THE YMCA OF SOUTHERN MAINE

www.ymcaofsouthernmaine.org

Maine State Subsidy Information

What is the Child Care Subsidy Program?

The Child Care Subsidy Program helps eligible families pay for child care so they can work, go to school, or

participate in a job training program.

The State manages several subsidy/voucher programs. There is one application for all programs. If your application

is approved, the State will assign you to the appropriate program.

Who is eligible to receive Child Care Subsidy?

Eligible families must meet the income guidelines and at least one of the following activities:

Work

School

Job training program

How do I apply?

1. At a local DHHS office or online at https://www1.maine.gov/benefits/account/login.html

You will complete a “pre-screen” application to see if you are eligible.

Once you are deemed to be financially eligible, proceed to Step 2.

2. Complete the Child Care Subsidy Program Application and return it to the Office of Child and Family Services:

Fax: 207-287-6308 Email: CCSP.DHHS@maine.gov

Mail: 2 Anthony Ave. SHS#11 Augusta, ME 04333

Once you are determined to be program eligible and the provider you choose is approved, payments

will be made directly to your provider on your behalf.

Once you have been approved, please complete the YMCA Camp Application for families receiving

State subsidies/vouchers. This includes two subsidy related forms and the full camp application.

Your approval letter is needed as well.

Maine State Income Guidelines

A household making less than the annual income listed below, for the various family sizes listed, will meet the

financial guidelines required for State subsidy/voucher support.

Family Size Annual Income Monthly Income

(Annual/12) Weekly Income

(Annual/52)

1 $35,022.75 $2,918.56 $673.512 $45,798.99 $3,816.58 $880.75

https://www1.maine.gov/benefits/account/login.html

THE YMCA OF SOUTHERN MAINE

www.ymcaofsouthernmaine.org

3 $56,575.22 $4,714.60 $1,087.984 $67,351.45 $5,612.62 $1,295.225 $78,127.68 $6,510.64 $1,502.466 $88,903.91 $7,408.66 $1,709.697 $90,924.46 $7,577.04 $1,748.558 $92,945.00 $7,745.42 $1,787.40 9 $94,965.54 $7,913.80 $1,826.2610 $96,986.09 $8,082.17 $1,865.12

*This chart can be found at www.maine.gov

APPLYING FOR CAMP WITH MAINE STATE SUBSIDY PROGRAMS

Your application is not complete until you have submitted the following forms. Applications will not be reviewed

until all forms are included.

DHHS Authorization to Release Information

Child Care Provider Information Form

YMCA State Subsidy Information Form

Personal Subsidy Award Letter (issued by the State)

Registration Packet (one per child)

DHHS Authorization Form 11/15 Page 1 of 2

Authorization to Release Information

We are committed to the privacy of your health information. Please read this form carefully.

Office of MaineCare Services Substance Abuse and Mental Health ServicesOffice for Family Independence including Medical Review Team Office of Child and Family ServicesMaine Centers for Disease Control and Prevention Office of Aging and Disability Services Dorothea Dix Psychiatric Center Office of Administrative Hearings Riverview Psychiatric Center Other:

Individual’s Name: Individual’s Date of Birth:

Individual’s Social Security Number:

Individual’s Address:

Street Town/City State Zip Code

Records to be released, including written, electronic and verbal communication:

All Healthcare, including treatment, services, supplies and medicines

Claims Information Billing, payment, income, banking, tax, asset, and/or other information regardingeligibility for DHHS program benefits such as MaineCare

Other: Any and all information related to child care subsidy award eligibility, award status, billing status, parent fees, or any otherinformation regarding payment or billing._________________________________________________________________________________________________ Limit to the following date(s) or type(s) of information:

(e.g. “lab test dated June 2, 2013” or “hospital records from 1/1/14 - 1/15/14”)

I authorize the DHHS office(s) checked above to: Release my information to: Obtain my information from:

