YMCA mission: To put Christian principles into practice through programs that build a healthy spirit, mind and body for all.

5th, 6th & 7th Grade

Camper's Name: Full Member Non Member

Birthday:

Week 1 - June 3-7 Week 6 - July 8-12 *Additional FeeBefore Camp $25 After Camp $32 Before Camp $25 After Camp $32

Traditional - Camp Kick Off! Traditional - OlympicsDungeons & Dragons Club $15

Week 2 - June 10-14 *Additional Fee Jr. Lifeguard Training $15Before Camp $25 After Camp $32 Volleyball $8

Traditional - GrossologyBaseball/Softball $8 Week 7 - July 15-19 *Additional FeeGarage Band Camp $15 Before Camp $25 After Camp $32Outdoor Adventure $15 Traditional - Wet-N-Wild

Bowling $35Week 3 - June 17-21 *Additional Fee Busy Builders $25

Before Camp $25 After Camp $32 Kick Start Fitness $10Traditional - Wizardly WondersBeauty Boot Camp $20 Week 8 - July 22-26 *Additional FeeEager Entreprenuers $5 Before Camp $25 After Camp $32Fishing Camp $15 Traditional - Camp Mayhem

Basketball $8Week 4 - June 24-28 * Additional Fee Cheer $15

Before Camp $25 After Camp $32 Trendy Tweens $20Traditional -Animal AnticsAct It Out $15 Week 9 - July 29- August 2 *Additional FeeCulinary Creations $25 Before Camp $25 After Camp $32Gymnastics $15 Traditional - Explore Your Senses

Art $25Week 5 - July 1-5 *Closed July 4 Football $8

Before Camp $25 After Camp $32 Soccer $5Traditional - Happy Birthday America

Week 10 - August 5-9Before Camp $25 After Camp $32

Traditional - Campers Vs. Counselors

*Publicly Funded Childcare participants arerequired to pay additional fees at time of registration.(This does not include Before/After Camp fees)

*Deposits & Specialty camp fees are non-refundable &non-transferable.

Camp Sign up

______________________________________________ _____________ Child’s Last Name First Date of Birth Shirt Size

Payment Method:

Private Pay Third Party Pay (Authorization required at time of registration)

___Cash, Check or Charge Weekly ___ODJFS (Minimum of 25 hours of attendance per week. All($25 deposit per week of camp due at registration.) specialty camp fees are due at time of registration.)

___Clinical Committee/Family First Counsel ___Bank Draft (additional form required) (No deposit required at registration. *This does not apply to ODJFS participants registering after their eligibility date.)

(Contract required at time of registration)

___MRDD (Contract required at time of registration)

___Other_______________________

FEES/ENROLLMENT SCHEDULE:Please use the camp selection form to select the weeks your child will be attending camp. There is a $25 non-refundable deposit for each week of camp enrolled. This amount is deducted from the weekly fees. Register before April 15, 2019 to receive early registration prices.

Wavier: I realize that there is a risk of being injured that is inherent in all programs. I realize the risk of injury may be severe. The LCFYMCA carries no medical coverage on any participant. If your child is injured, your insurance is responsible.

Payment: I agree to pay my child’s weekly fees no later than the Friday prior to each week of care provided. I understand a late fee of $15 may be assessed if payment is not made on time. I understand that returned checks for insufficient funds or declined credit cards are assessed a $20 processing fee.

Late Pick Up Fee: I understand that the YMCA Day camp program closes at 3:30 PM daily and After Camp closes at 6:00 PM daily. I understand that a late pick up fee will be assessed to my child care account for any pick up starting at 3:31 PM for Day Camp participants or 6:01 PM for After Camp participants as outlined in the Parent Handbook.

Membership Status: I understand that in order to receive the full member price for the Summer Day Camp at the YMCA, my child must be a Full Member of the Licking County Family YMCA. This membership is a separate cost from the Day Camp program. Please refer to the membership enrollment form for additional information regarding memberships.

YMCA Mission: To put Christian principles into practice through programs that build healthy spirit, mind and body for all.

