YMCA of Cape Breton
Summer Day Camp 2017
Registration Package
This package contains all of the forms and information required to register
your child for day camp. Please read and complete all of the forms and bring
them with you on registration day.
PLEASE NOTE: Applications will only be accepted in person during the
registration dates & times noted below. Registration is filled in a first come,
first serve basis. A child will only be confirmed at registration by a YMCA Staff
Member.
YMCA Summer Camp will be held at the New Dawn Centre for Social
Innovation (Former Holy Angels High School)
CHECKLIST
Registration Form Completed and Signed
Parent Policy Handbook Read and Signed
Payment Plan Completed and Signed
Void Cheque (if applicable)
$50.00 Deposit
9th:
REGISTRATION DATES:
Tuesday May
Registration for Children who require Support 5:00 pm – 8:00 pm
th
Wednesday May 10 : Registration for YMCA Members/Returning Campers 5:00pm – 8:00pm
Thursday May 11th: Open Registration for New Campers 5:00 pm – 8:00 pm
If you have any questions or concerns, please contact Jessica Burke, Children and Youth Coordinator
at (902)569-9622 ext 2225 or [email protected]
YMCA of Cape Breton
Children and Youth Department
Summer Day Camp
Parent Policies
And Procedures
Building healthy communities
YMCA of Cape Breton
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Established in 1886, the YMCA of Cape Breton is the oldest, most diverse charity on Cape
Breton Island. The YMCA is a volunteer driven, charitable organization serving all areas of Cape
Breton Island. We operate facilities in Sydney, Glace Bay, Port Hawkesbury and Ironville.
Our Values
The YMCA of Cape Breton is committed to practicing and demonstrating the core values of
respect, honesty, responsibility, and caring in all aspects of the organization
Our Mission
The YMCA of Cape Breton is dedicated to the growth of all persons in spirit, mind, body and in a
sense of responsibility to each other and the global community. We fulfill our charitable mission
by meeting the needs of our community in seven key functional areas:
Re-education and Training
• Employment
• Child Care
• Entrepreneurship
• Day Camp
• Wellness and Preventative Health
• International Development.
YMCA Etiquette Statement
The YMCA of Cape Breton is a shared experience for everyone. Each of us can make it better
for all by being considerate of others. YMCA participants, volunteers and staff all pledge to
treat one another with caring, honesty, respect and responsibility.
YMCA of Cape Breton Children and Youth Department Mission Statement
The mission of the YMCA of Cape Breton Children and Youth Department is to provide support to
families and to promote the development of the whole child by providing carefully planned, age
appropriate, stimulating and child-centered programming.
Our goal is to promote the importance of:
• Social acceptance by developing an understanding of other’s needs and feelings.
• Emotional health by developing a positive self-image and respect for individual
differences.
• Intellectual ability by developing each person’s enthusiasm for testing his/her own
abilities.
• Physical health by developing a positive attitude toward physical activity and hygiene.
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Philosophy Statement
The YMCA of Cape Breton Children and Youth Department believes in a Family Centered Approach. We
believe that each child is special and unique and deserves quality programs delivered in an environment
that is safe, warm, loving, challenging and stimulating.
Our programs promote the growth and development of the whole child: physically, emotionally, socially
and intellectually. We believe that our programs will ensure a child’s continued enthusiasm and
capacity for life-long learning.
At the YMCA of Cape Breton we believe that parents are an integral part of our program. Through
partnerships with families and communities we are able to strengthen our ability to meet the needs of
children and youth. Our job is to support parents by providing a safe environment for their child.
Through a team approach we can ensure that each young member has the maximum opportunity to
grow and develop to his/her full potential.
Inclusion Philosophy
The YMCA of Cape Breton Children and Youth Department, in keeping with our mission and vision,
believes in the development of healthy confident children. We’re committed to treating children with
respect and dignity and helping them grow and develop to their full potential. We believe that each
child is special and unique and deserves quality programs that are safe, warm, loving, challenging and
stimulating. Our program is open to all children regardless of their abilities or disabilities.
Central to our work at the YMCA is diversity and social inclusion. We believe that all children and
families should have an inclusive and respectful experience in our programs.
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YMCA programs are designed to develop children in spirit, mind and body. Every child is a
unique individual and will add value to our program.
Parents and families are involved, consulted and informed partners with YMCA staff and
volunteers.
