PHILADELPHIA FREEDOM VALLEY YMCA 2018 Day Camp Registration Packet

PHILADELPHIA FREEDOM VALLEY YMCA 2018 Day Camp Registration Packet Website: www.philaymca.org Updated 1/23/17

Office Use only: PLEASE CHECK EACH ITEM AS IT WAS RECEIVED AT REGISTRATION Registration Form- Completed indicating sessions desired Summer Camp Parent Checklist Signed Emergency Contact form- Completed; check each line and signatures Fee Agreement- Completed and signed Emergency Hospital or Medical treatment- Completed by parent Authorization Form Getting to Know You Form Third Party Subsidy Form (If Applicable) Child Health Assessment AND Immunizations (signed by dr.) Is child currently enrolled in Before/ After School YES/ NO If YES check Child Care file and verify Health Assessment form Staff Name Date:

Child's Name: Gender: M/ Age: DOB: School & Grade (Fall 2018): Street Address: City: State: Zip: Enrolled in Before/ After School Care? Y N Phone Number: E-mail: Member # Allergies: Shirt Size: (circle one) CS(5/6) CM(7/8) CL(9/10) AS AM AL AXL Camp Small Feet* 3½-5 8:30 AM-5:00 PM $280 $335 Camp Pioneers 6-7 9:00 AM-4:15 PM $280 $335 Camp Explorers 8-9 9:00 AM-4:15 PM $280 $335 Camp Pathfinders 10-11 9:00 AM-4:15 PM $280 $335 Camp Trailblazers 12-14 9:00 AM-4:15 PM $280 $335 Leaders in Training 14-16 9:00 AM-4:15 PM $140 $160 Philadelphia Freedom Valley YMCA Ambler Area YMCA Summer Day Camp 2018 Camper Registration Form Please put an "X" in the box for the particular weeks that you would like to register your child. The shaded boxes are weeks that camp is NOT offered. A $50 non-refundable deposit per week is due at the time of registration. Deposits are applied to the total camp fee. We offer automatic scheduled payments for camp fees. Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10 Week 11 Week 12 6/18-6/22 6/25-6/29 7/2-7/6 7/9-7/13 7/16-7/20 7/23-7/27 7/30-8/3 8/6-8/10 8/13-8/17 8/20-8/24 8/27-8/31 Specialty Day Camps Ages Camp Time Full Privilege Traditional Day Camps Ages Camp Time Full Privilege Non- Member Camp Small Feet* 3½-5 8:30 AM-1:00 PM $162 $217 Non- Member Creating Movement 3-5 8:30 AM-1:00 PM $280 $335 Creating Movement* Half Day 3-5 8:30 AM-5:00 PM $162 $217 Preschool Dance Camp* 3-5 8:30 AM-1:00 PM $162 $217 Preschool Dance Camp* 3-5 8:30 AM-5:00 PM $280 $335 Preschool Acting Camp*Half Day 4-6 8:30 AM-1:00 PM $162 $217 Preschool Acting Camp* 4-6 8:30 AM-5:00 PM $280 $335 Artrageous 6-12 9:00 AM-4:15 PM $280 $335 Imagine Y 6-12 9:00 AM-4:15 PM $280 $335 Investigation Station 6-12 9:00 AM-4:15 PM $280 $335 Movin' N' Groovin' 6-12 9:00 AM-4:15 PM $280 $335 Lego Robotics 6-12 9:00 AM-4:15 PM $280 $335 Adventure Camp 6-12 8:45 AM-4:00 PM $310 $365 Specialty Sports Camps Ages Camp Time Full Privilege Non- Member Sports Camp 6-12 9:00 AM-4:15 PM $280 $335 Tennis Camp 6-12 9:00 AM-4:15 PM $280 $335 Tennis Camp *Half Day 6-12 8:45 AM-12:00 PM $162 $217 Basketball Camp 6-12 9:00 AM-4:15 PM $280 $335 Basketball Camp *Half Day 6-12 8:45 AM-12:00 PM $162 $217 Special Needs Camp Ages Camp Time Full Privilege Dragonfly Forest Day Camp (formerly Camp Outlook) 6-12 Non- Member Lower Gwynedd $205 $220 12:00 PM-4:15 PM Ambler YMCA 12:00 $205 $220 PM-4:15 PM 9:00 AM-4:15 PM $335 $360 6/18-6/22 6/25-6/29 7/2-7/6 7/9-7/13 7/16-7/20 7/23-7/27 7/30-8/3 8/6-8/10 8/13-8/17 8/20-8/24 8/27-8/31 6/18-6/22 6/25-6/29 7/2-7/6 7/9-7/13 7/16-7/20 7/23-7/27 7/30-8/3 8/6-8/10 8/13-8/17 8/20-8/24 8/27-8/31 6/18-6/22 6/25-6/29 7/2-7/6 7/9-7/13 7/16-7/20 7/23-7/27 7/30-8/3 8/6-8/10 8/13-8/17 8/20-8/24 8/27-8/31 Teen Dragonfly Forest Day Camp (formerly Camp Outlook) 13-16 12:00PM- 4:15 PM $205 $220 13-16 9:00 AM-4:00 PM $335 $360 PLEASE NOTE: Extended Care is included in the camp fee: Before Care 7-9 am After Care 4-6 pm "*" indicates that extended care is NOT available * Camp will be CLOSED Wednesday, July 4th. Camp fees have been prorated for that week.