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LICKING COUNTY FAMILY YMCA 470 W Church St, Newark OH 43055

Phone: 740-345-9628 Fax: 740-349-8535 Summer Day Camp Registration

Child’s Name

School Attended Last Year City, State

Immunizations

Is your child current on all of their immunizations:

o Yes, they are current o No, they are NOT current (ODJFS Child Medical Statement Required)

Medical insurance provider:__________________________ Date of last tetanus vaccine: _____________Transportation

The YMCA vans and buses will be responsible for the transportation of children to and from any fieldtrip destinations specific to his/her specialty or traditional camp. Please indicate permission for these trips.

o Yes, I grant permission o No, I do NOT grant permission

Participation Statement

Is there any reason your child should NOT participate in camp or certain activities? o Yes o No If yes, please explain:

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Swimming Ability

Please check which category best describes your child’s swimming ability.

o Non-Swimmer o Beginner o Intermediate/Advanced Swimmer

*There will be a water test for any child entering 3rd - 7th grade or above who would like access to the deep end of the swimmingpool. Children in grades 1st and 2nd grade are not allowed access to the deep end while at camp.

Photo Permissions

The YMCA occasionally will take pictures of campers, LITs and CITs during camp activities for use in promotional materials. Do you grant the YMCA permission to take/use photographs of your child?

o Yes, I grant permission o No, I do NOT grant permission

Creek Walking Permission

The YMCA occasionally takes the campers Creek Walking as safety allows with the creek water level. You will be notified in advance to the day of the event, as your child will need to bring an extra pair of clothes and shoes to participate that day.

o Yes, I grant permission o No, I do NOT grant permission

Pick Up Permissions

The following people have my permission to pick up my child. Parents/Guardians and Emergency Contacts already listed on the ODJFS Child Enrollment form do not need to be listed here.

Name Relationship to Child Phone Number

* Please attach a copy of any custody paperwork that would affect your child while in our care.

By signing, I hereby acknowledge all of the above statements to be true and permissions granted.

___________________________________________________ _______________

Parent/Guardian Signature Date

YMCA Mission: To put Christian principles into practice through programs that build a healthy spirit, mind and body for all.

5th, 6th and 7th Grade Permissions

I hereby give permission for my child, _____________________ to participate in any of trips that apply to the camps he/she is registered for during the 2019 Summer Day Camp program. Transportation will be completed through the LCFYMCA bus.

• Traditional Camp will take a walking field trip to the Roll-A-Way Skating Center on the following dates; June 7, 14, 28 and July 5, 19, 26 from 12:30-2:15pm.

• Beauty Boot Camp will take a trip to C-TEC on June 19 and June 20 from 12:00-3pm.

• Garage Band Camp will take a trip to Martins Music on June 11 from 10:15-12pm.

• Outdoor Adventure Camp will take a trip to Broken Arrow Archery on June 13 from 9:15am-12pm.

• Act It Out Camp will take a trip to Weathervane Play House during the week of June 24-28 between the hours of 9:30-2pm.

• Bowling Camp will take a trip to Park Lanes Bowling Alley daily during the week of July 15-19 from 9:30-12:30pm.

• Art Camp will take a walking field trip to Flory Park daily during the week of July 29-August 2 from 9:30am-12pm.

• Culinary Creations Camp will take a trip to Auntie Anne’s at the Indian Mound Mall on June 26 from 9:30-11:30am.

• Baseball/Softball Camp will take a trip to Don Edwards Park on June 10 from 9:30-11:30am.

• Volleyball Camp will take a trip to Don Edwards Park on July 9 from 9:30-11:30am.

• Fishing Camp will take a trip to the Hebron Hatchery on June 17, 18 and 20 from 9:10-12:45pm.

• Fishing Camp will take a trip to TJ Evans Park on June 21 from 9:45am-12pm.

• Eager Entrepreneurs Camp will take a trip to the 21st Wal-Mart on June 17 and/or June 18 from 10:15-11:15am.

• Trendy Tweens Camp will take a trip to Flory Park during the week of July 22-26 from 9:30am-12:30pm.

__________________________ __________

Parent Signature Date

Camper Information

Camper Name: _____________________________________ Date of Birth: ______________________

By providing complete information about your child, you will be assisting counselors in creating a positive

experience for your child. List any information about your child’s habits, abilities or personality that you

feel will be helpful to the staff while caring for your child.