YMCA staff and volunteers (where appropriate) will strive to ensure the environment and
programs are adapted to meet the needs of all children.
YMCA staff and volunteers (where appropriate) will seek out community partners to enhance
our ability to support children with special needs through training and consultation.
Summer Day Camp Activities
During your child’s day with us he/she will participate in a variety of activities that will allow
them to develop their healthy mind, body and spirit
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Weekly themes
Variety of activities including: art, drama, music, games
Small and large group activities
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Supervised swim each day
Gym activities
Field trips
Outdoor play
Registration Procedure –Summer Day Camp
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Spaces are filled on a first come, first served basis.
Parents can book full weeks during the following registration times:
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Tuesday May 9th: Registration for Children who require Support 5:00 pm – 8:00 pm
Wednesday May 10th: Registration for YMCA Members/Returning Campers 5:00pm –
8:00pm
Thursday May 11th: Open Registration for New Campers 5:00 pm – 8:00 pm
Registration form completed including parent or guardian’s signature for outings,
emergency medical attention, parent policy agreement
Medical information is up to date
$ 50.00 (non-refundable)registration fee has been paid (used toward day camp fees
Method of payment form completed
Custodial arrangements are on file where applicable
Children who require additional supports must have inclusion form filled out to help us
provide the best possible day camp experience
Fee Structure
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Summer Day Camp - $140.00 per week $28.00 per day
Payment arrangements must be made prior to your child starting the program
Any child who is receiving a subsidy or third party billing must have those arrangements
made prior to enrolling their child.
No refunds will be issued. Our day camp payment policies require pre-payment of
services regardless if the child attends the program.
Requests to change dates will not be accepted as all registration dates are final.
Child Care Income Tax Receipts will be provided upon request in 2017.
Hours of Operation
The Summer Day Camp runs Monday to Friday (including holidays) from 7:30 a.m. to 5:30 p.m.
from July 3rd– August 25th, 2017 and will be held at New Dawn Centre for Social Innovation
(Former Holy Angels High School)
Sick Days.
A child must be well enough to participate fully in the summer camp daily program, including
swimming, out door and gym play. Parents are asked to call the YMCA if their child will not be
attending due to illness.
Full Fee will apply to all sick days
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Attendance
To ensure the constant safety of your children, all parents must accompany their children to the
designated camp room upon arrival. Parents are not to leave children alone in foyers, hallways
or classrooms. Please inform anyone involved in transporting your child of these procedures.
We ask that each child greets the camp staff upon arrival and says goodbye when leaving. This
allows staff to sign them in and out of the attendance book The attendance book also allows
our staff to know who is in the building at all times which is especially important during
emergency procedures and evacuations.
Health and Wellness
The promotion of healthy development is fundamental to YMCA programs. We know this is
important to parents of young children, therefore, please do not bring a sick child to any of our
programs. A parent or emergency contact will be called to pick the child up should a child
become unwell or develop symptoms. We ask that your child be kept at home until all
symptoms of the sickness disappear. We may ask for a doctor’s note before re-admitting a
child to our program. Children must be well enough to participate in all of our daily routine.
It is necessary that parents develop a back- up plan for the care of their child in the event of
illness. This plan should be communicated with the Centre.
Late Departure Fee
If you or the person designated to pick up your children are going to be late, please notify the
YMCA immediately. Parents who pick up their child after 5:30 p.m. will be charged an
additional fee per child. We ask that parents adhere to our hours of operation and recognize
that our staff also have family commitments. Parents who are consistently late may have their
space terminated.
Withdrawal of Service
The YMCA of Cape Breton may withdraw services in the following situations:
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Non-payment of program fees
Chronic late pick-up
Situations that require specialized services that the YMCA is not able to provide
Parents or children who exhibit abusive behaviour towards staff, volunteers, other
children and families
Children who are unable to manage in group settings
Refusal by parent/guardian to meet with the YMCA staff and/or consent to the use of
support services for children
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Financial Help
You or someone you know may qualify for financial support and can apply for a YMCA Strong
Kids Scholarship. As a registered charity, the YMCA of Cape Breton is committed to serving the
community through building strong kids and strong families. Applications for opportunity Fund
are available upon request.
