Bardmoor Registration Packet - YMCA of Greater St. Petersburg

BARDMOOR YMCA
SUMMER CAMP
REGISTRATION PACKET
CAMPER NAME
BARDMOOR YMCA
Thanks for your interest in the Bardmoor YMCA Summer Camp! Our goal is to help your child
have the best summer camp experience possible! Our caring staff, your child will come away
with new friendships and awesome memories. Let me know if you have any questions or know of
ways that I can improve your child’s camp experience.
Full-Day Camp
Half-Day Camp
Ashley Carter
acarter@stpeteymca.org
Jessica West
jwest@stpeteymca.org
SUMMER CAMP INFORMATION
Please check desired weeks:
FULL-DAY CAMP
AGES
HOURS
COST
6-12
7:00am-6:00pm
$125 Member
$165 Non-Member
Full-Day
HALF-DAY CAMP
AGES
HOURS
COST
3-5
9:00am-1:00pm
$65 Member
$90 Non-Member
SIGN IN & OUT:
Half-Day
June 9
June 16
June 23
June 30
July 7
July 14
July 21
July 28
August 4
August 11
Each child must be checked in and out, in person, with a valid photo ID.
Pick-up person must be on approved list.
Full-Day - Sign In: 7:00am-9:30am Sign Out: 3:30pm-6:00pm
Half-Day - Sign In/Out: 9:00am-1:00pm
SWIMMING!
Daily recreation swimming is included for full-day campers.
Swim lessons are available.
Swim Lessons
Age
Days
Times
Fee
3-12
Mondays & Wednesdays
11:00am, 11:50am, 5:45pm, 6:35pm
Member
$40
Non-Member
$75
LUNCH & SNACKS
Please send your camper with plenty to
eat and drink including morning and
afternoon snack and lunch.
If you prefer, a lunch menu
is available for purchase
through the Bardmoor
Golf and Tennis Club.
Pizza Friday’s
$3 for 2 slices and a drink
BARDMOOR YMCA
SUMMER CAMP REGISTRATION
YMCA CAMPER INFORMATION
Tshirt Size:
Youth XS
Youth S
Youth M
Youth L
Gender:
Child’s Full Legal Name:
Child’s Preferred First Name:
Ethnicity/ Race:
Native American
Alaskan Native
/
Date of Birth:
Grade Completed June 2014:
Male
Female
/
School Attending in August 2014:
African American/Black
Asian/Pacific Islander
Caucasian/White
Other:
Spanish/Hispanic/Chicano/Latino
Home Address:
State:
City:
EMAIL:
Zip:
Household Phone:
Who has legal custody?
Mother
Father
Both Parents
Guardian
Custody Order On File
(documentation required)
SUBSIDY INFORMATION
(This information helps us charge the proper fees for Summer Camp.)
Yes
Do you receive a Summer Camp Scholarship for the Bardmoor YMCA?
No
PARENT/ GUARDIAN INFORMATION
Mother/Guardian:
Ethnicity/ Race:
Date of Birth:
Native American
Alaskan Native
African American/Black
Asian/Pacific Islander
/
/
/
/
Caucasian/White
Other:
Spanish/Hispanic/Chicano/Latino
Home Address:
(If different from above)
City:
State:
Home Phone:
Cell Phone:
Employer:
City:
Work Phone:
Father/Guardian:
Ethnicity/ Race:
Zip:
Date of Birth:
Native American
Alaskan Native
African American/Black
Asian/Pacific Islander
Caucasian/White
Other:
Spanish/Hispanic/Chicano/Latino
Home Address:
(If different from above)
City:
Home Phone:
Employer:
State:
Cell Phone:
Zip:
Work Phone:
City:
BARDMOOR YMCA
PICK UP AUTHORIZATION FORM
Grade/Group:
Child’s Full Legal Name:
Parent/Guardian Name:
Are copies of custody/restraining papers on file for your child/ren?
Yes
No
Who has authorization to change/add/delete persons authorized for pick up?
Emergency Contact:
Home Phone:
Relationship:
Work Phone:
Emergency Contact:
Home Phone:
Cell Phone:
Relationship:
Work Phone:
Cell Phone:
The following people are allowed to pick up this/these child/ren:
Date Added/Deleted:
Staff Initials:
Date Added/Deleted:
Staff Initials:
Date Added/Deleted:
Staff Initials:
Date Added/Deleted:
Staff Initials:
Date Added/Deleted:
Staff Initials:
Date Added/Deleted:
Staff Initials:
Date Added/Deleted:
Staff Initials:
Date Added/Deleted:
Staff Initials:
Date Added/Deleted:
Staff Initials:
Date Added/Deleted:
Staff Initials:
BARDMOOR YMCA
PARENT AGREEMENT FORM
PARENTAL AGREEMENT
• Any outstanding balances due to the YMCA of Greater St. Petersburg must be paid in full prior to registering for
summer camp.
• I understand that I am responsible for adhering to the late fee policy if I fail to pick up my child on time each day.
• I understand that the YMCA of Greater St. Petersburg does not carry accident insurance.
• I realize that the responsibility for payment of an injury requiring medical care is mine.
• I give permission for the center to consult my child’s physician/dentist in case of an emergency if I cannot be reached.