Who is in your child’s immediate family?

____________________________________________________________________________

____________________________________________________________________________

Who lives at home with your child?

____________________________________________________________________________

____________________________________________________________________________

What is the primary language spoken in your child’s home? ____________________________________

Are there any special family arrangements, such as shared parenting, living in two homes, or custody

specifications, etc.?

____________________________________________________________________________

____________________________________________________________________________

Are there any changes or transitions that your child has recently experienced or is experiencing? (move,

divorce, new home, death of a family member, friend or pet)?

____________________________________________________________________________

____________________________________________________________________________

Are there any cultural or religious practices of your family we should be aware of?

____________________________________________________________________________

___________________________________________________________________________

Does your camper have any favorite foods?

____________________________________________________________________________

Does your camper dislike any foods?

____________________________________________________________________________

Does your camper have any mental health issues we should be aware of? If yes, please explain: __________________________________________________________

Please check all of the words that best describe your child’s personality and behavior?

❏ active

❏ adventurous

❏ affectionate

❏ bossy

❏ bright

❏ busy

❏ calm

❏ cautious

❏ cheerful

❏ content

❏ creative

❏ curious

❏ easily-angered

❏ emotional

❏ energetic

❏ excitable

❏ friendly

❏ gives-in-easily

❏ happy

❏ hesitant

❏ insecure

❏ jealous

❏ likes structure/routines

❏ loud

❏ loving

❏ mellow

❏ outgoing

❏ prefers adult attention

❏ quiet

❏ sensitive

❏ serious

❏ shares well

❏ social

❏ spontaneous

❏ stubborn

❏ tentative

Are there things that frighten your child? if so, how does he/she react and what do you do to comfort

him/her?

____________________________________________________________________________

____________________________________________________________________________

What routines/actions or items do you use to comfort your child?

____________________________________________________________________________

____________________________________________________________________________

What causes your child to feel angry or frustrated?

____________________________________________________________________________

____________________________________________________________________________

What methods do you use to respond to your child’s negative behavior?

____________________________________________________________________________

____________________________________________________________________________

What might you and/or your child be anxious about as he/she starts in the program?

____________________________________________________________________________

____________________________________________________________________________

What are you and/or your child excited about as he/she starts in the program?

____________________________________________________________________________

____________________________________________________________________________

What are your expectations of this program?

____________________________________________________________________________

____________________________________________________________________________

What other information would be helpful for the staff caring for your child to know?

____________________________________________________________________________

____________________________________________________________________________

✏ Parent Signature : _____________________________________Date: ________________________

Parents,

Attached is a new goals form. We are now a 4 star rated program through the state and we’re excited

to offer this high quality programming throughout the summer.

One of the requirements is to create two goals for students to accomplish throughout the summer.

Please choose two goals that you would most like your camper to focus on this year. Write those goals

into the boxes marked Developmental/Educational goal on the form. Fill in sections for Child Name, Date

of Birth, and Parent Signature and Date.

If you need suggestions on appropriate goals, you can choose from the list below:

Goals:

1. By the end of the summer, (Student’s name) will know how to disagree without starting a fight

or argument.

2. By the end of summer camp, (Students name) will practice age appropriate self-help skills such

as keeping track of personal belongings, tying shoes, dressing for swim, opening lunch items,

etc.

3. By the end of summer camp, (Student’s name) will build positive relationships with same aged

peers.

4. By the end of summer camp, (Student’s name) will show character traits of caring, honesty,

respect and responsibility.