Camp Registration Procedures 1. The camp registration packet contains the following pages: Page 3 Registration procedures Page 4 Registration Form Page 5 Parent Checklist Page 6 Emergency Contact Form Page 7 Fee Agreement Page 8 Authorization for Emergency Hospital or Medical Treatment Page 9 Authorization Form Page 10 Get to Know Form Page 11 Third Party Subsidy Form Page 12 Request for Modification (Optional) Page 13 Diabetes Medical Management Plan (Optional) Page 14 Non Discrimination Policy Page 15 EFT Schedule Page 16 EFT form (recommended) Page 15 Medical Form (to be completed by Dr.) 2. The entire camp registration packet minus the (optional) documents 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 31 st. After June 1 st a drop/switch/add form must be filled out and turned into the Camp Director or Camp Registrar for approval and processing.

Summer Camp Parent Checklist Your weekly camp fee includes: The camp day from 9am 4:15pm Extended care hours 7:00am 9am and 4:15pm 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: It is not a requirement to be a YMCA member however, members do receive a discount of $55 per week. A $50 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, 2018. After June 1, 2018 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 not 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

EMERGENCY CONTACT/PARENTAL CONSENT FORM 55 PA Code Chapters 3270.124 (a)(b); 3270.181 & 182; 3280.124 (a)(b); 3280.181 & 182; 3290.124 (a)(b); 3290.181 & 182 Does your child have an IEP Yes No Child s Name Home Address Mother s Name/Legal Guardian Home Address Business Name & Address Father s Name/Legal Guardian Home Address Business Name & Address Emergency Contact Person (s) - Name Child s Gender Male Female Birthdate Email Address Home Phone Cell Phone Business Phone Home Phone Cell Phone Business Phone Phone Number when child is in care 1). 2). Person(s) to Whom Child may be released Name/Address Phone Number when child is in care 1). 2). Name of Child s Physician/Medical Care Provider Phone Number Address Special Disabilities (if any) Medical or Dietary Information Necessary in an Emergency Situation Allergies (including medicine reaction) Medication/Special Conditions Additional Information on Special Needs of Child Health Insurance Coverage for Child or Medical Assistance Benefits PARENT S SIGNATURE REQUIRED FOR EACH ITEM BELOW TO INDICATE Obtaining Emergency Medical Care Walks and Trips Transportation by the Facility Photographs are permitted to be taken of my child & used on behalf of YMCA Policy Number (Required) PARENTAL CONSENT Administration of Minor First Aid Procedures Swimming Wading I received a Family Handbook Initial Here Signature of Parent/Guardian Date Signature of Parent/Guardian (Periodic Review - 6 months ) Date

Summer Day Camp Fee Agreement 55 PA CODE CHAPTERS 3270.123 & 181 (c); 3280.123 & 181 (C); 3290.123 & 181 (c) Child s Name FEE AMOUNT $ PER WEEK Day Payment Made *see payment schedule Services to be provided as part of care: Swimming (where applicable) / Camp Activities / Tee Shirt / Field Trips (where applicable) Child s Arrival Time Child s Departure Time Late Payment Fee $25.00 Late pick up fee $1.00 per minute per child Extra Service to be provided at an additional fee (Not Applicable) Person(s) to Whom Child may be Released Name Address Phone # 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 of Child s Admission (first day of care) Date Date of Child s Withdrawal (last day of care) 6 Month Periodic Review Date Parent s Signature 55 PA CODE CHAPTERS 3270.123 & 181 (c); 3280.123 & 181 (C); 3290.123 & 181 (c)

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

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. Use of Hand Sanitizer/ Sunscreen I,, the parent/legal guardian of, who is my minor child, hereby _ give permission for my child s to use liquid hand sanitizer containing alcohol for the purpose of removing germs during their time participating in YMCA programs. _ give permission for my child s to use sunscreen(parent provided or otherwise if forgotten) for the purpose of reducing chances of sunburn during their time participating in YMCA camp programs. 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.

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? Yes 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? Yes 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.) Yes 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? Yes 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.

Mandatory Family Information Philadelphia Freedom Valley YMCA THIRD PARTY SUBSIDY FORM (CCIS, or Other) Parent s Name: Name of child (ren) covered by Third Party subsidy: 1) 2)_ 3) Address: City State: Zip: County: _ Home Phone: _ Cell: _ ********************************************************************** Caseworker s Name: Caseworker s Phone: Ext_ Name of Organization: _ Address of Organization: City, State, Zip, & County ********************************************************************** Amount of Parent Co-pay: $ Parent s Name (Print): Parent s Signature: _Date:

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.)

