camp *

$155

Discovery & Lego Camp AM Lego Camp Only AM (9 am 12 Pm)

$225

$125

** Subsidy Vouchers accepted for Discovery Camp Only**

Sports Camp Selection Form

Childs Name __________________________________________________________________ Camp Location ____________________________________________________ 2. Select a Camp and place an X in the box under each session date needed.

A $20 deposit for each week of camp is required at the time of registration to reserve your childs spot, plus the one-time registration fee. The deposit and registration fees are non-refundable/non-transferable. The deposit will be put towards the weekly fee.

Reuter Sports & Estes Discovery Camp / 6- 12 Years Old

Camp Name Basketball Camp
(9:00 am12pm)

Registration Fee $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family $50 Individual / $75 Family

Weekly Rate $95 Members $115 Non Members $225 Members $245 Non members $95 Members $115 Non Members $225 Members $245 Non Members $95 Members $115 Non Members $225 Members $245 Non Members

Wk 1 6/4
$/ 3 Days

Wk 2 6/10

Wk 3 6/17

Wk 4 6/24

Wk 5 7/1
$/ 4 Days

Wk 6 7/8

Wk 7 7/15

Wk 8 7/22

Wk 9 7/29

Wk10 8/5

Wk11 8/12

Wk12 8/19

Discovery & Basketball Camp Soccer Camp

(9:00 am12pm)

$/ 3 Days $/ 3 Days $/ 3 Days $/ 3 Days

$/ 4 Days $/ 4 Days $/ 4 Days $/ 4 Days

Discovery & Soccer Camp T-Ball / Baseball Camp

(9:00 am12pm)

Discovery & TBall/ Baseball Camp

** Subsidy Vouchers accepted for Discovery Camp Only**

2013 YMCA Child Care Services Branch Summer Day Camp/Afterschool Policy Signature Form
Parents/Guardians, please read each area below carefully. Your signature on this document indicates your acknowledgement,

understanding, and agreement with all policies of the YMCA of Western North Carolina.
Policies/Procedures I have been informed of the Camp/Afterschool Handbook located online at ymcawcn.org/camp-information and agree to all policies. Weekly Deposit A non-refundable and non-transferable deposit of $20 is required to register campers for each weekly camp session. Registration Fees A one-time nonrefundable and non-transferable CCS registration fee of $50 per child, $75 per family is due at the time of Summer Camp AND Afterschool Registration. Payment of a separate registration fee is required for both programs. Refunds and Cancellations Any deposits and other fees paid are non-transferable and will not be refunded due to cancellation. Insufficient Funds If drafts or checks are not honored you are still responsible for the payment plus a $30 service charge applied by Federal Automated Recovery System. Child(ren) will be unable to attend any YMCA program until the account is paid in full. Subsidy Voucher Participation I agree to notify the YMCA of any changes in my subsidy voucher status and to abide by the rules set forth by the issuing agency. All subsidy voucher participants are responsible for paying the rate discrepancy between what the YMCA charges and what the voucher will reimburse. The parent/guardian is responsible for any payment for child care not covered by the voucher. Emergency Treatment/Emergency Transportation I agree that the operator, YMCA of Western North Carolina, may authorize the physician of their choice to provide emergency care in the event that I cannot be contacted immediately. I authorize for my child to be transported in the case of an emergency when medical attention by a physician is necessary. I understand that the YMCA will not transport children in their personal vehicles at any time and a hospital or fire/emergency department will always be contacted. I, as the operator YMCA of Western North Carolina, do agree to secure transportation to an appropriate medical resource in the event of emergency. In an emergency situation, other children in the facility will be supervised by a responsible adult. I will not administer any drug or any medication without specific instructions from the physician or the childs parent, guardian, or full-time custodian. Provisions will be made for adequate and appropriate rest and outdoor play. Signature of Operator/YMCA Representative: James Spearin and Paul Vest Date: June 2013-June 2014 Field Trips/Transportation I permit my child to leave the YMCA on authorized trips under the supervision of the YMCA staff. A written schedule of all activities to be conducted off the YMCA Camp premises will be posted for parents to review. By signing this form, you give your child permission to be transported in YMCA vehicles. I understand that field trips occur weekly in Summer Camp and that some field trips have an additional cost to attend. Field trips are on an infrequent basis during Afterschool. Activities Outside the Fenced Playground I hereby give permission to the YMCA of WNC for my child to participate in developmentally-appropriate supervised activities outside the fenced playground at Buncombe County School locations. I understand this statement is required to be signed for licensing and that this space is still on the school property. North Carolina Child Care Law and Rules I have received a copy of the North Carolina Child Care Law and Rules from the YMCA. Registration Paperwork Signature on this document indicates responsibility for payments and is the only one who can alter the forms. Sunscreen: (initial the appropriate statement) ______ I allow YMCA staff to provide NO-AD 45 sunscreen for my child (sunscreen product information available by request). ______ I will provide sunscreen for my child (in an individual bottle labeled with their name and date stored in a zip lock bag) School Success I understand that the YMCA works with the Buncombe County and Asheville City Schools to develop and deliver activities that engage and impact children. I give permission for YMCA staff to talk with school staff in regards to my childs grades, behavior and other information. Behavior Management Policy: I have read this policy in the Handbook and agree with all policies as outlined. YMCA Statement I hereby, for myself, my family, heirs, executors, and administrators, waive and release any and all claims and damages I may have against the YMCA of Western North Carolina and their respective agents, representatives, successors, and assigns, for any and all injuries which may be suffered by me or my family in connection with participation in YMCA activities and programs. I agree to adhere to all policies as outlined on this policy/signature page. I also grant full permission to the YMCA to use any photographs or video recording taken of me or my family. I agree to comply with YMCA policies and procedures and understand that my participation can be terminated without refund for exhibiting inappropriate behavior or abuse toward the YMCA staff and/or facilities. Parent/Guardian Name:__________________________________________ Parent/Guardian Signature:_________________________ (please print)

