Sky High Sports
Newark Aquatic Center
Diablo Rock Gym
Build-a-Bear Workshop
Six Flags Discovery Kingdom
Hercules Swim Center
Chuck E Cheese
Fremont Water Park
Oakland Zoo
Little Hills Picnic Ranch
The Jungle
Waterworld USA
Lawrence Hall of Science
Antioch Water Park
Pump It Up
Vacaville Ice Sports
Driven Raceway
Pinole Summer Adventures is filled with sports, cooking, games, arts, crafts, local field trips to the Pinole
pool, Parks, the Bowling Alley, and much more! Every Wednesday ALL CAMPS go on an exciting full day
field trip to different locations around the Bay Area, based on age. Additional liability
waivers must be signed prior to registration. Access them online or at the Pinole Youth Center.
Leader-in-Training (LIT)
For Ages 15-17 is a great program for High Schoolers to gain on-the-job
work experience for future employment; get the Community Service hours to graduate; be a role
model for younger youth and children; and most importantly, have fun! Register & Apply by May
24th, 6 pm and pay only after you have passed the interview May 29th, 4pm. Applications can be
found at PYC, City Hall, and online at www.ci.pinole.ca.us. Residents: $100 & Non-Residents:$120
Registration is based on a first come, first serve basis, per week. Participants may pre-register
by paying a $25 non-refundable fee that is applied to the cost of camp for that week.
Financial Aid not available for Summer 2013.
Register by Mail, E-mail, Fax, or in Person.
635 Tennent Avenue, Pinole, 94564 www.ci.pinole.ca.us/youth
off. (510) 724-9004
fax. (510) 724-1528
[email protected]
Payment Information
Registration will be available to the first 95 participants per week. Participants may preregister by paying a $25 non-refundable fee that is applied to the cost of camp for that week.
Note: Full payments & registration are due the WEDNESDAY before the week you are registering for by 5:30PM (applications will not be accepted after Wednesday). Late payment
fees are strictly enforced. A $25 cancellation fee will be charged for weeks that are paid in
full. If you do cancel, please do so by the Tuesday before the week you are registered, or the
entire amount will be forfeited. There is a $15 charge to transfer from one week to another.
Financial Aid is NOT available for 2013. LIT’s must fill out an LIT application and pass the interview before they register. Registration for LIT’s will be due on Friday, May 24th. We accept
the following forms of payment: Visa and Mastercard, Checks and Money Orders (made payable to the City of Pinole) and Cash.
Tax Information Notice
Please keep a copy of your registration forms and receipts for tax purposes. Our tax ID number is 94-6000394.
Late Pick Up Policy
Any child picked up later that 6:15pm will be charged $1 per minute after an initial grace period. This fee is payable at the Youth Center when the child is picked up.
In signing this form I understand the above policies and procedures and that completion of this
form is required for myself (or my child) to participate in the City of Pinole activities.
Print
PINOLE RECREATION OFFICE USE ONLY:
WS
PR
Signature
TS
PG
Date
PP
D/TR
FP
CITY OF PINOLE RECREATION DEPARTMENT Registration Form
635 Tennent Ave., Pinole, CA 94564
Phone: (510) 724-9004 · Fax: (510) 724-1528 · [email protected]
PARTICIPANT INFORMATION
Name: ________________________________________________ Birth Date:
Cell Phone: ________________________ Gender: M F Grade August 2013:
PARENT/LEGAL GUARDIAN INFORMATION
Name: ____________________________________________ Email:
Address: ________________________________ City:
Phone: Home _________________ Work
Zip:
Other (cell, pager, etc.)
Emergency Contact Information (In addition to Primary Parent/Guardian listed above)
1) Name: ______________________________ Relationship:
Phone: Home
Work __________________ Other (cell, pager, etc.)
2) Name: ______________________________ Relationship: ________________________________
Phone: Home _________________ Work ___________________ Other (cell, pager, etc.)
Medical Information (please attach additional page if needed—please fill out medical liability form if your child
will be taking and medications while in City of Pinole care.)
Allergies:
Medications:
Medical Carrier:
Completion of this Release Form is a prerequisite for participation in City of Pinole Recreation activities.
Consent to Treat: I hereby give my consent for the City of Pinole staff and instructors to take me (or my child/ward) to the
appropriate medical services and give appropriate medical authorization in the event that I cannot be immediately contacted.