Name: YMCA of Southern Maine

Address: 70 Forest Ave. Portland ME 04101 Street Town/City State Zip Code

Fax No., where applicable: 207-842-2966 Phone No. to verify Receipt of Fax : 207-874-1111

If requesting that electronic information be transmitted by email, please clearly print the email address below:

I understand that DHHS systems may not be able to send my information securely through email. I understand thatemail and the internet have risks that DHHS cannot control and that the information possibly could be read by a thirdparty. I accept those risks and still request that DHHS send my information by email. Initials _______

Please allow the office(s) named above to disclose my information for the following purpose(s):

For a legal matter, including an administrative hearing To see if I qualify for insurance coverage or benefits For coordination of my care A Personal Request Other (note here):

X

X

X X

X

X To confirm eligibility & payment for child care services.

DHHS Authorization Form 11/15 Page 2 of 2

By initialing below, I agree to disclose the following types of records:

_______ Mental health treatment provider or program

_______ Substance/alcohol/drug Abuse treatment provider or program

_______ HIV infection status or test results: Maine law requires us to tell you that releasing this information may have implications. Positive implications may include giving you more complete care, and negative implications may include discrimination if the data is misused. DHHS will protect your HIV data, and all your records, as the law requires.

I (individual/personal representative of individual) permit DHHS to release and/or obtain my records as written on Page 1 of this form. I understand and agree to the following:

• This form will expire one year from the date I sign below, unless I revoke (take back) my permission sooner. Imay revoke my permission to share my records at any time by contacting the Privacy Official of the officereleasing those records. If DHHS released my records, I may call 207-287-3707 and ask for the office where Ireceive services to revoke my permission.

• I understand that taking back my permission does not apply to the information that was already shared after Isigned this form.

• If I take back my permission, or if I refuse to release some or all of my healthcare or insurance information, thatmay result in improper diagnosis or treatment, denial of insurance coverage or a claim for health benefits, orother adverse consequences.

• This form permits the people or offices listed on Page 1 to speak to each other for the purpose(s) on this form.

• If I am disclosing healthcare information, I agree that records of other providers (such as doctors, hospitals, andcounselors) in my file are included in this release.

• Unless I am applying for benefits, DHHS will not condition my treatment, payment for services, or benefitson whether I sign this form.

• I have the right to make a written request to review my records. If I wish to receive a copy of my healthcareor billing information, a fee may be charged as permitted by law.

• If I want to review my mental health program or provider records before they are released, I must checkTHIS BOX. I understand that the review will be supervised.

• DHHS offices will keep my information confidential as required by law. If I give my permission to share myrecords with people who are not required by law to keep them private, they may no longer be protected byfederal confidentiality laws.

• If alcohol or drug treatment or program records are included in this release, federal law requires the personsharing those records to include a notice saying that such information may not be re-released or sharedwithout my written permission, unless required or permitted by law.

• I am signing this form voluntarily, and I have the right to a signed copy of this form if I request one.

Date: ____________ Signature_____________________________________________________________________

Personal Representative’s authority to sign: _____________________________________________________________

Child Care Subsidy Program Provider Information Sheet (To be completed by Provider)

Parent Name: ________________________________________________________________________________________________________________________________________

Child(ren’s) Name(s): _______________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________

When is child expected to attend your program? ___________________________________________________________________________________________(Must have specific start date)

Child Care Subsidy Program 2 Anthony Avenue, 11 State House Station Augusta, ME 04333-0011Email: CCSP.DHHS@Maine.gov Fax: 207-287-6308

Department of Health and Human ServicesChild and Family Services – Child Care Subsidy Program

2 Anthony Avenue11 State House Station

Augusta, ME 04333-0011Tel.: (207) 624-7999; Fax: (207) 287-6308

Toll-Free (877) 680-5866; TTY Users: Dial 711 (Maine Relay)