• I have reviewed the YMCA Discipline Policy.
• I give permission for my child to attend all YMCA activities and field trips.
• I understand that I am responsible for paying for YMCA summer camp.
• I give permission for photographs of my child to be used by the YMCA of Greater St. Petersburg for promotional
and/or educational purposes. I realize that neither my child nor I will receive any compensation of any kind for use
of the photographs.
DISCIPLINE POLICY
In keeping with the YMCA mission and character values of Caring, Honesty, Respect and Responsibility, appropriate
behavior is expected of all camp participants. Respectful interactions with other participants and staff are at the core
of the Y mission and essential to having a successful camp experience for all. Behavior that conflicts with these values
will be addressed in a nature appropriate to the disruptive and/or unsafe behavior and is at the discretion of Y staff
and leadership. If behavior is significant, you and your child might be asked to meet with the Camp Director or Executive
Director. Based on the behavior exhibited, the following sequence is referenced:
1) Verbal warning to child and parent with documention.
2) One day suspension
3) Multiple day suspension
4) Termination from the summer camp program
5) Possible dismissal from other Y programs
PAYMENT AGREEMENT
Weekly fee is due to the YMCA on the Monday prior to the week your child will be attending. If your payment is not
received by due date, your child may lose their spot.
• Any payments received after the designated due date will be charged a late fee of $25.00.
• If you are late picking up your child, you will be charged a late fee of $10.00 per 10 minutes, or portion thereof.
• You will be notified if your payment is returned to us due to insufficient funds and payment is expected immediately.
• Please note there is a $25.00 insufficient fund fee.
DISCLAIMER
The YMCA of Greater St. Petersburg does not discriminate on the basis of race, religion, gender, creed of
socio-economic status. Financial assistance is available to those who qualify. Please ask for a scholarship assistance
application if you would like to apply for a scholarship for your child. Failure to fill this form out accurately may result in
your being charged incorrect fees. A scholarship application must be completed and approved prior to receiving financial
assistance. Please complete each section in its entirety to insure appropriate charges. If you receive government
subsidy (ELC), your signature indicates that you understand that the correct paperwork must be turned in and you will
adhere to the attendance policy set by the funding agency.
RELEASE AND WAIVER OF LIABILITY
AND INDEMNITY AGREEMENT
In consideration for 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 program affiliated with the YMCA,
without respect to location, 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
acknowledgment that such premises and all facilities and equipment thereon and such affiliated programs 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 PROGRAM AFFILIATED WITH
THE YMCA, WITHOUT RESPECT TO LOCATION, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:
1. THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the YMCA, 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, without respect to location.
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 releasees 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 forgoing RELEASE, WAIVER AND INDEMNITY AGREEMENT is
intended to be as broad and inclusive as is permitted by the law of the State of Florida and 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.
Parent/Guardian Signature:
Date:
YMCA of Greater St. Petersburg - Program Registration Form
SWIM LESSONS
Participant Name _______________________________________________________________________________________________________________________
Street Address _____________________________________________________________ City_______________________________Zip___________________
DOB ____/____/_______ Age________ Gender_______ School Attending _________________________________ Grade________________
Email __________________________________________________________________________ Phone___________________ _______________________________
Membership Type
Session: ___A
___MEMBER ($40)
___B
___C
Level: _____Preschool (3-5)
___ NON-MEMBER ($75)
Time:
___11:00am
___11:50
___5:45
___6:35
_____Youth (6-12)
Participant Release and Emergency Contact
signature.
All participants under age 18 must have parent or guardian
Parent/Guardian Name ______________________________________________________________
Phone____________________________________
Additional Emergency Contact ______________________________________________________
Phone ____________________________________
I understand the YMCA carries only Liability Insurance. Participants are responsible for providing their own Accident Insurance. I give permission for myself or
my child to participate in all activities and programs scheduled by the YMCA. I give my permission to the YMCA staff to authorize emergency medical
treatment. I give the YMCA permission to take photos of myself or child participating in YMCA sponsored programs. I understand that those photos may be used in promotions for the YMCA and are the sole property of the YMCA. Participant/Guardian Signature ______________________________________________________
Date _____/_____/_______
OFFICE USE ONLY
STAFF _______________________
DATE ______/_______/_______
ID #____________________________________
RECEIPT # ______________________
AMT PD _________________ SUBSIDY ______________
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MY PROGRAM INFORMATION
Thank you for registering for Swim Lessons! Please keep this portion to remember important details of your program.
Class Name:
!Preschool Swim Lessons
Session
Dates:
Session
Day(s)/Times:
(Mon/Wed for 3 weeks)
!”A” June 9 – June 25
Please bring:
Bathing Suit, towel, sunscreen
!Youth Swim Lessons
!”B” July 7 – July 23
!Mon/Wed 11:00am-11:40am
!Mon/Wed 5:45pm-6:25pm
!”C” July 28 – August 13
!Mon/Wed 11:50am-12:30pm
!Mon/Wed 6:35pm-7:15pm
Classes may be cancelled due to weather. Classes cancelled due to weather may be made up on Tuesday, Thursday or Friday.
Refunds and credits for missed classes will only be granted for a documented medical excuse.