Philadelphia Freedom Valley YMCA Diabetes Medical Management Plan (DMMP) Date of Plan: Participant s Name: This plan is valid for the following period: - Date of Birth: Date of Diabetes Diagnosis: type 1 type 2 Other School/Program: Grade: Program Director: Program Phone Number: 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:

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 affectional 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 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.

Payment Schedule Summer Camp 2018 Payment Session Beginning Date Session Ending Date (All payment methods) Due Date 6/18/18 6/22/18 6/4/18 6/25/18 6/29/18 6/11/18 7/2/18 7/6/18 6/18/18 7/9/18 7/13/18 6/25/18 7/16/18 7/20/18 7/2/18 7/23/18 7/27/18 7/9/18 7/30/18 8/3/18 7/16/18 8/6/18 8/10/18 7/23/18 8/13/18 8/17/18 7/30/18 8/20/18 8/24/18 8/6/18 8/27/18 8/31/18 8/13/18 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

CHILD HEALTH REPORT (55 PA CODE 3270.131, 3280.131 AND 3290.131) Parent/Provider fill in this part. CHILD S NAME: (LAST) (FIRST) PARENT/GUARDIAN: DATE OF BIRTH: HOME PHONE: ADDRESS: CHILD CARE FACILITY NAME: FACILITY PHONE: COUNTY: WORK PHONE: I authorize the child care staff and my child s health professional to communicate directly if needed to clarify information on this form about my child. PARENT S SIGNATURE: DO NOT OMIT ANY INFORMATION This form may be updated by a health professional. Initial and date any new data. The child care facility needs a copy of the form. HEALTH HISTORY AND MEDICAL INFORMATION PERTINENT TO ROUTINE CHILD CARE AND DIAGNOSIS/TREATMENT IN EMERGENCY (DESCRIBE, IF ANY): NONE DESCRIBE ALL MEDICATION AND ANY SPECIAL DIET THE CHILD RECEIVES AND THE REASON FOR MEDICATION AND SPECIAL DIET. ALL MEDICATIONS A CHILD RECEIVES SHOULD BE DOCUMENTED IN THE EVENT THE CHILD REQUIRES EMERGENCY MEDICAL CARE. ATTACH ADDITIONAL SHEETS IF NECESSARY. NONE CHILD S ALLERGIES (DESCRIBE, IF ANY): NONE LIST ANY HEALTH PROBLEMS OR SPECIAL NEEDS AND RECOMMENDED TREATMENT/SERVICES. ATTACH ADDITIONAL SHEETS IF NECESSARY TO DESCRIBE THE PLAN FOR CARE THAT SHOULD BE FOLLOWED FOR THE CHILD, INCLUDING INDICATION OF SPECIAL TRAINING REQUIRED FOR STAFF, EQUIPMENT AND PROVISION FOR EMERGENCIES. NONE IN YOUR ASSESSMENT, IS THE CHILD ABLE TO PARTICIPATE IN CHILD CARE AND DOES THE CHILD APPEAR TO BE FREE FROM CONTAGIOUS OR COMMUNICABLE DISEASES? YES NO IF NO, PLEASE EXPLAIN YOUR ANSWER: Parents may write immunization dates; health professional should verify and complete all data. HAS THE CHILD RECEIVED ALL AGE APPROPRIATE SCREENINGS LISTED IN THE ROUTINE PREVENTIVE HEALTH CARE SERVICES CURRENTLY RECOMMENDED BY THE AMERICAN ACADEMY OF PEDIATRICS? (SEE SCHEDULE AT WWW.AAP.ORG) YES NO NOTE BELOW IF THE RESULTS OF VISION, HEARING OR LEAD SCREENINGS WERE ABNORMAL. IF THE SCREENING WAS ABNORMAL, PROVIDE THE DATE THE SCREENING WAS COMPLETED AND INFORMATION ABOUT REFERRALS, IMPLICATIONS OR ACTIONS RECOMMENDED FOR THE CHILD CARE FACILITY. VISION (subjective until age 3) HEARING (subjective until age 4) LEAD RECORD DATES OF IMMUNIZATIONS BELOW OR ATTACH A PHOTOCOPY OF THE CHILD S IMMUNIZATION RECORD IMMUNIZATIONS DATE DATE DATE DATE DATE COMMENTS HEP-B ROTAVIRUS DTAP/DTP/TD HIB PNEUMOCOCCAL POLIO INFLUENZA MMR VARICELLA HEP-A MENINGOCOCCAL OTHER MEDICAL CARE PROVIDER: ADDRESS: PHONE: SIGNATURE OF PHYSICIAN, CRNP OR PHYSICIAN S ASSISTANT TITLE: LICENSE NUMBER: DATE FORM SIGNED: CD 51 09/08