Business Name: YMCA of Southern Maine

Name of Contact Person: Stela Markova-Kanin

Provider Address: 70 Forest Av, 04101 Portland, ME

Provider Telephone: 207-874-1111 Ext. 317

Provider E-mail: smarkova@ymcaofsouthernmaine.org

TYPE OF PROVIDER (one type)

☐ Licensed Child Care License Number: _________________________________________________________________________________________

Do you currently participate in the Quality for ME Quality Rating System? ☐ Yes ☐ No

☐ License-Exempt ProviderMust be 18 years old and may not reside at the same address as the child(ren); and,Can only Can only watch a maximum of two (2) children in provider home; and, In-Home License-Exempt Provider can care for no more than six (6) children total (including provider’s children).

CHECK ONE:in Provider’s Home ☐ Unrelated

☐ Related (Must Indicate relationship) _______________________________________________________________________

in Child's Home ☐ Unrelated☐ Related (Must Indicate relationship) _______________________________________________________________________

☐ School Age Program/Recreational

SIGNATURE REQUIRED: Please sign, date and return:

By signing below, you acknowledge that the Child Care Subsidy Program does not pay retroactively and the parent is responsible for all payments until you receive an award letter. If you are a new provider to the Child Care Subsidy Program, you will be receiving additional paperwork that needs to be completed.

____________________________________________________________________________ ____________________________________________________________Provider’s Signature Date

*Background check paperwork for License-Exempt Providers may take up to 45 days to process.

RETURN COMPLETED FORM TO:Questions? Call: (877) 680-5866 / (207) 624-7999 Email: CCSP.DHHS@Maine.govFax: (207) 287-6308

x

x

THE YMCA OF SOUTHERN MAINE www.ymcaofsouthernmaine.org

2019 DAY CAMPSTATE SUBSIDY INFORMATION FORM

YMCA OF SOUTHERN MAINE

Child’s Full Name: DOB:

Parent’s Full Name:

Program(s) Child is Attending:

DHHS Agency:

Aspire Child’s “A” Case Number (Required):

Transitional (Award Letter Required – Please Attach)

Child’s “A” Case Number (Required):

CPS: Child’s “A” Case Number (Required):

Voucher (Award Letter Required – Please Attach)

Other – Please List:

Case Manager:

Address:

Phone Number:

County:

2019 CAMPER REGISTRATION FORMYMCA OF SOUTHERN MAINE - DAY CAMPSChild’s First Name: Last Name:Please note you must fill out a separate registration form for each child attending camp.

Date of Birth: Age as of 7/1/2019: Grade Entering Fall 2019:

Gender (identifies as:) Male Female Other

Ethnicity (this is used ONLY for statistical information for grants): WhiteAfrican/African AmericanLatino/Hispanic

PARENT/GUARDIANFirst Name: Last Name:

Address: City: State: Zip:

Best Phone to reach you: 2nd Best Phone:

Relationship to Child: Employer:

Email:

PARENT/GUARDIAN (Only if approved for pick up)First Name: Last Name:

Address: City: State: Zip:

Best Phone to reach you: 2nd Best Phone:

Relationship to Child: Employer:

Email:

With whom does this child live?

Please list at least one NON-PARENT emergency contact:

FIRST EMERGENCY CONTACT First Name: Last Name:

Best Phone *required: Address:

Relationship to Child:

SECOND EMERGENCY CONTACT First Name: Last Name:

Best Phone *required: Address:

Relationship to Child:

Other than those listed above, who is allowed to pick up your child?

If you would like our staff to better understand specific family structures/agreements that could affect your child’s drop-off, daily program, or pick-up, please list here in detail.

AsianPacific IslanderNative American/Alaskan Native

MultiracialOther:Prefer not to answer

Where did you hear about us? Press Herald Friends/Family YMCA Website /Facebook Online search The Sentry The Forecaster Journal Tribune Parent & Family Magazine Other:

1

WAIVERSGeneral Waiver (Required): I hereby, for myself, heirs, and executors waive and release all claims against the YMCA of Southern Maine for any danger my child may suffer or acquire during the YMCA Summer Camp Program.