Insufficient Funds
A supplementary fee of $20 will be charged to your account for any payment returned to us
from the bank (i.e. NSF). After an NSF charge has occurred it is the parent’s responsibility to
provide the YMCA with cash or certified cheque to cover the account balance that was returned
NSF plus the NSF $20.00 fee.
Medication
From the NS Day Care Act and Regulations
• Selected Day camp staff are authorized to dispense medication only after the necessary
forms are completed and signed by the parents.
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Prescription Drugs - may be administered as ordered by the physician, and as stated on
the original (readable) prescription container for the child, once a YMCA Medication
Permission Form has been filled in by the parent.
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Non-prescription Drugs – may only be administered by YMCA staff if the medicine is
supplied in the original container and the parent fills in and signs the YMCA Medication
Permission Form to be kept on file.
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Parents must send dispenser/measuring utensils along with any medication.
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Medication of any kind is not to be left in a child’s backpack! All medication should be
given to the camp staff. All medication and medical supplies must be properly stored in
a locked cupboard or locked box in refrigerator.
Allergies/Food Sensitivities
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Children who attend our Multi Activity Day Camp are required to bring their own lunch and
snacks daily.
Children are also required to bring a water bottle as well.
We are a peanut-sensitive facility. We ask that you please take into consideration food
sensitivities/allergies when doing so.
Please inform the Centre of any food allergies or diet restrictions your child may have.
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Emergencies
In the case of a serious accidental injury or illness, we will make an immediate call for an
ambulance, and then attempt to contact: (in order)
1. The parent(s)
2. The designated emergency contact person/back up care in event of illness
3. The child’s physician
In the event of an early closure due to an emergency, the staff will do everything possible to
contact the parent or emergency contacts. Notifications will also be posted on our website,
facebook page and the local radio stations.
Please ensure that we have current phone numbers, address changes, special emergency
numbers and contact persons, custodial arrangements, schedules, and any other pertinent
information on file. All parents or guardians must sign an Emergency Medical Attention Form
Privacy
At the YMCA of Cape Breton, we respect your privacy. We protect your personal information
and adhere to all legislative requirements with respect to protecting privacy. We do not rent,
sell or trade our mailing lists. The information you provide will be used to deliver services and
to keep you informed and up-to-date on the activities of the YMCA of Cape Breton, including
programs, services, special events, funding needs, opportunities to volunteer or to give, open
houses and more through periodic contacts. If at any time you wish to be removed from any of
these contacts simply contact us by phone at 1-902-562-9622 and we will gladly accommodate
your request.
Media
The YMCA receives occasional requests from the media for photographic, audio or videotape
material of YMCA of Cape Breton Children and Youth Department programs and activities.
When agreeing to these requests, the YMCA will attempt to notify parents, and obtain
permission for specific media events, but because of the time factor, this is not always possible.
We ask that you be aware that this may occur, and that you discuss with the director of
children and youth any concerns you may have regarding your child/family and the media.
What Will I Need To Bring
Children should wear inexpensive, comfortable clothing so that they can participate in all
aspects of the program. Please ensure that children have:
• Sneakers
• Hat
• Bathing suit and towel
• Sunscreen
• Water/beverage bottle
• Change of clothes
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Behaviour Management Policy
The staff of the YMCA of Cape Breton Children and Youth Department will follow the guidelines
outlined in the Behaviour Guidance Policy from the Nova Scotia Department of Community
Services. The following policies are designed to help a child develop self-control and selfconfidence so that she/he will have the ability to act appropriately in given situations.
We recognize that a well-planned program with a variety of interesting and developmentally
appropriate activities helps to prevent many inappropriate behaviours. Through our program
our staff will help the children in our care develop and grow by using play as a way to teach
appropriate behaviours.
The following Behaviour Management Techniques will be used by the staff of the YMCA of Cape
Breton Children and Youth Department:
Redirection - whenever possible staff will use redirection as the primary tool in
behaviour guidance. Many inappropriate behaviours can be curbed when the staff are
observant and direct the child to a different activity
Acceptable Alternatives - the staff will explain why a behaviour is unacceptable and
provide an alternative behaviour, ie. “When you throw sand at Johnny, it hurts his eyes.
Please keep the sand in the sand box”. It is done in a matter of fact way and in terms
simple enough for a child to understand.
Positive Reinforcement - The teacher will recognize when a child is displaying
appropriate behaviour and reward the behaviour with praise, ie. “Kelly you helped Suzy
put the blocks away, good helping”.
