2020 YMCA SOUTHCOAST Summer Camp Registration Form(One form per child, please print - MUST be completed and returned to the Camp of your choosing)

Camper’s Name: First_________________________________________________________ Last_________________________________________________________Gender: F M

Home Phone______________________________________________ Birth Date____________________________________ Age as of 7/1/20_______ Grade as of 9/1/20 _______

Home Address _________________________________________________________________________ City/Zip ___________________________________________________________________

Parent/Guardian Name:______________________________________________________________Work #____________________________________________________________________Address (If different from above) ________________________________________________________________________________________________________________________________Cell (Required) __________________________________________________________________________Day/Work Location_____________________________________________________

Parent/Guardian Name:______________________________________________________________Work #____________________________________________________________________Cell (Required) __________________________________________________________________________Day/Work Location_____________________________________________________Primary Email (Required) _________________________________________________________________Secondary Email ___________________________________________________

Email is our primary method of communicating camp information, schedules, and any possible last minute changes throughout the summer. Early registration is recommended. In order to ensure the safety of all children and the appropriate staffing ratios, a completed registration form along with payment must be received 1 week prior to camp session start date. If the session is full, you will be placed on a waiting list.

Emergency Notification Information (Required): In case of emergency, if after both primary guardians cannot be reached, please list 2 additional people who can be contacted and would be authorized to pick up your child. Photo ID required.

1) Name ________________________________________________________ Phone # ______________________________________________Relation ___________________________________2) Name ________________________________________________________ Phone # ______________________________________________Relation ___________________________________

Authorized Pick Up Information: Please list 2 additional people who are authorized to pick up your child at any time. Photo ID required.

1) Name ________________________________________________________ Phone # ______________________________________________Relation ___________________________________2) Name ________________________________________________________ Phone # ______________________________________________Relation ___________________________________

DO NOT RELEASE TO: Please list anyone to whom you do not want your child released.

Name: _______________________________________________________ Name: _______________________________________________________

Health History (Required):

List any current allergies: __________________________________________________________________________________________________________________________________________

List any current dietary restrictions: ____________________________________________________________________________________________________________________________

List any current or past medical treatment that would affect your child’s day at camp: _________________________________________________________________________

List any activities your child should be restricted from: ____________________________________________________________________________________________________

Describe any current physical, mental, or psychological conditions requiring medication, treatment, or special restrictions or considerations while at

camp: ____________________________________________________________________________________________________________________________________________________________________

List any current medications (prescriptions AND over the counter): __________________________________________________________________________________________

Reasons for the above medications: ____________________________________________________________________________________________________________________________

Medications to be administered at camp must be in original container accompanied by written and signed instructions from the parents or doctor on a Y Medication Consent Form. Example: EpiPen must be in original container. Campers may not carry medication at any time.

Protection from biting insects and the sun: Camp staff shall at times encourage campers to reduce ultraviolet exposure from the sun and exposure to biting insects. Such measures shall include, but need not be limited to; encouraging the use of wide brim hats, long sleeve shirts, long pants, screens with a solar protection factor of 25 or greater and the use of sunscreen, lip balm, and insect repellent. Please initial below to acknowledge that you have read and understood this policy:

I have read and understood YMCA SOUTHCOAST’s sun protection and insect repellent policy: (INITIALS required) ________________________

I authorize that the information provided above is accurate and complete to the best of my knowledge.

Per DPH regulations, parents may request copies of background check, health care and discipline policies as well as the procedure for filing grievances.

Required Forms: Copy of Physical within the last year Copy of Immunization Record Copy of Health Insurance Card Individual Health Care Plan (If Applicable) Medication Consent Form (If Applicable)

** Please note that all campers with special conditions or medications will be required to complete and return an Individual Health Care plan and/or Medication Consent Form prior to starting camp.

Your child’s medical insurance carrier: ________________________________________________________________ Policy #: ______________________________________________

Name of Physician: ________________________________________________________________________________________ Phone #: ______________________________________________

Signature (Required): _________________________________________________________________________________________ Date: ___________________________________________

Camper’s preferred pronouns: (circle) He/His She/Hers They/Theirs Other_______________________

Camper’s Name: First _______________________________________ Last: _______________________________________ DOB: _________________________

I have read and understand the payment and refund policies for the YMCA SOUTHCOAST Summer Day Camp Program. I give my child permission to participate in camp activities and walking field trips. I approve photos to be taken of my child for the use in Y marketing materials. I am aware that incomplete or unsigned registration forms will be returned to me for completion. I hereby give permission to the medical personnel selected by the camp director to act in the best interest of my child in the event of an emergency. Every effort will be made to contact the parent, guardian and emergency contacts.

