2016 CAMP OAKES REGISTRATION
Camper’s Last Name:
Address:
Camper’s Birthday:
First Name:
___
Sex: M / F
City:
/
/
State:
Age:
Parent/Guardian Name:
_____
__ Zip:
Grade in Fall 2016:
_____
Relationship to Camper:
____
Home Address (If different than Camper):
Best Contact Phone #:
____
_____
Business Phone:
____
Camper lives with (Circle One): Mom / Dad / Both / Other (Explain):
_____
Emergency Contact Name:
_____
Phone:
Do you have YMCA Family Facility Membership: Yes / No If Yes, please list the YMCA:
___
How did you learn about camp?
____
Cabin Mate request:
_____________
Session Dates
July 16th through July 23rd
Drop-off and Pick-up will be at:
Los Cerritos YMCA
15530 Woodruff Avenue, Bellflower, CA 90706
(562) 925-1292
Drop-off/Check-in scheduled for 8:00 AM on July 16th
Pick-up/Check-out scheduled for 4:00 PM on July 23rd (subject to change based on actual travel time)
Fees (All fees must be paid by July 8th, 2016)
Please Circle One:
Greater Long Beach Family Facility Member Fee: $435
Non-Member Fee:
$445
Deposit (Each resident camp participant must pay deposit at time of registration)
$75 (Non-refundable)
Office Use Only
Fee:_______________________________________
Date Deposit Paid:_____________________
Campership Allocation:____________________
Home Branch Location:___________________
POLICIES AND PARTICIPATION AGREEMENT
Please read the following rules and policies carefully, they will be strictly enforced.
All campers, parents/guardians and relatives will agree to abide by the rules and regulations set by
Camp Oakes for the health, safety and welfare of the campers.
1.
Campers are not permitted to use inappropriate language, are not allowed to smoke, chew tobacco, possess any smoking
materials, and possess alcoholic beverages or illegal drugs.
2.
Clothing must be appropriate for camp, may not be immodest, and may not have inappropriate or degrading messaging.
3.
All medications including over the counter medications will be kept in the camp health cottage under the control of the
Health Care Coordinator.
4.
Incoming and outgoing camper phone calls are permitted only with the approval of the camp director when absolutely
necessary. Campers may not receive visitors without the permission of the camp director and his/her parents.
5.
Campers are encouraged to develop friendships with members of the opposite sex, but no displays of affection (i.e. handholding, kissing, going steady, etc.) or other inappropriate physical or verbal contact is permitted.
6.
Campers have a duty to immediately report to the camp director any inappropriate behavior on the part of any staff
member, counselor, CIT, LIT, camper or other individual.
7.
Campers are to remain in their living units after “lights out”.
8.
All personal belongings are to be marked with ID. Camp Directors reserve the right to examine any camper’s gear for
inappropriate items. Camp is not responsible for personal belongs lost or damaged during the camp session. Expensive
personal items should not be sent to camp.
9.
During the camp session(s), Camp Staff must have current up to date phone numbers, names, and general emergency
contact information, should we need to contact anyone concerning your child (i.e. homesickness, injury or other illness).
10. Campers are to respect the rights and belongings of others. There are no facilities for security in the cabins (no lockers)
and we rely on the honor system when dealing with camper and staff gear. In short, if it is not yours, don’t touch it.
11. A written notice of cancellation must be received in the camp office one month before your child’s first day of camp for a
refund. All deposits are non-refundable; all other fees will be forfeited for cancellations received after that time.
ALL rules and policies are strictly enforced including curfew. Any criminal act(s) or failure to abide by camp rules will result in
IMMEDIATE DISMISSAL FROM CAMP. Upon notification of dismissal, parent/guardian(s) are expected to retrieve camper from
camp as soon possible. All fees are forfeited. If you fail to pick up your child in a timely manner when requested, camp has the
right to transport your child home at a cost to you of $500.
I understand that the YMCA is not responsible for lost, stolen or damaged personal articles. I, hereby, give the YMCA of Greater
Long Beach permission with respect to photographs, videos, motion pictures, and/or sound recordings being taken of my child to
use, publish, and republish in the same, in whole or in part, on the YMCA website or in YMCA printed materials, separately or in
conjunction with other photographs or recordings. I release and discharge the YMCA of Greater Long Beach from any claims and
demands arising out of or in connection with the use of such photographs, videos, motion pictures and/or recordings. I agree to
waive any claims against the YMCA and its members and volunteers for injuries or damages that may result from the conduct of
other participants in YMCA programs. I approve this application and certify that the applicant is capable of such an experience.
