YMCA OF GREATER NEW YORK SUMMER CAMP REGISTRATION FORM

Branch: FLUSHING

Early Childhood Camp – Ages 3-5.8 (Campers going into Kindergarten in Sept. 2015)

PARTICIPANT INFO

Child’s Name ___________________________________________________________________________________________________ Age ____________________________________________

Date of Birth _______________________________________________________ Gender ______________________________

Grade in September 2015 _______________________________ School _____________________________________________________________________________________________

Mailing Address ________________________________________________________________________________________________________________ ____ Apt.# _______________________

City ______________________________________________________________________________ State ___________________________________ Zip ____________________________________

Home Phone (________) _____________________________________________________ Email Address _____________________________________________________________________

My child will: Be picked upWalk home (Only 10 yrs. or older, please sign bottom of page 2)

T-Shirt Size Child: S M L XL Adult: S M L XL

PARENT/GUARDIAN INFO

Mother/Guardian Name ___________________________________________________ Home Phone (_______)_____________________________________

Work Phone (_____) ___________________________________ Cell Phone (_____) _____________________________________ Email _________________________________________

Father/Guardian Name _____________________________________________ Home Phone (_______)______________________________________

Work Phone (_____) ___________________________________ Cell Phone (_____) _____________________________________ Email _________________________________________

EMERGENCY CONTACT INFO Please list two (2) contacts that are NOT the parent/guardian in case of an emergency and the parents cannot be reached

Name ___________________________________________________________________ Relation ________________________________ Home Phone (_____)_________________________

Work Phone (_____) ___________________________________________________ Cell Phone (_____) ____________________________________________________

Name ___________________________________________________________________ Relation ________________________________ Home Phone (_____)_________________________

Work Phone (_____) ___________________________________________________ Cell Phone (_____) ____________________________________________________

PHYSICIAN INFO

Name ________________________________________________________________________________ Telephone Number (_______)______________________________________________

Address ____________________________________________________________________ City ________________________________ State _________________ Zip ___________________

AUTHORIZATION / CONSENT

EMERGENCY AUTHORIZATION: I understand that in the event of an emergency affecting my child while participating in a YMCA program, a

designated employee of the YMCA will attempt to contact me and inform me as soon as possible. In the event I cannot be reached, I hereby give

permission for my child to be treated or hospitalized by a licensed physician or hospital selected by the YMCA.

__________________________________________________________________________________________ ___________________________________________________________________________________

Parent/Guardian Name Parent/Guardian Signature

___________________________________________________________________________________________ ____________________________________________________________________________________

Participant Signature Date

NAME RELATIONSHIP PHONE NUMBER

YMCA OF GREATER NEW YORK SUMMER CAMP REGISTRATION FORM

PERMISSION FORM I hereby grant permission for my child to use all equipment and participate in all activities of the FLUSHING YMCA. I hereby grant permission for my child to leave the FLUSHING YMCA premises, under proper supervision of FLUSHING YMCA staff, for

neighborhood walks, park activities and field trips. It is my understanding that these trips will be taken over the camp session without

further consent from me.

______________________________________________________________________________________ __________________________________________________________________________

Child’s Name Camp Type

_______________________________________________________________________________________ ___________________________________________________________________________

Parent/Guardian Signature Date

AUTHORIZED PICK-UP FORM The following individuals are 18 years old or older and are allowed to pick up my child from the FLUSHING YMCA Camp Programs.

All authorized persons must show picture ID at pickup

I understand that no one else will be allowed to pick up my child unless I notify the FLUSHING YMCA in advance and in writing. This person will

also be asked for their photo ID for verification.