My child is 12 or older and has my permission to walk from the bus YES NOI do not wish photos to be taken of my child

Signature of Parent or Guardian (Required) ____________________________________________ Date ________________________I am currently registered in the Y Child Care program. Please continue drafting my EFT account on file, with new camp fees. Full payment enclosed EFT account on filePayment Information

Check Total $____________________ Cash Total $____________________ Credit Card Total $____________________

Credit Card Type/Number ________________________________________________________________________________________ Exp Date _________________________

Name as it appears on Credit Card _____________________________________________________________________________ CVV _______________________________

Signature _____________________________________________________________________________________________________________ Date ______________________________

Total • All Sessions $_________

Extended Care & $_________Transportation Fees

Discounts $ ________

Total Fees Due $___________

Parent Agreement Payment is due one week prior to the camp session start.

Please contact me to set up a payment plan!

Email _________________________________________ Phone ______________________________

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YES! I want to donate to support sending kids to Camp! Donation $ ________________________________

REGISTRATIONPlease fill out the chart below with all necessary information including which camps and sessions you would like your child to attend.

Please note that a non-refundable deposit fee of $25 per session, per child, is required at the time of registration.

A B C D E F G H I

Session June 22-26June 29 -

July 3July 6-10 July 13-17 July 20-24 July 27-31 Aug 3-7 Aug 10-14 Aug 17-21

Camp Name (location)

Traditional Camp

Specialty Tier 1

Specialty Tier 2

Specialty Tier 3

CIT Counselor In Training • Session B-I (8 Weeks)

BEFORE AND AFTER CAMP OPTIONS

**Please Note: Transportation is provided at Mattapoisett & Dartmouth ONLY. See bus schedule for routes. **

Transportation Rates

Bus Each Way: Members $10 Program Participants: $20

Extended CareAM or PM Extended Care AM & PM Extended Care Members: $30 Members: $50Program Participants: $40 Program Participants: $60

Session A B C D E F G H I

7am-9amExtended Care

4pm-6pmExtended Care

AMBus

Bus: Stop #

Bus: Stop #

Bus: Stop #

Bus: Stop #

Bus: Stop #

Bus: Stop #

Bus: Stop #

Bus: Stop #

Bus: Stop #

PMBus

Bus: Stop #

Bus: Stop #

Bus: Stop #

Bus: Stop #

Bus: Stop #

Bus: Stop #

Bus: Stop #

Bus: Stop #

Bus: Stop #

Parent Approved Drop Off

Parent Approved Pick Up

Group with friend (both campers must request each other):

2020 YMCA SOUTHCOAST SUMMER DAY CAMPREQUIRED FORMS

Please provide the camp with any information that will help give your child a positive camp experience. • Registration Form – Every camper must have this form signed by a parent/guardian. • Health History – Every camper must have this form completed each year. • Immunization Record – Every camper must have this form or equivalent signed by physician. •HealthInsuranceCard-EverycampermusthaveacopyoftheirHealthInsuranceCardonfile. • A current physical within last 12 months.

Medication Forms are available upon request.

PAYMENT OPTIONS

Weekly payment plans are available. Sign up for electronic payments using your checking account or credit card. Contacttherespectivecampofficeformoreinformation.Registrationswillnotbeheldpasttheduedatewithoutfullpayment.

DEPOSIT

A deposit fee of $25 per session, per child is required at the time of registration. The deposit fee is not refundable and cannot be transferred to other programs, persons or sessions. This deposit is applied toward your total camp fee. Families with a current PACE voucher do not need to provide a deposit, but all paperwork including a copy of the voucher is required to reserve your child’s place at camp.

PAYMENT DUE DATES

Payment is due one week prior to the camp session start date. If payment lapses, your child may not be able to participate.

CANCELLATIONS, REFUNDS, AND WITHDRAWALS

A written one week notice is required to withdraw your child from camp. Tuition, less than the $25 deposit, will be refunded if notice is received one week prior to your child’s camp session. Refunds after the start of the camp sessions are made only if the child has an illness or an injury requiring doctor’s care or a note from the physician stating that he/she is unable to participate in camp activities. Please be advised that refunds take 2-3 weeks. Requests for session changes should be submitted at least one week prior to the earliest session involved in the change.