It is understood that the cost thereof will be at my expense. If a physician is listed above, every effort will be made to contact
such physician. However, the location of the activity or the nature of the injury or illness may require the use of emergency
medical personnel.
I do not give my consent to treat and I request that medical or surgical services be withheld.
Photo Consent: By signing this registration form, you authorize the City of Pinole to use your name (or child’s/ward’s name)
and/or photograph in any future educational and/or community informational purposes, either printed or otherwise (including,
but not limited to, use on the city’s website and on its public television station) produced by the City of Pinole. There is NO
monetary compensation for this consent.
Check here only if you do not give photographic consent.
Liability Waiver:
1) I understand that my (or my child’s) participation in City of Pinole activities may involve the risk of harm.
2) With knowledge of the potential risks involved, I hereby release and discharge the City of Pinole or City of Pinole officials, officers, employees, agents, volunteers, or appointees, including, without limitation, appointees sitting as Youth
Commission Members, Community Services Commission Members, Pinole Area Senior Foundation Board Members,
Pinole Youth Foundation Board Members (“Indemnities”), or partnerships that have been formed for the sheer benefit of
the participant, including but not limited to Diablo Rock Gym, Pump It Up, Sky High Sports, Six Flags Discovery Kingdom, Waterworld USA, or any other corporate or private party contracted to provide services, from any and all claims
arising from my participation in City of Pinole Recreation Department activities, except when such claims arise from the
gross negligence or willful acts of the Indemnities.
3) I hereby certify that I (or my child) is physically and mentally capable of participating in Pinole Recreation activities at or
sponsored by the City of Pinole.
Printed Name ________________________________Signature ________________________ Date
2013 General Weekly Registration - Camp Hours: 8:30am - 6pm, Early Care 7:00-8:30am
Discover (Grades 1st - 3rd)
Check
Week(s)
Adventure (Grades (4th - 6th)
ICE (Grades 7th - 9th)
Resident: $132/Week Non-Resident: $154/Week
Early Care: $28/week Space Holder: $25/week (deducted from total due)
Space
Holder
Leader-in-Training: Resident: $100/Summer Non-Resident: $120/Summer
Summer Kick Off Party
Pinole Youth Center
CANCELLED
Number of Family Members Attending------->
Week 1
June 10th - 14th
Sky High Sports Indoor Trampoline
ALL CAMP FIELD TRIP
Week 2
Discover
Adventure & ICE
Week 3
(additional waiver must be signed)
June 17th - 21st
Chuck-E-Cheese (lunch Included)
Lawrence Hall of Science
Leader-in-Training (Grades 10th-12th)
Camp
Week
Early
Care
Total
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
June 24th - 28th
Oakland Zoo
Driven Raceway)
Discover
Adventure & ICE
Week 4
Discover
Adventure & ICE
Week 5
Discover
Adventure
ICE
Week 6
Discover & Adventure
ICE
(additional waiver must be signed)
July 1st - 5th CLOSED July 4th
Build-a-Bear Workshop
Six Flags (must being money for lunch)
July 8th - 12th
Pump It Up - lunch included
(additional waiver must be signed)
Chuck-E-Cheese - lunch Included
Diablo Rock Gym
(additional waiver must be signed)
July 15th - 19th
Little Hills Ranch
Hercules Swim Center
Week 7
ALL CAMP FIELD TRIP
July 22nd - 26th
Week 8
Discover & Adventure
ICE
July 29th - August 2nd
Fremont Water Park - lunch included
Vacaville Ice Sports
$
$
$
$
Week 9 *Kindergarten Week
Discover
Adventure & ICE
August 5th - 9th
The Jungle - lunch included
Waterworld USA - lunch included
$
$
$
$
Antioch Water Park
Week 10 *Kindergarten Week August 12th - 16th
$
Snack Bar Punch Card ($5, $10, $15, $20, $25) can only be used at the PYC Snack Bar (expires: 8/16/13)
$
Youth
Adult
$
X 2013 Summer Camp T-Shirt (required) T-shirt Size:
Note: In addition to the above field trips, youth may go Bowling, to Swimming, and/or to the movies each week. Total Cost: $
ALL CAMP FIELD TRIP
Newark Aquatic Center
$
$
$
PINOLE YOUTH CENTER
PAYMENT FORM
Participant Name: ______________________
Adult Name: ________________________________ Phone:
Activity
Fee
Pinole Summer Camp T-shirt
METHOD OF PAYMENT
Check enclosed (made payable to the City of Pinole)
Cash/Money Order
Credit Card
Visa
MasterCard
$12
Total:
Card # _______________________________________________________ Exp. Date (Mo/Yr): _________________
Name (as appears on card) _______________________________________ Signature:
Billing Address: ___________________________________________________________________________________
Street
City
Zip Code
I agree that by signing this form I am authorizing the City of Pinole to charge my credit card for the cost of enrollment in the
Pinole Recreation programs listed above.