Positive Directions - when speaking with the children staff will use positive phrasing
rather than the negative, ie. “walk please’ instead of “don’t run inside”.
Offer Choices - the staff will offer the children acceptable alternatives, ie. “Do you want
to clean up the playdough or the puzzles?” instead of “Do you want to clean up?” which
will invite a “No” response from the child.
Positive Role Modelling - The staff will model appropriate behaviours for the children
each day in all aspects of their day.
Setting Limits - The staff will set age appropriate limits in a positive way with occasional
reminders when needed.
Time Out - When a child is hurtful or aggressive the teacher may remove a child from
the situation in order for the child to calm down and ensure the safety of everyone.
Such “Time Out Talks” are brief and to the point, perhaps a minute away from the
action. The teacher will explain why such behaviour is inappropriate and unacceptable
and in terms the child can understand. The behaviour and not the child is bad. When
Time Out is used the teacher will inform the parent of the situation.
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Good Behaviour Management - NEVER ridicules, insults or scares, BUT guides, respects
and reinforces positive behaviour.
Staff Will Not:
- Use corporal or physical punishment in any form.
- Use harsh, humiliating, belittling or degrading responses of any form, including verbal,
emotional or physical.
- Confine or isolate children.
- Deprive a child of the basic needs, including food, shelter, clothing or bedding (ie. with
holding meals, snacks or desserts).
- require or force a child to repeat physical movements.
Staff
The YMCA of Cape Breton Children and Youth Department provides quality programs by
employing qualified staff and volunteers who fulfill our high expectations for program delivery.
Day Camp staff are supported and guided by the Coordinator of Children and Youth and
together we work as a team to ensure that the standards and services are consistent and
appropriate. All YMCA of Cape Breton Children and Youth Department staff receives a full week
of training and orientation in regards to our programs, policies, and procedures prior to
working with the children. All of our staff must have a valid First Aid and CPR Training
Certificate and are screened through the Child Abuse Registry and have had Criminal Record
Checks completed.
Under the Influence
Children will not be released from our program to accompany a parent or guardian who
appears to be under the influence of drugs or alcohol. In such circumstances, our staff will call
the other parent/guardian, or emergency contact person, and request that he/she come to pick
up the child. The police will be contacted if the child is taken from the premises despite staff
concerns.
Duty To Report
If our staff suspects that a child is being abused or neglected they will contact the local child
welfare agency. Everyone has the duty to immediately report to a child welfare agency even a
suspicion that a child under 16 may be in need of protective services. Once a report is made,
child protection staff considers the information provided to determine whether an investigation
into the matter is necessary.
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Parent Involvement
The YMCA of Cape Breton Children and Youth Department believes that parent-staff
communication is important for the creation of a healthy child environment. Please make an
effort to stay up to date with our program information, and be sure to communicate to us any
relevant information regarding your child’s experiences outside of our program. If at any time
you wish to discuss a matter with one of our staff or our coordinator please do not hesitate to
contact us.
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YMCA of Cape Breton
Summer Day Camp
Registration Form
Please Note: Summer Day Camp will be held at the New Dawn Centre for
Social Innovation (Former Holy Angels High School)
Child’s Name: ____________________________________________________________________________
Nickname: ______________________________________________________________________________
Date of Birth: ____________________________________________________________________________
What grade is your child entering in September? _______________________________________________
What school does your child attend? _________________________________________________________
Home Address:
Mailing Address:
____________________________________ ______
_______________________________________
____________________________________ ______
_______________________________________
__________________________________________
_______________________________________
Home Phone Number: _____________________________________________________________________
Parent/Guardian (1): ___________________________
Home Phone: ____________________________
Employer: ____________________________________
Work Phone: ____________________________
Cell Phone: ___________________________________
Email: __________________________________
Parent/Guardian (2): ___________________________
Home Phone: ____________________________
Employer: ____________________________________
Work Phone: ____________________________
Cell Phone: ___________________________________
Email: __________________________________
Emergency Contact Number (if parent/guardian cannot be reached)
Name: _______________________________________
Phone: ___________________________________
Name: _______________________________________
Phone: ___________________________________
Who other than the child’s parent/guardian has permission to pick the child up from the program?
Name: ___________________________________
Relationship: _______________________________
Name: ___________________________________
Relationship: _______________________________
Background Information
Language(s) spoken at home: __________________________________________________________________
Has your child had any experience with Day Camp or structured child care before?