CAMP FOR ALL FINANCIAL ASSISTANCE

Ifeconomicorotherfamilycircumstancespreventyourchildfromparticipatinginourcamp,pleasefilloutafinancialassistance application and return it to the camp of your choice by May 1, 2020. Financial aid will be awarded based on eligibility and in the order applications are received. Priority will be given to those received by the deadline. •Allrequireddocumentationmustaccompanyrequest.Allrequestsarekeptconfidential. • YMCA SOUTHCOAST welcomes all recipients of state vouchers and subsidy programs. If you are eligible to receive funding through a voucher agency, a copy of the voucher is required to reserve a space for your child. If you have an approved voucher for camp you will be charged according to your parent fee amount.

MULTI-CHILD DISCOUNT

Tothankyouforyourfamily’scommitmenttoourcampsweofferdiscountsformultiplechildrenattendingthesameweekfromthesamehousehold.Familieswhoreceivefinancialaidorothersubsidizedfundsarenoteligibleforthisdiscount. •2ndChild-$20offpersession •3rdChild-$25offpersession •4ormoreChildren-$30offpersession

EARLY REGISTRATION DISCOUNT REGISTER NOW & SAVE!

•Registerfor4weeksofcampatfullpriceby5/1/20andreceive20%offeachadditionalweekperchild. •Registerfor4weeksofcampatfullpriceafter5/1/20andreceive10%offeachadditionalweekper child.

AUTHORIZED PICK UP

Please list anyone who is 16 or older that you would allow your child to be released to when it is time to pick them up fromcamp.Properidentificationisrequiredbeforeachildwillbereleased.Thispolicyisstrictlyenforced.

2020 CAMP RATES

1 Week Sessions 2 Week Sessions 8 Week Sessions

Traditional Camp

Member: $235Program Participant: $285

Member: $470Program Participant: $570

Counselor in TrainingMember: $490 Program Participant: $535

Specialty Tier 1

Member: $270Program Participant: $320

Member: $540Program Participant: $640

Specialty Tier 2

Member: $290Program Participant: $340

Member: $580 Program Participant: $680

SUMMER 2020 SPECIALTY CAMP TIERSCAMP STANDARD SPECIALTY TIER 1 SPECIALTY TIER 2

FREDERICK DOUGLASNew Bedford

Traditional Camp

MASSASOITMattapoisett

Traditional Camp,Leaders in

Training (LIT)

All Stars, Ocean Kayak, Camp Chefs, Fishing, Silly Science, Spy, Sailing Explorers, Picasso, Camp Champs, Movie Making, Drama, Pottery, Spy

Sailing: Advanced Opti Racing, Golf ($50 Add Greens Fee), Sailing

METACOMETDartmouth

Traditional Camp,Leaders in

Training (LIT),Scampers

Adventure, Picasso, Sports, Learn to Swim, Jr. Lifeguard, Lego Masters,

Camp Chefs, Young Farmers, Fitness & Yoga, Up & Atom, Drama, Summer

School

Ocean Kayak & SUP

NEP-IN-NAEWareham

Traditional Camp,Leaders in

Training (LIT)

Gymnastics, Flag Football, Basketball, Dance, Floor Hockey, Adventure,

Picasso, Movie Making, Jr. Lifeguard Science, Learn to Swim, Water Sports,

Karate, Strength & Conditioning

QUEQUECHANFall River

Traditional Camp

WEETAMOESwansea

Traditional Camp,Leaders in

Training (LIT),Scamper

Magic, Basketball, Silly Science, Soccer, Tennis, Ninja Warrior, Karate, Flag Football, Survivor, Acro, Cheer, Dance, Spy, Ropes Course Challenge, K’Nex Engineering, Theater, Picasso,

Shark Tank, Camp Chefs

Mastermind

QUESTIONS? WE ARE HERE TO HELP!Visit us at ymcasc.org or call your local Y branch for more information.

