YMCA OF GREATER ROCHESTER
CAMP WESTSIDE
2017 Summer Camp Registration Form
BEST.
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rochesterymca.org/camps
585-341-3278
2017 YMCA Camp Westside Registration and Health Fo
Camper Name
REGISTRATION
IS AS EASY AS...
1
SCHOOL AGE CAMP
1
2
CAMP SESSIONS
CAMP HOURS:
June 19 - September 1
Review
Camp Sessions
and Dates
Session 1: June 26-30
2
Session 3: July 10-14
Select
Camp Program
and Sessions
3
Select
Payment Option
7:00-9:00am
Before Care
9:00am-4:00pm
Camp Hours
Session 2: July 3-7*
NO
AL
ADDITIONE
CHARG r Care!
& Afte
for Before
Session 5: July 24-28
Entering Kindergarten
9:00am-4:00pm
Rangers
Entering Grades 1-2
9:00am-4:00pm
Vikings
Entering Grades 3-4
9:00am-4:00pm
Explorers
Entering Grades 5-6
9:00am-4:00pm
Teen Trekkers
Entering Grades 7-9
9:00am-4:00pm
Colts
Entering Grades 1-2
9:00am-4:00pm
Ponies
Entering Grades 3-4
9:00am-4:00pm
Mustangs
Entering Grades 5-8
9:00am-4:00pm
SPORTS UNIT
4:00-6:00pm
After Care
Session 4: July 17-21
Pioneers
Session 6: July 31-Aug. 4
Session 7: Aug. 7-11
LEADERSHIP TRAINING
Session 8: Aug. 14-18
LIT
(Leader in Training)
Session 9: Aug. 21-25
CIT
Session 10: Aug. 28-Sept. 1
(Counselor in Training)
Entering Grades 9-10
9:00am-4:00pm
Entering Grades 10-11
9:00am-4:00pm
*Camp closed on July 4th
HEALTH INFORMATION
Immunization History (required by New York State Department of Health):
Health History
I certify that all of my child’s immunizations are up to date.
I give permission for my child to use sunscreen at the YMCA.
I understand that I must submit a full copy of my child’s immunization history
before he/she may attend YMCA Camp Westside. Please provide the most current
immunizations history to the YMCA by May 30, 2017.
Allergies
Hay Fever
Convulsions
Nuts/Peanuts
Asthma
Diabetes
Insect Stings
Special Diet
Chicken Pox
Poison Ivy, etc.
Hearing
Mumps
Penicillin
Vision
Medication (Name and Dose)
Other Drugs
Ear Infections
Foods (supply list)
Rheumatic Fever
Latex
Doctor’s Name:
Phone:
Insurance Carrier:
Policy Holder Name:
Policy No.:
Recent surgery (type and date):
Recommendations and Restrictions While at Camp
Are there any medical or developmental conditions requiring attention or accommodation?
Serious injury (type and date):
Chronic or recurring illness:
Other conditions or details of above:
Will your child need any medication at camp?
No
Yes
If yes, list name(s) and dosage(s)*
Have any significant events occurred in your family within the last few years?
Does your child have any serious fears? If so, please explain.
Are there any other concerns your child may have at camp?
*Note on medication: All prescriptions and over-the-counter medications must be in original bottle and have complete instructions from the doctor with a signed copy of the medication authorization form.
Form
How did you hear about YMCA Camp Westside?
Postcard
Website
Email
Phone
Friend
SESSIONS
3
4
5
6
7
8
9
10
pm
YMCA Members $202
Prog. Members $259
1
2
3
4
5
6
7
8
9
10
pm
YMCA Members $202
Prog. Members $259
1
2
3
4
5
6
7
8
9
10
pm
YMCA Members $202
Prog. Members $259
1
2
3
4
5
6
7
8
9
10
pm
YMCA Members $202
Prog. Members $259
1
2
3
4
5
6
7
8
9
10
pm
YMCA Members $202
Prog. Members $259
1
2
3
4
5
6
7
8
pm
YMCA Members $202
Prog. Members $259
1
2
3
4
5
6
7
8
pm
YMCA Members $202
Prog. Members $259
1
2
3
4
5
6
7
8
Floo
r Ho
cke
y
Bas
ket
ball
II
2
Bas
ket
ball
I
1
Soc
cer
II
Prog. Members $259
Flag
Foo
tba
ll
Oly
mpi
cW
eek
Bas
eba
ll
YMCA Members $202
Soc
cer
I
pm
LITs and CITs choose 4 Sessions to attend:
pm
YMCA Members $467
Prog. Members $647
1-4
5-8
pm
YMCA Members $467
Prog. Members $647
1-4
5-8
3
PAYMENT OPTIONS
A one-time registration fee of $20 per camper, a $25 per camper per session deposit for sessions 1-10 and full payment of all additional services is
due with registration. All deposits and registration fees are non-refundable.
Select Payment Option:
Easy Payment Option (EFT):
I hereby authorize the YMCA of Greater Rochester to debit the account listed below for summer camp fees on the Monday, two weeks prior
to each registered session.
Payment in Full: Enclosed is full payment for all registered camp sessions.