Parent/Guardian Signature: Date:

Field Trip Transportation Liability Agreement: I give permission for the YMCA to take my child on field trips (bus or walking). I give my permission for my child to be transported by the appropriate YMCA of Southern Maine staff in a YMCA approved vehicle. I assume any and all liability for damages to or caused by my child in connection with the transportation services offered by the YMCA, except those caused by gross negligence or intentional act of the YMCA. I also understand that the YMCA will not be responsible for my child between the YMCA and his/her residence and vice versa.

Parent/Guardian Signature: Date:

Aquatic Permission Slip and Liability Agreement: I give permission for the YMCA of Southern Maine (“YMCA”) to provide scheduled, aquatic opportunities to my child. This permission covers any instructional and recreational activi-ties conducted by the appropriate YMCA staff. I assume any and all liability for damages to or caused by my child in connection with the aquatic services provided by the YMCA, and unconditionally release the YMCA from any and all liability therefor or relating thereto, except those caused by the gross negligence or intentional wrongful act of the YMCA.

Child’s Name: ______________________________________________________________________________

Parent/Guardian Signature: _______________________________________ Date: _____________________________

____ I decline. Signature: __________________________________________ Date: _____________________________(Check here, sign and date if you do not wish to grant permission).

Camp Handbook Agreement: The Camp Handbook can be found on our website, or can be provided by the Camp Director or Membership Team at each Branch location.

I hereby acknowledge receipt of the YMCA of Southern Maine’s Camp Handbook. I understand that the policies and procedures may be changed at any time and I will receive notification if and when these changes occur. I have had ex-plained to me any portions of the Camp Handbook about which I did not understand. I realize that by signing I agree to comply with the noted camp policies and procedures.

Parent/Guardian Signature: _______________________________________ Date: _____________________________

Printed Name: _____________________________________________________

Camper’s Name: ___________________________________________________ Camp(s) Attending: _______________

Media waiver on next page…

2

3

PHOTO/AUDIO VISUAL/NARRATIVE RELEASE

Consent. With respect to my child/children named below I hereby give my consent for the National Council of Young Men’s Christian Associations of the United States of America (YMCA of the USA), and/or the YMCA of Southern Maine (YMCA), YMCA of the USA, YMCA and collaborating third parties to make, reproduce, edit, broadcast or rebroadcast:

• video film or footage• sound track recordings• photo reproductions• any narrative account of their experience

My consent gives permission to use the above materials for publication, display, sale or exhibition in promotions, advertising, education and legitimate business uses. Use includes reproductions in any form and media, adaptations and/or revisions.

I understand and agree there may be no compensation for this, and I will not make any claim for payment of any kind. I may, or may not be, identified in such reproductions; however, my child/children’s will not be used to endorse any particular commercial products or commercial services.

Should I wish to revoke this consent at any point in the future, I may do so, but I understand that images may already have been released to the public if such a revocation occurs after publication.

Ownership, Confidentiality, and Shared Use. With respect to any of the above uses, I further agree:

• All uses shall belong to YMCA of the USA and YMCA and either may share them with others;• There is no obligation of confidentiality• YMCA of the USA, YMCA, and collaborating third parties will not be liable for any use or disclosure to a third party• YMCA of the USA and YMCA shall exclusively own all known or later existing rights to the uses worldwide.• YMCA of the USA and YMCA can use any video film, footage, sound track recordings and photo reproductions of

me and/or my narrative account for any purpose and without compensation to me.

Release from Liability. I hereby release and discharge YMCA of the USA, YMCA and their related parties from any and all claims, actions, lawsuits or demands of any kind arising out of my consent, the use, or the shared use of the above materials.

Name(s) of child/children (if applicable):

1. 2.

3. 4.

5. 6.