AGES FOR ALL CAMPSPROGRAM MASSASOIT METACOMET NEP-IN-NAE WEETAMOETraditional 5 to12 5 to 12 5 to 12 5 to 12

CIT 15 to 16 15 to 16 15 to 16 15 to 16

LIT 13 to 14 13 to 14 13 to 14 13 to 14

All Stars 7 to 10

Camp Champions 9 to 14

Sailing Explorers 7 to 8

Scamper 4 to 5 4 to 5

Learn to Swim 5 to 12 5 to 12

Mastermind 8 to 14

Jr. Lifeguard 11 to 15

Ocean Kayak & SUP 11 to 15

All Other Specialty Camp Programs

8 to 14 8 to 12 7 to 12 8 to 12

*Camp Frederick Douglas & Camp Quequechan offers Traditional Camp only for ages 5 to 12 years old.

CAMP MASSASOIT BUS SCHEDULE • Sessions A-IBus A Stop # Marion • Mattapoisett • Rochester • Wareham AM PM

1 Rochester Memorial School, 16 Pine Street, Rochester 7:45 5:10

2 Gleason Family YMCA, 33 Charge Pond Road, Wareham 8:06 4:52

3 Decas Elementary School, 760 Main Street, Wareham 8:13 4:45

4 Brew Fish, 210 Spring Street, Marion 8:24 4:34

5 Intersection of Point Road & Delano Road, Marion 8:33 4:25

6 Sippican Elementary-Rear Enterance, 16 Spring Street, Marion 8:43 4:14

7 ORRHS, 135 Marion Road, Mattapoisett 8:50 4:07

Bus B Stop # Dartmouth • New Bedford AM PM

1 DeMello School, 654 Dartmouth Street, Dartmouth 7:50 5:11

2 Potter School, 185 Cross Road, Dartmouth 8:05 4:56

3 Quinn School, 529 Hawthorn Street, Dartmouth 8:15 4:46

4 Winslow School, 561 Allen Street, New Bedford 8:21 4:40

5 Taylor School, 620 Brock Avenue, New Bedford 8:30 4:31

6 Keith Middle School, 225 Hathaway Blvd, New Bedford 8:43 4:18

Bus C Stop # Acushnet • East Freetown • New Bedford • Fairhaven AM PM

1 Acushnet Fire Department, 26 Russell Street, Acushnet 7:45 5:00

2 Acushnet Elementary, 800 Middle Road, Acushnet 7:56 4:50

3 Irving Gas, 4 Chase Road, East Freetown 8:09 4:40

4 Pulaski School, 1097 Braley Road, New Bedford 8:18 4:34

5 Fairhaven High School, 12 Huttleston Avenue, Fairhaven 8:34 4:17

6 Tractor Supply Co., 9 Plaza Way, Fairhaven 8:45 4:12

7 Wood School, 60 Sconticut Neck Road, Fairhaven 8:50 4:09

Bus D Stop # New Bedford • Fairhaven AM PM

1 Campbell Elementary School, New Bedford 8:10 4:50

2 Swift Elementary, 2203 Acushnet Avenue, New Bedford 8:16 4:44

3 Lincoln Elementary, 445 Ashley Blvd, New Bedford 8:23 4:37

4 Carlos Pacheco School, 1261 Mt Pleasant Street, New Bedford 8:43 4:24

5 Carney Academy, 247 Elm Street, New Bedford 8:43 4:17

6New Bedford YMCA, 25 South Water Street, New Bedford *Side of Y on S SecondStreet (not Y Parking lot

8:48 4:12

CAMP METACOMET BUS SCHEDULE • Sessions A-IBus A Stop # Westport • Dartmouth • New Bedford AM PM

1 Whites of Westport, Route 6, Westport 8:00 5:00

2 McDonalds, 135 Faunce Corner Road, North Dartmouth 8:20 4:50

3 Ocean State Job Lot Plaza, Kings Highway, New Bedford 8:35 4:35

4New Bedford YMCA, 25 South Water Street, New Bedford*Side of Y on S SecondStreet (not Y Parking lot)

8:50 4:20

5 Dartmouth YMCA, 276 Guld Road, Dartmouth 9:00 4:00

CAMP WEETAMOE • Sessions A-IBus A Stop # Fall River AM PM

1 Fall River YMCA, 199 North Main Street, Fall River 8:30 4:15

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OfferAvailablethrough5/1/2020.OffercannotbecombinedwithanyotheroffersorFinancial Assistance.

BEST SUMMER EVER.Register the same child for 4 weeks of camp at full price and receive each additional week (per child) at 20% off.

Register for all nine weeks and your camper will receive an exclusive camp t-shirt!

IF YOU REGISTER FOR THE FULL SUMMER THIS EQUALS A FREE WEEK!