________________________________________________________________________________________________ ___________________________________________________________

Parent/Guardian Signature Date

Contact Telephone Number: ____________________________________________________________

2015 BRANCH NAME SUMMER CAMP FEE SCHEDULE * Session dates DO NOT include Saturday and Sunday. *

SESSION

Session I

Session II

Session III

Session IV

FEE

$360.00

$400.00

$400.00

$400.00

Early Childhood Camp Ages 3-5.8

DATES

June 29 - July 10 (Camp is closed July 3rd)

July 13 - July 24

July 27 - August 7

August 10 - August 21

Extended Camp Hours

Ages 3-5.8

SESSION FEE TIME

AM Session $50.00 7:30 - 9:00 am

PM Session $50.00 5:00 - 6:00 pm

AM & PM Session $ 90.00

(Check Session) 1 2 3 4

Camp Fees DEPOSIT/

SESSION FEE EXTENDED FEES DISCOUNTS SESSION TOTAL

Session I ______________ _ + AM/PM _____________ - _____________ = _____________

Session II ______________ _ + AM/PM _____________ - _____________ = _____________

Session III ______________ _ + AM/PM _____________ - _____________ = _____________

Session IV ______________ _ + AM/PM _____________ - _____________ = _____________

Session Total ______________ _ + Total _____________ - Total _____________ = Grand Total _____________

Payment Information

Check Credit Card Bank Draft Money Order

Credit Card # __________________________________________________________________________________ Exp. Date: ____________________________________________________

Bank Name: __________________________________________________________ Account #: ___________________________________________________ Routing #: __________________________________________

Authorized Signature: __________________________________________________________________________________________________________________

PARENT AGREEMENT

I, the undersigned, give permission for my child to participate in the camp for the days he/she attends. I am aware that a

completed medical form signed by a physician is required before my child may begin camp. In addition, I am fully aware that to

reserve a space, I must make a deposit of $100 per two-week session and submit a completed registration form. I am fully

aware that should my child change camps after the start of the session there is a $25 change fee. I fully understand and

approve of my child being photographed for Flushing YMCA publicity. Lastly, I fully understand that my child is responsible for

his/her possessions. I have read, signed, and agreed to the registration requirements.

Signature of Parent/Guardian:_________________________________________________________ Date: ________________

There is a non-refundable $100.00 deposit per session per child which is applied to session fee.

s s Y Y er er m

s ay ay

re re Fil dw dw

Ca Ca

die oa oa

In Br Br

YMCA OF GREATER NEW YORK SUMMER CAMP REGISTRATION FORM

STANDARD RELEASE FORM

From time to time, the YMCA of Greater New York (the “YMCA”) takes pictures or records videos of members and non-members

participating in YMCA programs, using its facilities, or attending one of its special events. Additionally, the YMCA may permit

members of the media (the “Media”) to take such pictures or record such videos in order to promote the YMCA’s charitable

mission and for other journalistic purposes.

The individual person named below is signing this Release for the purposes of allowing the YMCA and the Media to use one or

more such photographs, video recordings, and/or sound recordings (collectively, “Recordings”) of such person for any purpose

consistent with the YMCA’s charitable mission, which includes, but is not limited to, the YMCA or the Media publishing such

Recordings in newspapers, web sites, and other print or electronic publications, on television, or on the radio. By signing this

Release, such person acknowledges that he or she has freely consented to be photographed, filmed, or otherwise recorded and

has signed this Release of his or her own free will. If the person named below is under age 18, a parent or guardian of such

person must sign on such person’s behalf.

1. I agree that I am willing to be photographed, filmed, or otherwise recorded by the YMCA, its contractors, and the

Media, either individually or as part of a group Recording, which may include my image, likeness, and/or voice.

further agree that my name may be used to identify me as a subject of any Recordings featuring my image,

likeness, and/or voice.

2. I understand that the YMCA will own all rights in the Recordings of me that the YMCA or a YMCA contractor takes

or records (“YMCA Recordings”), and that the YMCA will have the exclusive right to use, or allow others to use,

such YMCA Recordings in any medium for any purpose consistent with the YMCA’s charitable mission as

determined by the YMCA.

3. I understand that the Media will own all rights in the Recordings of me that the Media takes or records (“Media

Recordings”), and that the Media will have the exclusive right to use, or allow others to use, such Media Recordings

in any medium for any lawful purpose.

4. I understand that I am waiving any and all rights that may preclude the YMCA’s or the Media’s use of the

Recordings as described above.