Signature: Printed Name: Date:

Address:

I do not give consent. Signature: Printed Name:

Date:

4

CAMP 2019 REGISTRATIONStep 1: Choose Your Weeks - Check the boxes that correspond with the camp weeks for which you are registering.

Application D

ate:

JUN

EJU

LYA

UG

UST

DAY

CAM

PSA

ges:1

01

72

41

*8

15

22

29

51

21

92

6Total

Weeks:

Fee/Week*:

Total Due

(# weeks

x fee)

Camp Sokokis

5 - 1

2$2

05

$2

35/2

05*

Camp O

sprey5

- 12

$20

5

$235/2

05*

Camp Pineland

5 - 1

2$2

05

$2

35/2

05*

Otter Pond O

utdoor Adventure Cam

p5

- 12

$22

0

$255/2

20*

In-Town Cam

p5

- 12

$20

5$2

35/2

05*

JUN

EJU

LYA

UG

UST

SPECIALTY

CAM

PSA

ges:1

01

72

41

*8

15

22

29

51

21

92

6Total

Weeks:

Fee/Week:

Total Due

(# weeks

x fee)

Adventure G

irls9

- 12

$255

Creature Catching6

- 9$2

55

Creature Catching9

- 12

$255

Outdoor A

dventure Skills9

- 12

$255

JUN

EJU

LYA

UG

UST

LEAD

ER IN

TRA

ININ

G (LIT)

Ages:

10

17

24

1*

81

52

22

95

12

19

26

Total Sessions

Fee/Session:

Total Due

(# weeks

x fee)

Camp Sokokis

13

- 16

Session 1

Session 2Session 3

$38

5

Camp O

sprey1

3 - 1

6

Session 1Session 2

Session 3$3

85

Camp Pineland

13

- 16

Session 1

Session 2Session 3

$38

5

Otter Pond O

utdoor Adventure Cam

p1

3 - 1

6

Session 1Session 2

Session 3$3

85

In-Town Cam

p1

3 - 1

6

Session 1Session 2

Session 3$3

85

Continued on page 5…

5

CAMP 2019 REGISTRATIONStep 1: Choose Your Weeks - Check the boxes that correspond with the camp weeks for which you are registering.

* Week of 7

/2 is a 4-day w

eek; closed 7/4. See w

eek for pricing. ** M

ust be registered at Otter Pond Cam

p for same w

eek as overnight.*** M

ust be registered at a YMCA

of Southern Maine cam

p for the same w

eek as this overnight.

JUN

EJU

LYA

UG

UST

OV

ERN

IGH

TS!**A

ges:2

71

11

82

32

52

81

41

5Total

Weeks:

Fee/ O

vernight:

Total Due

(# weeks

x fee)

Otter Pond Cam

p Overnights**

8 -1

6

$82

All Cam

ps Overnight at O

tter Pond***8

- 16

$82

Otter Pond LIT-O

nly Overnights**

13

- 16

$82

Total weeks/sessions m

y child will be attending this sum

mer: ___________

Total Fees:$

CAMP 2019 REGISTRATIONStep 2: Calculate Camp Fees

6

1. Carry your total camp fees listed on the bottom of page 4 to line 1 of the Fee Calculator below. 2. Complete the Fee Calculator below. (If you prefer, we can help you with this.)3. Proceed to payment information on page 7.

At the Y, we believe all kids should have the opportunity to discover who they are and what they can achieve through programs like summer camp. That’s why we are committed to serving everyone, regardless of ability to pay. If you have any questions about registering for camp or applying for the Y’s financial assistance or Maine State subsidies, please call us.

1. Total due for camp weeks (from pages 4-5): $Are you.. If yes, apply this adjustment

a. Registering before 5/1? Early Bird ($10 x ___ weeks) $

b. Registering for 7+ weeks Multi-week ($10 x ___ weeks) $

c. Registering siblings Sibling ($10 x # of additional siblings x ___ weeks) $

2. Total Adjustments (add up lines a through c): $

3. Total for Summer Camp 2019 (subtract line 2 from line 1): $

4. Deposit due at registration ($50 per week x ___ weeks) If receiving financial assistance, this amount will be adjusted at the same rate. This adjusted weekly deposit is still required in advance.