5. By the end of summer camp, (Student’s name) will show empathy toward peers.

Best,

YMCA Childcare

Developmental and Educational Goals For Step Up to Quality Name of Child: Date of Birth:

Developmental/Educational Goal (1):

Goal timeline: June 3-Aug 9 2019 Goal met: Yes/No

Comments on Progress:

Developmental/Educational Goal (2):

Goal timeline: June 3-Aug 9 2019 Comments on progress:

Comments on Progress:

Parent/Guardian's Signature: Date:

Teacher's Name/Signature: Date:

I hereby authorize the LCFYMCA to automatically charge the credit card referenced below for my child’s

Summer Day Camp account balance. I understand that the balance for each session of camp will be charged

on the Friday, three days prior to each session. Further, I understand that the charge to my account will take

place on a weekly basis for the camp in which my child is enrolled. It is my responsibility to check my credit

card statement and report any discrepancies to the Camp Site Director within 7 days of the charge in

question. I understand that I am financially responsible for all payments. Should any charge be rejected by

my financial institution for any reason, I agree to be responsible for that payment and any additional late

fees incurred. If full payment is not made I agree to pay for all fees associated with the collection of funds. I

understand that it is my responsibility to notify the LCFYMCA of any change in my credit card information,

including the expiration date, and that changes must be submitted in writing at least 7 business days in

advance of the draft date. This agreement will remain in effect until LCFYMCA receives a written notice of

cancellation from me or until the end of camp.

ACCOUNT INFORMATION

Print your name as it appears on card or bank account:__________________________________________________

Credit Card Number:__________________________________________ CRV_________ Expiration Date: ______/_______

Zip Code:____________ Financial Institution:______________________________

Account #:______________________________________ Routing #:______________________________________

First withdrawal date:______________________________

Savings:______ -or- Checking:_______

SIGNATURE

Authorized Signature:__________________________________________Date:_____________

Camp Location:_____________________________________________________________________

Child #1 Name: _______________________________________Child # 2 Name:______________________________________

Child #3 Name:_______________________________________ Child #4 Name:_______________________________________

Parent’s Name:_______________________________________________________________________________

AUTOMATIC PAYMENT OPTION FORM

Scholarships are available based on camp capacity,

demonstrated need and the YMCA’s ability to fund the

assistance. In order to provide the most assistance for

the largest number of people, we request that you first

determine whether you are eligible for child care

assistance through the county in which you reside. Once

approved, bring us a copy of your Notice of Approval

and your YMCA Day Camp registration form.

Contact your County ODJFS office early as you must

be approved in the online Ohio system before we can

register your child.

If it has been determined that you are ineligible for

assistance through the county program, please ask for a

letter of declination and we will gladly review your

eligibility for assistance through the YMCA Scholarship

Program. Scholarship applications are available at the

Member Service Desk. Applicants need to supply their

most recent W-2 forms and most recent tax returns.

ODJFS Child Care Assistance and YMCA Scholarship Information

LICKING COUNTY FAMILY YMCA RELEASE and WAIVER of LIABILITY and INDEMNITY AGREEMENT for GUESTS

IN CONSIDERATION of being permitted to utilize the facilities, services and programs of the YMCA for any purpose, including, but not limited to observation or use of facilities or equipment, or participation in any off-site program affiliated with the YMCA, the undersigned, for himself or herself and any personal representatives, heirs, and next of kin, hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating will, inspect and carefully consider such premises and facilities or the affiliated program. It is further warranted that such entry into the YMCA for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgement that such premises and all facilities and equipment thereon and such affiliated program have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use or participation.

IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY OFF-SITE PROGRAM AFFILIATED WITH THE YMCA. THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:

1. THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the YMCA and all branches thereof, its directors, officers, employees, and agents (hereinafter referred to as “releasees”') from all liability to the undersigned, his personal representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the releasees or otherwise while the undersigned is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the YMCA.

2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees and each of them from any loss, liability, damage or cost they may incur due to the presence of the undersigned in, upon or about the YMCA premises or in any way observing or using any facilities or equipment of the YMCA or participating in any program affiliated with the YMCA whether caused by the negligence of the releasees or otherwise.

3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE due to negligence of releasee or otherwise while in, about or upon the premises of the YMCA and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the YMCA.

THE UNDERSIGNED further expressly agrees that the foregoing RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of Ohio that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made.

I HAVE READ AND UNDERSTAND THIS DOCUMENT AND RELEASE

D a t e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Print Name of Child:_____________________________ DOB:______/______/______

Address:_________________________________________________________________________________________________________________________________________

Parents Signature :_________________________________________________________________

YMCA mission: To put Christian principles into practice through programs that build healthy spirit, mind and body for all.