I grant permission for the applicant to participate in all planned camp activities including out of camp trips by van or bus, hiking,
aquatic activities, and zipline. I understand that deposits are non-refundable, agree to pay the balance of the camp fee by
July 9, 2015 and that all other camp fees are only refundable when written cancelation is received one month prior to camp or
by doctor for medical reasons. I understand that no refunds are given if a camper leaves early because of homesickness,
voluntary withdrawal or for disruptive behavior as determined by the camp director. In case of accident or illness, the YMCA will
in its best efforts contact me, and has my authorization, at my expense, to secure medical attention as deemed necessary for the
individual included in this application.
We understand the importance of this agreement and have discussed, as a family, the consequences of choosing not to follow
the above stated rules.
Camper’s Signature
Parent’s Signature
Date
CAMPER HEALTH HISTORY /
MEDICAL CONSENT FORM
Camper’s Name:
Birthday:
Address:
City:
Parent/Guardian Name:
Home/Cell #:
/
/
State:
Sex: M / F Age:
__
Zip:
__________________ Work #:
Alternate Emergency Contact Name:
_________
_________
Phone #:
________
Name of Family Physician:
_______ Phone#: _________________ Date of Last Physical:
Medical Insurance Carrier:
_______ Policy #:
_________
Camper Social Security #: _____________
Health History
Include Past and Present Conditions
*Asthma
___Yes ___No
*Heart Defects/Disease
___Yes ___No
*Recent Hospitalizations
___Yes ___No
*Currently Under Dr’s Care
___Yes ___No
*Seizures
___Yes ___No
*Diabetes
___Yes ___No
ADD/ADHD
Head Lice (recent)
Bedwetting
Sleepwalking
Tuberculosis
Chicken Pox
___Yes ___No
___Yes ___No
___Yes ___No
___Yes ___No
___Yes ___No
___Yes ___No
Measles
___Yes ___No
German Measles
___Yes ___No
Other Diseases or Conditions:
For Females Campers Only
Has menstruation begun? ___Yes ___No
If yes to any of the above, please explain:
Any Other Special Medical Considerations:
NOTE: If marked yes for any asterisk (*) item listed above, a written doctor’s authorization will be required prior to the applicant
attending camp. (See Next Page)
Allergies:
Hay Fever
Oak/Ivy Poisoning
Foods
___Yes ___No
___Yes ___No
___Yes ___No
Bee Stings
___Yes ___No
Bee Sting Kit?
___Yes ___No
Other insect/animals ___Yes ___No
Penicillin
Other Drugs
Any other allergies
___Yes ___No
___Yes ___No
___Yes ___No
If yes to any of the above, please explain:
Dietary Restrictions:
Current Medications to be continued at Camp
Medication
Dosage
Time
(We will not issue any product which is not in its original container and clearly marked by the manufacturer or pharmacy.)
Non-Prescription Medications
I authorize the following medications to be administered as needed.
Non-Aspirin Pain Reliever (i.e. Tylenol) ___Yes ___No
Cough/Throat Drops/Syrup
Throat Spray (i.e. Chloraseptic)
___Yes ___No
Ibuprofen (i.e. Advil)
___Yes ___No
___Yes ___No
Benadryl
___Yes ___No
Pepto Bismol ___Yes ___No
Immunization Record - Mandatory
Please provide the dates of your child’s immunization program.
Tetanus________ Polio________ Mumps________ Rubella________ Diptheria________ Pertussis________ Measles______ Other___________
Has the camper been exposed to any communicable disease during the three weeks prior to attending camp? ___Yes ___No
If yes, what?
Please notify the YMCA if any exposure occurs after this form is turned in.
Is there any reason to restrict full activity including swimming, long hikes, strenuous physical games? Yes No
Important Note: A Doctor’s physical exam & written authorization is required if the person has a history of asthma, heart
defect/disease, seizures, diabetes, has been recently hospitalized, or is currently under a Doctor’s care. An exam is also recommended
for campers who have not had a physical exam for 2 years or more.
CAMPER HEALTH HISTORY/
MEDICAL CONSENT FORM CONTINUED
Special Note to Physician: Because of the applicant’s medical history, we have asked that your written authorization be
provided prior to their attendance at our YMCA Camp Program. Please realize that this event will be held at YMCA Camp
Oakes, situated at 7,200 feet elevation in a heavily wooded environment. The program constitutes an active life-style,
with strenuous hiking, games and camp activities. Your careful consideration is appreciated.
Health Care Recommendations by Licensed Physician (if required as stated above)
Camper’s Name:
Birthday:
/
/
Sex: M / F
Parent/Guardian Name:
I have examined the applicant within the past two years and in my opinion, the above listed condition (check one)
____does/____ does not, preclude his/her participation in an active camp program.
Date Examined:
__________
Height:
Weight:
Blood Pressure:
The applicant is under the care of a physician for the following condition(s):
The following specific activities are to be limited by physician’s advice?