Childs Name:_____________________________________________________________________ Date:________________________

YMCA OF WESTERN NORTH CAROLINA Child Care Services Branch - Summer Day Camp 2013
REGISTRATION CHECKLIST Camps typically fill very quickly. Early registration is recommended. There is a one week waiting period from the date the completed application is received until the date the child is able to start the program. Incomplete forms will delay a childs start date.

CAMPERS NAME:________________________________ CAMP LOCATION:___________________________

FORMS Youth Information Form You are required to complete a new Youth Information Form annually. 2013 Summer Day Camp and Afterschool Policy Signature Form Please read our policies and procedures. Parent signature required. Mobile Text Alert Form You are required to complete this form with updated information to ensure proper receipt of texts. Parent signature required. Camp Selection Form Select the camp locations and dates you would like your camper to attend. Individualized Care Plan Please complete if you have noted on the Youth Information Form your camper will be taking prescription medication at the camp, or has any special need, concern or difference. A youth development director will review every ICP and will meet with parents if necessary to determine how to best meet the campers needs. Current Copy of Immunization Record We can use the immunization record on file if the information is the same and there are no updates. Current Color Photo of Child Please place on the Youth Information Form in the spot labeled photo. Child Care Subsidy Vouchers Three (3) original copies labeled Summer Camp Care Please note YMCA Explorer and Kiddie Camps do not accept vouchers. Recipients of Child Care Vouchers Please present SEEK card at time of registration. YMCA Financial Assistance Application Applications are accepted throughout the summer camp season early submission is recommended by March 31, 2013. Registration Fee and Deposit and/or Weekly Payment The Registration Fee and Weekly Deposits are Due at Time of Registration. Registration Fee: $50 per child $75 per family

***EARLY REGISTRATION DISCOUNT*** The first 100 completed registrations received in the Child Care Services YMCA office will receive a waiver of the $50/75 registration fee.
Weekly Deposit: $20 per week/per camp required to reserve this will be applied to the weekly fee. The weekly deposit is non-refundable should your child not attend camp. Weekly Summer Day Camp Fee: $____________ Payment Method: Check # _______ Cash Money Order Credit Card* Other *Balances under $10 paid by credit/debit card will be assessed a $5.00 surcharge. Parent/Guardian Signature _____________________________________________________Total Payment Amount Enclosed $ ________________________