$

5. Total Remaining Balance Prior to Financial Assistance (subtract line 4 from line 3): $

YMCA Financial Assistance (Please complete Financial Assistance Application) To be completed by

the YMCAASPIRE or other State Subsidy (Please complete Subsidy Application)

Adjusted Balance:

Deposit is due at registration. Weekly balances are due in full the Wednesday prior to each week of camp through an automatic draft payment. If an automatic payment is not possible, please contact your Camp Director.

Fee Calculator

Payment methods on next page…

7

PAYMENT METHODS

I wish to pay my balance due in full. Total Balance Due: $_________________

I have applied for Financial Assistance (the completed application is enclosed with this registration form). (NOTE: Billing information must be completed below. No payment will be made prior to your acceptance of your awarded fee.)

The following must be completed if not paying in full.I authorize automatic payments for the amount due, as listed below: (NOTE: I understand I am responsible for payment and will be charged an additional $20 NSF charge if any payment is returned or fails to authorize.)

Visa/MasterCard/American Express Charge Name on Credit Card:Card Number: CVC Number: Exp Date:

Auto Draft from Bank Account Name on Account: Account Number: Routing Number:

I am requesting a payment plan other than the week before camp. (NOTE: The Camp Director will be in touch to set this plan up.)

If a State Agency or Independent Agency is assisting you with your child’s camp fees, please fill out the Subsidy Forms and attach it to your camp registration packet.

Signature: Date:

Weekly balances are due in full the Wednesday before camp starts through an automatic draft payment (credit card or checking account). If an automatic payment is not possible, please contact your Camp Director. We are dedicated to working with all families and will not turn a child away due to financial need. Payment schedules, options and financial assistance are available, please ask. Checks, credit card payments, and bank account drafts returned to us by the bank will incur a $20 fee.

You must select one box. Registration cannot be completed (your spot will not be reserved) unless payment information is provided.

Camp SokokisCheyenne Geyer, Camp Director3 Pomerleau St. Biddeford, MEcgeyer@ymcaofsouthernmaine.org207-874-1111 x121

Camp OspreyJohn Lee, YD Director14 Old S. Freeport Rd., Freeport, MEjlee@ymcaofsouthernmaine.org207-865-9600 x204

Camp PinelandKara Phillips, Camp Director25 Campus Dr., Ste. 100, New Gloucester, MEkphillips@ymcaofsouthernmaine.org207-688-2255 x611

Otter Pond Outdoor Adventure CampLiza Stratton, Camp Director25 Campus Dr., Ste. 100, New Gloucester, MElstratton@ymcaofsouthernmaine.org207-688-2255 x609

In-session address:71 Chadbourne Rd., Standish, ME

In-TownCheyenne Geyer, Camp Director70 Forest Ave., Portland, MEcgeyer@ymcaofsouthernmaine.org207-874-1111 x121

CONTACT US

1

2019 DAY CAMP CHILD ACCOMODATIONS FORM

YMCA OF SOUTHERN MAINE

Child’s Last Name: First Name:

This form is used to assist us in providing the best possible experience for your child while s/he attends

camp. Your signature on this form gives us permission to share this information with the counselors and

staff who will be working with your child.

Does your child have an Individualized Education Plan (I.E.P.) during the school year?

YES _________ NO __________

Does your child have any behavioral or health concerns that you want us to be aware of?

What is your recommendation for the best way for us to help your child?

Are there any specific situations that trigger this concern in your child?

What is typical and/or atypical behavior from your child?

Please note, all of our participants must be able to participate safely in our programs. We do not provide

one-on-one supervision and retain the discretion not to enroll or to remove a participant from our

program if that participant is not able to participate safely in the program. Open communication is the

best way to ensure a happy and safe summer for your child. Please contact your Camp Director with any

questions.