Medically prescribed meal plan or dietary restrictions:
Any additional treatments or medications to be continued at camp not listed on the prior page (please give specific
dosages):
Recommendations, restrictions, or other comments:
Physician’s Name:
Physician's Signature:
Physician’s Address:
Phone #:
Date:
Form Completed By:
Camper’s Signature (if restrictions established):
Parental Consent - Signature required for camp attendance.
I hereby certify that the individual on this application is in good health and capable of participating in and using the camp
program, equipment and facilities. I understand that my child must comply with the camp's rules and standards for
participant behavior. I agree that the YMCA of Greater Long Beach has the right to enforce appropriate standards of
conduct and that the organization may terminate my child's participation in the camp program if he/she does not maintain
these standards. Further I give my consent for the use of my son/daughter's comments and photographs to be used in
promotional materials for the YMCA of Greater Long Beach. This Health History is correct so far as I know, and the
person herein described has permission to engage in all prescribed camp activities, except as noted on this health form.
The undersigned, as parent or legal guardian of the child registered on this form, hereby authorizes the YMCA and its
delegated leaders and directors to consent to any medical and hospital care, (which may include but not be limited to Xrays, anesthesia, surgery, hospital care and dental work), to be rendered to said minor upon the advice of a licensed
physician or dentist. This authorization is given pursuant to the provisions of the California Medical Practice Act. It is
understood that if time and circumstances reasonably permit, the YMCA will endeavor, but is not required, to
communicate with me prior to such treatment. The undersigned further agrees that the YMCA and its designated leaders
and directors are not responsible for costs incurred for medical care or for any claim arising from any consent given in
good faith in connection with such diagnosis or advised treatment. This authorization and consent to treatment is given
to the YMCA in conjunction with any authorized event.
______________
Parent’s Signature
_____________
Date
CAMPER INFORMATION RECORD
This information is given in confidence to your child’s counselor to help them know him/her better. It is very
important that the PARENT/GAURDIAN rather than the child fill out this form. Please be as candid as
possible when completing your answers.
Camper’s First Name:
Camper’s Birthday:
Last Name:
/
/
Age:
_____
Grade in Fall 2016:
Sex: M / F
_____
Camper lives with (Circle One): Mom / Dad / Both / Other (Explain):
_____
Does your child have: Brother(s), how many?_____ Age(s)? ________ Sister(s), how many?_____ Age(s)? _________
Has your child been to camp previously? ___Yes ___No
If yes, where?
Does she/he get along with others (check one): ______easily
______fairly easily
______ difficulty
Please Explain:
Friends tend to be:
older _____younger _____same age
What are his/her major interests or hobbies?
Indicate what activities, if any, he/she should not participate in while at camp:
Please Explain:
Is your child:
Slow at getting dressed? ___Yes ___No
A Slow Eater? ___Yes ___No
Afraid of water, darkness, etc.? ___Yes ___No
Sensitive about nickname, weight, height, etc.? ___Yes ___No
If Yes, please explain:
Allergic to or have strong dislikes for certain foods? ___Yes ___No
If yes, please explain:
Is your child subject to:
Bed Wetting ___Yes ___No
Nightmares ___Yes ___No
If yes, please explain:
Fainting ___Yes ___No
Sleepwalking ___Yes ___No
Tiring Easily ___Yes ___No
Constipation ___Yes ___No
Asthma ___Yes ___No
Nervousness ___Yes ___No
_______________________
What attitudes, traits or habits are you trying to strengthen or correct?
Are there any medical problems, which the counselor should be aware of?
What is the most common problem you have with your child?
Please comment on your child’s behavior and personality.
Do you have any special suggestions for working with your child at camp?
Please note any special social or recreational skills that you hope your child will develop at camp.
Has your child been active in any other YMCA programs? ___Yes ___No If yes, which?
YMCA OF GREATER LONG BEACH
RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT
IN CONSIDERATION of being permitted to utilize the facilities, services and programs of the YMCA (or for my
children to so participate) 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 such participating children 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 by the undersigned and such children.
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, ON HIS OR HER BEHALF AND BEHALF OF SUCH CHILDREN, HERBY
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 or
such children and all his personal representatives, assigns, heirs, and next of kin for any loss or
damage, and any claim or demands therefor on account of injury to the person or property or
resulting in death of the undersigned or such children whether caused by the negligence of the
releasees or otherwise while the undersigned or such children 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 of such children 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 negligence of the releasees or otherwise.
3.
THE UNDERSIGNED HERBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY
INJURY, DEATH OR PROPERTY DAMAGE to the undersigned or such children 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 California 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 of inducement apart
from the foregoing written agreement have been made.