5. I acknowledge that neither the YMCA nor the Media has any obligation to use any Recordings of me or to use such

Recordings for any particular purpose.

6. I understand that I will receive no monetary payment or other compensation in exchange for the rights to use

Recordings of me.

______________________________________________________________ ____________________________________________________________________

Signature Date

______________________________________________________________ ____________________________________________________________________

Name (printed) Name of Parent/Guardian

_____________________________________________________________________________________________ ____________________________________________________________________

Mailing Address Phone Number (optional)

____________________________________________________________________

Email (op

Camper Information Sheet (The Flushing YMCA Early Childhood uses this information to best meet the needs of your child. If you prefer to speak with the Director in

person regarding this information, feel free to call to set up a time to meet)

HOME INFORMATION

1. With whom does the child live? 2. What is the primary language spoken at home? 3. What language does the child speak? 4. Please list other members of the household (people other than parents) Sibling Age: ________ Sibling Age: ________ Others living in the household: Name:________________________________ Relationship______________________ Name:________________________________ Relationship______________________ 6. Please describe the child's relationship with sibling(s):

7. Is either parent away from home for long periods of time (for example: days, weeks, months)? Which parent and how often?

8. What does your family like to do together? _____________________________________

____________________________________________ ___________________________ 9. Is the child frequently under the care of a caregiver or babysitter?_________________

Who and how often? 10. Does your child have any specific fears? Please describe. 11. Please discuss any other specific events, which have had a serious impact on your child's life:

SOCIAL & PHYSICAL DEVELOPMENT 1. Will your child play contently by him/herself? If so, how long? 2. Does your child have frequent playmates? Ages: 3. Where does he/she usually play? 4. Has your child had any previous group experiences (school, church, camp, playgroup, YMCA classes, etc.)? If so, please describe the type of experience(s) and how have your child responded: ______________________________________________________________ 5. Were you pleased with the previous group experience(s)? If not, please briefly describe why and what you would have liked to occur: 6. How many hours of television is the child allowed daily? 7. Favorite Programs? 8. Favorite activities and toys? 9. Is the child toilet trained? Any accidents?

10. Any specific problems or concerns that your child has about going to the bathroom? _________________________________________________________________________ 11. What do you do if the child refuses a particular food?

12. Does the child eat with the family? 13. Does the child sleep through the night? If not, why does he/she wake up?________________________

What time does your child go to bed and what time does your child wake up in the morning?

14. What does your child do before he/she goes to bed? (I.e. read a story, etc.)

15. Does your child take a nap? If so, how Iong and at what time? 16. Can your child dress and undress him/herself? _ 17. How has the child handled separating from you (in school, babysitting, camp, etc.) and what things do you say or do to ease the separation?

18. Briefly describe the child's personality and temperament:

19. Is there anything in particular about his/her behavior important that you feel is unique or important for us to know about?

20. What benefits do you want your child to derive from the YMCA Early Childhood Camp?

21. Any additional comments or concerns? Parent/Guardian Name:

Parent/Guardian Signature:

Date:

HEALTH RECORD FOR CHILDREN IN DAY CAMPS & AFTERSCHOOL & YOUTH CENTERS (This side to be filled in by Parent before presentation to Physician)

NAME OF PROGRAM: Flushing Early Childhood Camp _____________________________ ______________________ ____/____/____ Male Female Child’s Last Name First Name Date of Birth Sex Home Address: ____________________________________________ Tel. No. _______________________

Parent or Guardian: __________________________________________ Tel. No. _______________________ Place of Employment: Father Guardian: ______________________________________ Tel. No. _______________________

Mother Guardian: _____________________________________ Tel. No. _______________________

In Case of Emergency, please notify: ____________________________ Tel. No. _______________________ If Parent/Guardian are not available in an emergency, please notify: 1. ________________________________________________________ Tel. No. _______________________ 2. ________________________________________________________ Tel. No. _______________________ Important: Has this camper been exposed to any communicable disease during the three weeks prior to camp attendance. Yes No If yes, state type of exposure: ____________________________________________ ============================================================================================== HEALTH HISTORY: (Check and give approximate dates)