Yes _____
No _____
Please describe the child’s experience:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Has your child been cared for by other family members or neighbours?
Yes _____
No _____
Please describe the child’s experience:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Is this your child’s first experience in the YMCA Summer Camp?
Yes _____
No _____
What is your child’s comfort level in regards to the pool? ______________________________
____________________________________________________________________________
____________________________________________________________________________
Other than school, has your child had any other structured group experience? (ie. Brownies, Cubs, sports)
Yes _________
No __________
Please describe the child’s experience:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Health and Development History
Describe your child’s general health: (ie. recurrent colds, ear infections, stomach aches, etc.)
__________________________________________________________________________________________
__________________________________________________________________________________________
Are there currently any serious medical problems?
Yes _________
No ________
__________________________________________________________________________________________
__________________________________________________________________________________________
If your child is taking any medications, what is the medication and what is it for: (if the child requires
medication to be administered during the program a Medical Administration Form must be filled out prior)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Does your child have any allergies: (food, medications, environmental)
Yes _____
No _____
If yes please list along with the symptoms:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Is the allergy severe enough to require medication or emergency treatment?
Yes _____
No _____
If yes please describe in detail any medications or treatment required:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Does your child have any diet restrictions: (cultural, religious)
Yes _______
No _______
__________________________________________________________________________________________
__________________________________________________________________________________________
Name of Family Doctor:
Phone Number:
_________________________________________
____________________________________
Address: __________________________________________________________________________________
__________________________________________________________________________________________
Behaviour Patterns and Habits
Describe your child’s behaviour and habits: (ie. temperament, energy level)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Describe how your child communicates:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
How would you describe your child’s emotional, physical, social growth and development to this point?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Describe your child’s particular attachments: (ie. toy, blanket, pet, person) and any particular habits (ie. thumb
sucking, rocking)
__________________________________________________________________________________________
__________________________________________________________________________________________
Describe any particular fears your child has shown: (ie. to animals, loud noises, strangers)
__________________________________________________________________________________________
__________________________________________________________________________________________
Describe how your child reacts to stressful situations: (ie. cries, withdrawals, temper tantrum, nightmares)
__________________________________________________________________________________________
__________________________________________________________________________________________
How does your child usually react to new situations?
__________________________________________________________________________________________
__________________________________________________________________________________________
We would appreciate your views on guiding your child’s behaviour and setting limits:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Is there anything else that you feel we should know about your child that will assist us in providing
them with a positive camp experience?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Parent Policy and Procedures Agreement
I have read the policies and procedures for the YMCA of Cape Breton Multi Activity Camp. This includes the
behaviour guidance policy, fee structure, health, and attendance policies. I understand my responsibilities as a
parent / guardian and agree to abide by these policies and procedures.
__________________________________________
Parent/Guardian Signature:
__________________________________________
Date:
Outside Expeditions
I am willing for my child ________________________________________________ to go on
outside expeditions with adequate adult supervision.
_______________________________________
Parent/Guardian Signature
__________________________________________
Date
Emergency Medical Attention
I am willing for my child ________________________________________________to have
medical attention and be taken to the hospital in the case of an emergency if I/we cannot be reached.
______________________________________
Parent/Guardian Signature
__________________________________________
Date
YMCA of Cape Breton
Summer Day Camp
Please fill out ONLY if your child requires special Support
Inclusion Policy
The YMCA of Cape Breton Children and Youth Department believes that each child is special and unique and
deserves a quality program that is safe, warm, loving, challenging and stimulating. Our program is open to all
children regardless of their abilities or disabilities. Through our partnerships with families, government and
community agencies we are able to strengthen our ability to meet the needs of all the children we work with.
With limited funding for additional staff, this summer we are offering our campers who require additional
supports one week time slots. Each family can choose one week for their child to attend so that we can serve
as many families as possible. If there are any spaces left after each family has chosen a week, families will be
able to pick further days for their child to attend. First choice time slots will be filled based on order of
received applications. We will do our best to accommodate each family’s preference.
Please indicate your preferred time slots for your child to attend (in order of preference)
__________________________________________
______________________________________
__________________________________________
______________________________________
__________________________________________
______________________________________
Are you interested in additional weeks if they are available?