Signature of Parent/Guardian: _________________________________ Date: __________________

2019 DAY CAMP HEALTH HISTORY FORM

YMCA OF SOUTHERN MAINE

Child’s Last Name: First Name:

HEALTH HISTORY

Does your child have any chronic or recurring Illness? Please explain.

Does your child have any reactions to insect bites/stings? (If any, how severe is the reaction?)

Does your child have any allergies? Please explain.

Are there any camp activities your child should be exempt from because of health reasons?

Record of past medical treatment if any:

Does your child have Epilepsy: Yes No

o If yes, date of last seizure & severity ________________________________________________________________________________

Does your child have Diabetes: Yes No

o If yes, does your child take medications or insulin?

________________________________________________________________________________

Does your child have Asthma: Yes No

o If yes, does your child carry an inhaler?*** Yes No

Does your child carry an epi-pen? *** Yes No

o If yes, what for: ___________________________________________________________________

Will your child be taking medications while attending camp? Yes No

o If yes, an Authorization to Dispense Medication form is required.

NOTE: Campers/parents MUST check-in ALL medications, epi-pens, inhalers, etc. (including over the counter

medications) with the Camp Director, and proper paperwork for dispensing medications must be provided.

ALL self-administered medications are to be handed to the staff leader in the campers’ group. The staff member

(after checking the medication in with the Camp Director), will carry the medication in their bag while with the

camper, and will pass off the medication to other counselors should the camper switch groups.

If your camper will be taking medications while at camp, please send a week’s worth of medication. This will stay

on campus in a double locked cabinet for the duration of the week, and the bottle will be sent home with the child

(staff passing off to parents), on the last day of the week the camper will attend. If campers are attending multiple

weeks, the medication will need to be re-stocked and sent in with the camper on Monday.

Hospital Preference: ___________________________________________________________________________________________

HEALTH HISTORY FORM WAIVER

This health history form is correct to the best of my knowledge, and my child herein described has permission to

engage in all prescribed camp activities except as noted. I hereby give permission to the medical personnel

selected by the camp director to order x-rays, routine tests, treatment, to release any records necessary for

insurance purposes, and to provide or arrange necessary related transportation for my child. In the event I cannot

be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and

administer treatment, including hospitalization for my child named above.

My child’s immunization records are attached.

I understand the Y does not provide one-on-one supervision.

I understand the Y retains discretion to remove a child if they are unable to safely participate.

Parent/Guardian Signature: ______________________________________________ Date:________________________

2019 DAY CAMP AUTHORIZATION TO DISPENSE MEDICATION

YMCA OF SOUTHERN MAINE

______ I hereby authorize the YMCA of Southern Maine to administer the following medication to:

Child’s Last Name: First Name:

Prescribing Physician (when applicable):

__________________________________________________________________________________________

Name of medication: __________________________________________________________________________________________

Dosage: __________________________When to give: _____________________________________________

Continue this medication until: __________________________________________________________________________________________

NOTE: ALL MEDICATIONS MUST BE IN THE ORIGINAL CONTAINER CLEARLY LABELED WITH THE

DOCTOR’S NAME AND THE CHILD’S NAME.

I have given the first dosage on: _________________________________________________________________________________________

Signature of parent/guardian: _______________________________________ Date: ___________________

RECORD OF MEDICATION The YMCA uses this to record the amount, date, time that the medication was given with staff initials.

It is a reference for sharing information with the child’s parent/guardian.

NOTE: A new form must be used for each prescribed medication.

DATE TIME AMOUNT IN

/REMAINING

AMOUNT

GIVEN

INTIALS DATE TIME AMOUNT IN

/REMAINING

AMOUNT

GIVEN

INITIALS

Maine State Subsidy InformationAuthorization to Release Information - Blankprovider sheet2018 Camp_State Sub Info Form