2014 Resident Camper Application for children ages 6-15

OFFICE USE ONLY
Date Received:______________________
2014 Resident Camper Application for children ages 6-15
Complete and return to:
KANATA, 13524 Camp Kanata Rd., Wake Forest, NC 27587-8078
Phone (919)556-2661  Fax (919)556-9459
campkanata@ymcatriangle.org  www.campkanata.org
Returning Kanata Camper  No  Yes
Please complete this application in its entirety.
Send a separate application for each camper.
Shirt Size___________
Camper’s Full Name _____________________________________________________ Name Called________________________
First
Middle
Last
Birth Date___________________ Age (as of June 8, 2014) ___________ Sex___________ School____________________________
Address _______________________________________________ City __________________ State _________ Zip __________
Mother’s Name__________________________ Occupation__________________ Email___________________________________
Mother’s Cell # __________________________ Work #_____________________ Home #__________________________________
Mother’s Date of Birth _______/________/_________ (This is required for future online registration)
Father’s Name___________________________Occupation__________________Email___________________________________
Father’s Cell #___________________________Work #_____________________Home #___________________________________
Father’s Date of Birth ________/_________/_________ (This is required for future online registration)
Emergency Contact-not parent Name______________________________Phone#_______________Relationship__________________
Parent Relationship:
Camper Lives With:
 Married
 Divorced
 Separated
 Single
 Remarried
 Widowed
 Mother
 Father
Other________________
FEES
_______# of Sessions × $752 = __________________
Check Sessions Attending
 1st—Pirate Week ......................... June 8-14
Horseback Riding $160.00 = __________________
 2nd—Jungle Week ...................... June 15-21
Neuse River Canoe Trip $67.00 = __________________
(12 yrs and older)
 3rd—Olympics Week………........June 22-28
No weekend stayovers between these sessions
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4th—Stars
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5th—Super
Laundry For Stayovers $30.00 = __________________
($30.00 per weekend, includes Kanata laundry bag)
& Stripes Week ...June 29-July 5
Hero Week ................. July 6-12
Sibling Discount (-$25.00) = __________________
 6th—Christmas Week ................. July 13-19
No weekend stayovers between these sessions
We Build People—our annual support campaign makes the Kanata experience accessible for
all children, regardless of their ability to pay. Please consider helping someone else
experience the joy of camp
 that might not otherwise be able to attend.
 Yes! I would like to add this tax-deductible donation to
my registration & payment today:
__________________
 7th—Hollywood Week ................ July 20-26
 8th— *Color Wars Week....... July 27- Aug. 2
 9th— Blast from the Past ............. Aug. 3-9
GRAND TOTAL = ___________________
*Week 8 Campers: (please check if applicable)
___Gluten Free Diet .......................................
($150 Deposit Required with Application)
Are you registering the camper’s Brother/Sister?  Yes  No
Name ___________________________________________________________________________________ Session
_____________________
Financial aid is available on a limited basis to those in need. If applying for financial aid, this camper application must accompany a completed financial aid application and a
$25 non-refundable deposit. Call the camp office (919-556-2661) if you would like to request an application for financial assistance.
COMPLETE REVERSE SIDE
Please read each of the following policies and sign below to indicate your understanding of these policies.
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Recommendation: If faxing application, call for confirmation 30 minutes after sending. Kanata cannot be responsible for faxes that are not received.
Likewise for emails, if you do not receive a response, chances are Kanata did not receive your application.
I am enclosing a deposit of $150.00 per week representing a reservation fee of $100.00 and a processing fee of $50.00. This fee is applied to the total
tuition.
I will pay the remaining balance of camp fees on or before April 1, 2014. I understand that if I do not pay the remaining balance, my child’s registration
may be cancelled for non-payment.
I understand that in the event of cancellation prior to April 1, 2014 Camp Kanata will refund all fees except the $50.00 processing fee.
I understand that in the event of cancellation between April 1, 2014 and three weeks before scheduled arrival at camp, Camp Kanata will refund all fees
except the $150.00 deposit.
I understand in the event of cancellation less than three weeks before scheduled arrival at camp or if I fail to bring my child to their scheduled session,
Camp Kanata will not refund any fees.
Payment Plan Option: If interested, please see next page for information about a payment plan. All fees must be paid in full by April 1, 2014 even with
the payment plan.