Allergies Diseases Ear Infections _________________ Hay Fever _____________________ Check Pox ____________________ Rheumatic Fever _______________ Ivy Poisoning, etc. ______________ Measles ______________________ Convulsion ___________________ Insect Stings ___________________ German Measles _______________ Diabetes _____________________ Penicillin ______________________ Mumps ______________________ Behavior _____________________ Other Drugs ___________________ Other Contagious Illnesses _______ Asthmas _____________________ ____________________ ____________________________ Other Past Illnesses: ______________________________________________________________________________

Operations or Serious Injuries (Dates): _______________________________________________________________

Hospitalization (Dates): ___________________________________________________________________________

Chronic or Recurring Illness: ______________________________________________________________

Any specific activities to be encouraged? ____________________________________________________________

Conditions that require activity to be restricted? _______________________________________________________

Permission for all program activities unless otherwise noted by doctor: _____________________________________

Appliance worn (glasses, contacts, etc.): ______________________________________________________________

Medication taken: _______________________________________________________________________________

Suggestion from Parent/Guardian: __________________________________________________________________

CONSENT FOR EMERGENCY MEDICAL TREATMENT I do hereby give authority to the Day Camp and Year Round Afterschool and Youth Center Program staff to obtain necessary

emergency medical treatment for my child with the understanding that the family will be notified as soon as possible.

______________________ _________________________________ _______________ _________________________

Relationship Signature Date Telephone No. Department of Health The City of New York Bureau of Inspections

TYPE OF EXAM: NAE Current NAE Prior Year(s)

Comments

REVIEWER:

Date Reviewed:

DOHMHONLY

PROVIDER I.D.

__ __ / ___ ___ / ___ ___

I.D. NUMBER

Health Care Provider Signature Date__ __ / ___ ___ / ___ ___

Health Care Provider Name and Degree (print) Provider License No. and State

Facility Name National Provider Identifier (NPI)

Address City State Zip

Telephone ( __ __ __ ) ___ ___ ___ – ___ ___ ___ ___

Fax ( __ __ __ ) ___ ___ ___ – ___ ___ ___ ___

Hep B __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Rotavirus __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

DTP/DTaP/DT __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

__ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Hib __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

PCV __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Polio __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

RECOMMENDATIONS � Full physical activity � Full diet

� Restrictions (specify) ___________________________________________________________________________

Follow-up Needed � No � Yes, for _________________________ Appt. date: __ __ / ___ ___ / ___ ___

Referral(s): � None � Early Intervention � Special Education � Dental � Vision

� Other ________________________________________________________________________

ASSESSMENT � Well Child (V20.2) � Diagnoses/Problems (list) ICD-9 Code

_____________________________________________________________ __ __ __ __ __

_____________________________________________________________ __ __ __ __ __

_____________________________________________________________ __ __ __ __ __

Health insurance � Yes(including Medicaid)? � No

Does the child/adolescent have a past or present medical history of the following?� Asthma (check severity and attach MAF/Asthma Action Plan): � Intermittent � Mild Persistent � Moderate Persistent � Severe Persistent

If persistent, check all current medication(s): � Inhaled corticosteriod � Other controller � Quick relief med � Oral steroid � None

� Attention Deficit Hyperactivity Disorder � Orthopedic injury/disability� Chronic or recurrent otitis media � Seizure disorder� Congenital or acquired heart disorder � Speech, hearing, or visual impairment� Developmental/learning problem � Tuberculosis (latent infection or disease)

� Diabetes (attach MAF) � Other (specify) ___________________

Explain all checked items above or on addendum

Birth history (age 0-6 yrs)

� Uncomplicated � Premature: ________ weeks gestation

� Complicated by _______________________________

Allergies � None � Epi pen prescribed

� Drugs (list)

� Foods (list)

� Other (list)