Select Payment Form:
Mastercard
Visa
Discover
Billing Name:
Account No:
Exp. Date:
/
/
Signature:
Date:
/
/
Electronic Fund Transfer (EFT) is the preferred billing method for Camp Westside. Simply provide a credit or debit card and tuition will be
automatically paid on Monday two weeks prior to the beginning of each session for which you are registered. If you prefer not to participate
in the EFT payment option please contact our billing registration specialist at 341-3278 to discuss a statement billing plan.
I need a Flex Receipt for Child Care Reimbursement.
My completed Financial Assistance Application is attached.
I plan to receive DSS funding.
Split billing is available with written consent from both parties. Visit rochesterymca.org/camps for an authorization form.
Other
2017 YMCA Camp Westside Registration
I will be enrolling
multiple children.
Complete one registration form per child. Please Note: application will not be processed without one-time registration fee ($20 per camper)
and a $25 deposit per child for sessions 1-10 (which is applied toward the camp fee). All deposits and registration fees are non-refundable.
$15 sibling discount
per additional child
CAMPER INFORMATION
Camper Name:
Gender:
School Name:
/
Date of Birth:
Address:
M
F
/
YMCA Member:
Age:
Yes
No
No. of Years at Camp Westside:
No
Grade (entering 9/17):
City:
This will be my first summer at Camp Westside:
Yes
State:
Camper T-shirt Size:
PARENT/GUARDIAN 1 INFORMATION
Youth - S
M
L
Adult - S
ZIP:
M
L
XL
PARENT/GUARDIAN 2 INFORMATION
Relation to Camper:
Relation to Camper:
First Name:
First Name:
Last Name:
Last Name:
Occupation:
Occupation:
/
Date of Birth:
/
/
Date of Birth:
Address:
/
Address:
City:
State:
Home Phone: (
Cell Phone: (
Work Phone: (
ZIP:
City:
)
State:
Home Phone: (
)
)
Cell Phone: (
)
)
Work Phone: (
Email:
ZIP:
)
Email:
Yes, I would like to receive the Camp Westside weekly e-newsletter to hear what fun
activities my camper is participating in!
Camper lives with: (please check)
Parent/Guardian 1 and Parent/Guardian 2
Yes, I would like to receive the Camp Westside weekly e-newsletter to hear what fun
activities my camper is participating in!
Parent/Guardian 1
Parent/Guardian 2
PERSONS AUTHORIZED TO PICK UP CAMPER AND EMERGENCY CONTACTS
Parent/Guardian 1:
Yes
No
Parent/Guardian 2:
Yes
No
Name:
Relationship:
Cell Phone:
Name:
Relationship:
Cell Phone:
Name:
Relationship:
Cell Phone:
ADDITIONAL INFORMATION
Group placement: If possible, I would like to request my child be with these two campers:
2.
1.
Parent/Guardian Agreement: I hereby register my child for designated session(s) at YMCA Camp Westside. I will access the parent packet online at rochesterymca.org/camps and understand I
am responsible for reading and reviewing the camp policies including but not limited to payment procedures and deadlines, refund policy, camper release policy, camp hours of operation and
behavior policy. I understand that the New York State Department of Health requires my child to have completed health information including immunization dates in order to attend camp. It
is understood that the YMCA will make every reasonable effort to contact the parents and emergency contacts listed should any type of emergency arise. In the event I cannot be reached I
authorize the YMCA staff to act for me according to his/her best judgment in any emergency requiring medical or surgical care. I authorize the physician selected to hospitalize, secure proper
treatment for, and to order injection, anesthesia, or surgery for my child named above. I expect the YMCA to attempt to contact me immediately. I further understand I am responsible for the
cost of all medical care. The health information is correct as far as I know, and the person described has permission to engage in all camp activities except as noted by me and his/her physician.
I have provided the staff with any pertinent information which may assist the YMCA in caring for my child including but not limited to allergies, previous existing illness or condition, sunburn
sensitivity, diet requirement, long term medications, disability, limiting conditions or accommodations or emotional, developmental, or behavioral challenges. I agree to notify YMCA Staff
immediately, in writing, of any changes in address, phone number, places of employment, or persons authorized to pick up child, etc. I understand that not fully disclosing the above may put my
child’s health and safety at risk. I give consent for my child to take part in field trips or excursions off camp property under proper supervision. Finally, I give consent that the YMCA may use
photographs, slides, and video of my child, as may be needed for its records or promotional purposes including website material. I further understand that my child’s spot is reserved
only upon receipt by the YMCA of the fully completed registration form and health information, a $25 deposit per camper for sessions 1-10, and the $20 per camper
registration fee for weeks 1-10, and that failure to pay balance due and complete balance payoff information by the deadline, may forfeit my child’s registration.
Signature of Parent/Guardian
Date
The YMCA is required to report membership and program participation information to the United Way and various government
agencies in support of annual allocation, grant, and community service requests. This information is not reported on an
individual basis and is used for statistical purposes only. Please check the correct answer for both A and B:
A. Racial Status:
African American
Hispanic
Asian
Native American
Caucasian
Other
B. Annual Household Income:
Less than $15,000
$25,000-$44,999
$75,000 or over
$15,000-$24,999
$45,000-$74,999
For Official Use Only: Date Received
Time Received
Initials
BECOME A MEMBER
Become a member and
save up to $500
on your child’s camp
tuition. Sign up from
March through May and
we’ll waive the
joining fee on your cam
per’s youth
membership!