I agree to have my child examined by a licensed physician and to present a completed Kanata Health Examination form signed by the physician to the
camp prior to the camper’s arrival.
In the event of an emergency in which the parent cannot be contacted, emergency medical staff and Camp Kanata staff may take appropriate action in the
best interest of my child.
I permit the YMCA to use pictures of my child as a program participant in promotional literature, promotional videos & the YMCA Web site, which are
published and used by the YMCA. I understand that my child’s photo or likeness may appear in news media. I understand that my child’s name will not
be published or broadcast.
Outside Contact Policies: During staff time off or when no longer employed with the YMCA, these persons are private citizens and are not subject to our
employment rules and procedures. Knowing this, we instruct our staff that any contact with campers outside of our programs, whether in person, by phone
or online, can only happen with the express approval and involvement of the camper’s parent or guardian.
Babysitting Policy: It is our policy not to endorse or recommend staff as babysitters. Any babysitting arrangements with present or former YMCA staff shall
be based on the judgment of the parent/guardian. For the complete YMCA of the Triangle babysitting policy, please see our Youth Information Form.
Online Social Networks: As an organization that holds personal character in the highest regard, the YMCA may terminate staff members for publishing
public web pages and blogs that are contrary to the YMCA’s mission or are detrimental to the community. In addition, the YMCA will not tolerate online
bullying or posting of inappropriate material on the Internet. We reserve the right to refuse acceptance of any child involved in these or similar activities in
order to ensure a safe YMCA community.
I understand that Kanata is not responsible for articles of clothing or personal belongings lost or damaged at camp.
I understand that Kanata offers some activities that could put my child at physical risk including but not limited to High Ropes, Horseback Riding, and
Target Sports (such as archery and riflery). If eligible, I allow my child to participate in such activities and I release Camp Kanata from responsibility for
injuries or illnesses, which my child may sustain from participation in these activities, or if I do not want my child to participate I will alert the camp.
I give consent for my child to leave camp to participate in authorized camp trips and to be transported in Camp Kanata vehicles.
I understand that Camp Kanata activities have inherent risks, and I hereby assume all risks and hazards incident to my child’s participation in all Camp
Kanata activities. I further waive, release, absolve, indemnify and agree to hold harmless Camp Kanata and its employees, organizers, volunteers,
supervisors, officers, directors and participants from any legal claims, liabilities, damages and costs for any physical injury to my child or damage to my
child’s personal property sustained during my child’s participation in any Camp Kanata activities.
I understand that while Camp Kanata will make every attempt to provide reasonable accommodations for every applicant, the camp reserves the right to
decline the application of, or send home, any child who according to the Director’s discretion is detrimental to the general welfare of camp and other
campers. I understand that in such a situation tuition is not refundable.
Signature of Parent/Guardian: ________________________________________________________________________Date:
__________________________
The parent/guardian signing above represents by executing this document that he or she has the full authority to give permission for the minor child to participate in this program and
intends unconditionally for the YMCA of the Triangle to rely upon this representation for all purposes related to the program.
AT THIS TIME, PLEASE DO NOT LIST CABIN MATE PREFERENCES. THIS WILL BE REQUESTED ON A SPECIAL FORM.
YMCA Mission: To put Christian principles into practice through programs that build healthy spirit, mind and body for all.
Complete and return to:
KANATA, 13524 Camp Kanata Rd., Wake Forest, NC 27587-8078
Phone (919)556-2661  Fax (919)556-9459
campkanata@ymcatriangle.org  www.campkanata.org
Kanata Payment
For child(ren) ___________________________________________________________________________________________________________
CHARGE:  MASTER CARD  VISA
 AMEX
ACCOUNT #___________________________________________________________
EXPIRATION DATE: ______________ AMOUNT $____________
PRINT CARD HOLDER NAME ___________________________________ SIGNATURE ____________________________________________
Deposit may be paid by credit/debit card or by check. Credit/debit cards will not be automatically charged for balance due.
We will not keep any credit card information on file after the payment has been processed.
Please do not write credit card numbers on any forms other than the specified payment form.
Please contact us at 919-556-2661 regarding a payment plan.
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You may pay by mail with a check, money order or credit/debit card (complete information above).
You may pay by fax with a credit/debit card (complete information above and fax to number above).
***On your credit card/bank statement the charge will show as YMCA of the Triangle not Camp Kanata. ***
Thank you!