STUDENT ID NUMBEROSIS

CHILD & ADOLESCENT HEALTH EXAMINATION FORMNYC DEPARTMENT OF HEALTH & MENTAL HYGIENE — DEPARTMENT OF EDUCATION

Please Print Clearly

Press Hard

Child’s Last Name First Name Middle Name

Child’s Address

City/Borough State Zip Code

� Parent/Guardian Last Name First Name� Foster Parent

School/Center/Camp Name

Sex � Female � Male

Hispanic/Latino?� Yes � No

Race (Check ALL that apply) � American Indian � Asian � Black � White� Native Hawaiian/Pacific Islander � Other ____________________________

PHYSICAL EXAMINATION

Height ____________________ cm ( ___ ___ %ile)

Weight ____________________ kg ( ___ ___ %ile)

BMI ____________________ kg/m2 ( ___ ___ %ile)

Head Circumference (age ≤2 yrs) ______________ cm ( ___ ___ %ile)

Blood Pressure (age ≥3 yrs) _________ / __________

DEVELOPMENTAL (age 0-6 yrs) � Within normal limits

If delay suspected, specify below

� Cognitive (e.g., play skills) ____________________________

� Communication/Language _________________________

� Social/Emotional __________________________________

� Adaptive/Self-Help ________________________________

� Motor ___________________________________________

SCREENING TESTS Date Done Results

Blood Lead Level (BLL)__ __ / ___ ___ / ___ ___ _________ µg/dL

(required at age 1 yr and 2 yrsand for those at risk) __ __ / ___ ___ / ___ ___ _________ µg/dL

Lead Risk Assessment � At risk (do BLL)(annually, age 6 mo-6 yrs)

__ __ / ___ ___ / ___ ___ � Not at risk

Hearing � Pure tone audiometry � Normal� OAE __ __ / ___ ___ / ___ ___ � Abnormal

—— Head Start Only ——

Hemoglobin or __________ g/dLHematocrit (age 9–12 mo)

__ __ / ___ ___ / ___ ___ __________ %

Date Done Results

Tuberculosis Only required for students entering intermediate/middle/junior or high schoolwho have not previously attended any NYC public or private school

PPD/Mantoux placed __ __ / ___ ___ / ___ ___ Induration ______mm

PPD/Mantoux read __ __ / ___ ___ / ___ ___ � Neg � Pos

Interferon Test __ __ / ___ ___ / ___ ___ � Neg � Pos

Chest x-ray � Nl � Not(if PPD or Interferon positive)

__ __ / ___ ___ / ___ ___� Abnl Indicated

Vision

__ __ / ___ ___ / ___ ___

Acuity Right ___ / ___(required for new school entrants Left ___ / ___and children age 4–7 yrs) � with glasses Strabismus � No � Yes

General Appearance:

Nl Abnl Nl Abnl Nl Abnl Nl Abnl Nl Abnl

� � HEENT � � Lymph nodes � � Abdomen � � Skin � � Psychosocial Development� � Dental � � Lungs � � Genitourinary � � Neurological � � Language� � Neck � � Cardiovascular � � Extremities � � Back/spine � � Behavioral

Date of Birth (Month/Day/Year )__ __ / ___ ___ / ___ ___ ___ ___

Phone Numbers

Home _____________________

Cell ______________________

Work ______________________

TO BE COMPLETED BY PARENT OR GUARDIAN

TO BE COMPLETED BY HEALTH CARE PROVIDER If “yes” to any item, please explain (attach addendum, if needed)

CH-205 (5/08) Copies: White School/Child Care/Early Intervention/Camp, Canary Health Care Provider, Pink Parent/Guardian

Medications (attach MAF if in-school medication needed)

� None � Yes (list below)

Dietary Restrictions� None � Yes (list below)

Influenza __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

MMR __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Varicella __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Td __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Tdap __ __ / ___ ___ / ___ ___ Hep A __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Meningococcal __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

HPV __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___ __ __ / ___ ___ / ___ ___

Other, specify: ____________ __ __ / ___ ___ / ___ ___ ; _______________ __ __ / ___ ___ / ___ ___

IMMUNIZATIONS – DATES CIR Number of Child

Describe abnormalities:

District __ __Number __ __ __