I HAVE READ AND UNDERSTAND THIS RELEASE
Printed Name of Parent/Guardian
Name of Child in Program
Signature of Applicant/Parent
Date
YMCA OF GREATER LONG BEACH
ACUERDO DE EXONERACIÓN Y CESIÓN DE RESPONSABILIDAD CIVIL
E INDEMNIZACIÓN
EN CONSIDERACIÓN de haber sido otorgado permiso del uso de las instalaciones, servicios y programas del
YMCA (o para que un menor participe en ellos) por cualquier propósito, incluyendo, pero sin limitarse, a la
observación o uso de los equipos de las instalaciones, o participación en cualquier programa en otro sitio
pero afiliado al YMCA, el/la que firma, por si mismo(a) y en nombre de cualquier menor participante,
representante, heredero y pariente, reconoce, acuerda y asevera que ha inspeccionado y cuidadosamente
considerado, o que inmediatamente antes de ingresar o participar inspeccionará y cuidadosamente
considerará las premisas e instalaciones del programa afiliado. Además, queda sobreentendido que tal
ingreso al YMCA para observación o uso de cualquiera de los equipos de las instalaciones o la participación
en tales programas afiliados, constituirán un reconocimiento de que tales premisas, toda instalación, los
equipos de las mismas y tales programas afiliados han sido inspeccionados y cuidadosamente considerados y
que el/la que firma los halla y los acepta como seguros y razonablemente adecuados para los propósitos de
tales observaciones, uso o participación por su parte o del menor.
ADEMÁS DE CONSIDERAR EL HABER SIDO OTORGADO PERMISO PARA INGRESAR AL YMCA PARA CUALQUIER
PROPOSITO INCLUYENDO, PERO NO LIMITANDOSE, A LA OBSERVACIÓN O USO DE LAS INSTALACIONES Y
EQUIPOS, O LA PARTICIPACIÓN EN CUALQUIER PROGRAMA AFILIADO AL YMCA, EL/LA QUE FIRMA ACUERDA
LO SIGUIENTE:
1.
EL. LA QUE FIRMA, POR SU PARTE Y LA DEL MENOR, EXIME, CEDE, LIBERA Y GARANTIZA NO
DEMANDAR AL YMCA, sus directores, oficiales, empleados y agentes (de aquí en adelante se refirerá
a estos como los eximidos) por cualquier responsibilidad hacia el/la que firma, o el menor, sus
representantes, herederos y parientes, por cualquier pérdida o daño y cualquier reclamo o demanda
por los mismos, con relación a lesiones a la persona o a la propiedad o que causarán la muerte a el/la
que firma o al menor, haya sido a causa de negligencia del eximido o no, mientras el/la que firma o el
menor esté en, dentro o en los alrededores de las premisas o cualquiera de los equipos de las
instalaciones o participando en cualquier programa afiliado al YMCA.
2.
EL/LA QUE FIRMA ACUERDA INDEMNIFICAR, SALVAGUARDAR Y NO PERJUDICAR a ninguno
de los eximidos por cualquier pérdida, responsabilidad, daño o costo que pudiera tener, debido a la
presencia de el/la que firma o del menor en, dentro o en las instalaciones del YMCA, o participando
en cualquier programa afiliado al YMCA, haya sido a causa de la negligencia del eximido o no.
3.
EL/LA QUE FIRMA ASUME COMPLETA RESPONSABILIDAD Y LOS RIESGOS DE LESIONES
CORPORALES, MUERTE O DAÑO A LA PROPIEDAD a el/la que firma o al menor debido a la negligencia
del eximido o no, mientras esté en, dentro o en los alrededores de las premisas del YMCA, y/o
mientras esté usando las premisas o cualquiera de los equipos de las instalaciones, o participando en
cualquier programa afiliado al YMCA.
EL/LA QUE FIRMA además acuerda expresamente que este ACUERDO DE EXONERACIÓN, CESIÓN E
INDEMNIZACIÓN ha de ser tan amplio e inclusivo como la permita la Ley del Estado de California y que si
cualquier parte del mismo fuera invalidado, se acuerda que el saldo, no obstante, continuará en plena fuerzo
y efecto.
EL/LA QUE FIRMA HA LEÍDO Y VOLUNTARIAMENTE FIRMA EL ACUERDO DE EXONERACIÓN Y CESIÓN DE
RESPONSABILIDAD CIVIL E INDEMNIZACIÓN y además que no se le ha hecho ninguna aservación oral,
declaración o inducción, aparte del presente acuerdo por escrito.
YO HE LEÍDO ESTE ACUERDO
Nombre del Padre
Firma de el/la Solicitante/Padre
Nombre del Menor Matriculado en Programa
Fecha