Yes____________
No____________
In order for us to provide the best possible day camp experience for your child, we ask that you give us as
much detail as possible in regards to any additional supports your child may require.
Does your child have a specific diagnosis?
Yes____________
No___________
______________________________________________________________________________________
______________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Which professional gave your child the diagnosis?
___________________________________________
______________________________________________________________________________________
Please list all the professionals and supports who work with your child
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Does your child have any allergies (food, medications, environmental)
If yes please list along with the symptoms:
Yes__________
No__________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Is the allergy severe enough to require medication or emergency treatment?
Yes________
No________
If yes please describe in detail any medications or treatment required:
__________________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Does your child use any assistive devices (ie. wheelchair, iPod, picture board, etc)? Yes _______
If yes please describe:
No ______
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
If your child is taking any medications, what is the medication and what is it for: (if the child requires
medication to be administered during the program a Medical Admin Form must be filled out prior)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
List the activities your child enjoys: _____________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
List any activities your child dislikes: ____________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What are your child’s strengths? _______________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
COMMUNICATION
What current communication skills does your child have (for example, verbal, vocalizations, words, sign
language, PECS, etc.)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Is your child able to communicate their needs effectively?
Yes _________
No _________
Is your child familiar with the use of visuals?
If yes how and when are they used?
Yes _________
No _________
_________________________________________________________________________________________
__________________________________________________________________________________________
SELF CARE
Does your child go to the washroom independently?
If not please describe assistance required
Yes ________
No _________
__________________________________________________________________________________________
__________________________________________________________________________________________
Is your child able to get dressed independently?
If not please describe assistance required
Yes ________
No __________
__________________________________________________________________________________________
__________________________________________________________________________________________
SENSORY
Is your child hypo (under) of hyper (over) sensitive to any of the below. Please provide examples and
strategies used to assist in regulating sensitivity.
Tactile (touch, getting messy) _________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Auditory (sound, crowds) _____________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Smell (certain scents )
______________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Movement (swing, spin)
____________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Visual (lighting, stimming) ____________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Is your child aware of his/her sensitivities? How does he/she self-regulate?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
BEHAVIOUR
Does your child have any behaviour issues (flight risk, aggressive, non-compliant, self injurious,
self stimulatory etc.)? Please explain and describe
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
How often do the behaviours occur? What is their duration?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What are the triggers / antecedents to the challenging behaviours?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What are the usual interventions that you find effective? (ie. removed from situation)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What are the most useful strategies in calming / de-escalation your child if they do become upset (ie. deep
pressure, music, breathing techniques, remove from the environment)?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
List any motivators or special interests your child may have
__________________________________________________________________________________________
__________________________________________________________________________________________
How does your child do with transitioning between activities?
__________________________________________________________________________________________
__________________________________________________________________________________________
How does your child do with changes to routine?
__________________________________________________________________________________________
__________________________________________________________________________________________
Is there any other information you would to share with us to ensure your child has a successful day camp
experience?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________
Parent/Guardian Signature
_____________________________
Date
Thank you for taking the time to provide us with this information
YMCA of Cape Breton
Summer Day Camp
Payment Form
Child’s Name:
Parent or Guardian:
Please select the following weeks your child will be attending:
 July 3 - 7
 July 24 - 28
 Aug 14 - 18
 July 10 - 14
 July 31 – Aug 4
 Aug 21 - 25
 July 17 - 21
 Aug 7 - 11
Total # of weeks
x $140.00 per week =
Less Deposit:
Balance Owing:
A non-refundable deposit of $50.00 is required at the time of registration to secure your child’s spot.
CHECK OFF PAYMENT DATES:
 June 1
$
 June 15
$
 July 3
$
 July 14
$
PAYMENT METHOD:
 Bank Account Information (Please attach void cheque)
 Credit Card Information
Type of Card:
Card Number:
 Visa
 MasterCard
________/________/_________/__________/
Expiry Date:
______/_____
Account Holder Name:
PRE-AUTHROZIED DETAILS:
You, the Payer, authorize The YMCA of Cape Breton to charge your account or credit card listed above
for the amounts and dates listed.
The week(s) your child will be attending day camp must be paid in full prior to attending.
I agree with the weeks selected for my child. I know that once these weeks are selected they cannot be changed and no
refund will be given. Refunds are not given for sick days or days unattended.
Parent’s Signature
Date