For Pinole Youth Center Summer Camp Program ONLY:
In checking this box, I give the City of Pinole Recreation
Department authority to automatically charge my credit card
on the Tuesday before the week that I am pre-registered.
I understand that at any time before the
specified Wednesday, I may call to cancel.
If you have decided to utilize the $25 space holder, the box
to the right specifies the due dates for the remaining balance(s)
for each week. As a reminder, full payments are due by 5:00PM
or the $25 fee and the space for that week are forfeited.
There is a $15 charge to transfer from one week to another.
There is a $25 cancellation fee per week, per participant.
Payment Due Dates
Week
1
2
3
4
5
6
7
8
9
10
Dates
June 10th - 14th
June 17th - 21st
June 24th - 28th
July 1st - 5th
July 8th - 12th
July 15th - 19th
July 22nd - 26th
July 29th - Aug 2nd
August 5th - 9th
August 12th - 16th
Due
June 5th
June 12th
June 19th
June 26th
July 3rd
July 10th
July 17th
July 24th
July 31st
August 7th
PINOLE YOUTH CENTER
CHILD PICK-UP PROCEDURE
PLEASE ONLY FILL OUT IF YOU ARE A NEW APPLICANT OR YOU HAVE CHANGES
Please specify below whether your child will have permission from you as their legal guardian to leave the
Pinole Youth
Center by them self, or with another adult you have specified below, or if you choose to waive this right
and will sign them out on a daily basis.
Please check one of the following boxes:
I agree that my designated person(s) or I will come INTO the Pinole Youth Center to sign my child
out on a daily basis.
I agree that my child
may leave on the following designated days
without my signature. I understand that Pinole Youth Center is not responsible for my child once they sign
them self out and they leave the Pinole Youth Center Building for that day.
Monday
ex. Leave @ 5:30
Tuesday
Leave @ 6:00
Wednesday
I will Sign Out
Thursday
John Doe Sign Out
Friday
I will Sign Out
The following person(s) may sign my child out:
Self:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
I understand that I may at any time change my mind and will fill out this form again to specify any change
for my child. I understand that the Pinole Youth Center closes 15 minutes after the program time ends
and that my child will no longer be supervised by Pinole Youth Center staff, will be asked to wait outside
regardless of weather, and that Pinole Youth Center is not liable for my child.
Printed Name
Signature
Date
PINOLE YOUTH CENTER
BEHAVIOR CONTRACT
PLEASE ONLY FILL OUT IF YOU ARE A NEW APPLICANT
1. RESPECT EACH OTHER AND RESPECT DIVERSITY
No put-downs, swearing or fighting. Respect everyone’s personal and public property. Do not use
others’ property.
2. SAFE AND SOBER SPACE
Absolutely no smoking, drugs, alcohol, and weapons are allowed anywhere in or around the Youth
Center, regardless of age.
3. BE NICE AND PLAY FAIR
Play fighting/wrestling, fighting, destructive behavior, and comments are not tolerated.
4. THE YOUTH CENTER BELONGS TO EVERYBODY
Share… It’s for all of us. Help keep your Youth Center clean. Clean up trash and put away what you
use.
5. APPROPRIATE BEHAVIOR AT THE YOUTH CENTER
Listen to the staff, be aware of your surroundings, and behave appropriately in public.
6. STAY IN THE PROGRAM BOUNDARIES
This includes the Youth Center and on field trips.
DISCIPLINE PROCEDURES
If a rule or policy is violated the following steps will be taken:
The staff will discuss the violation with the youth participant and give an appropriate warning with
clear consequences if their behavior continues.
If the behavior does continue or is initially severe enough, the staff will contact the parent/guardian
and remove the youth from the situation as needed.
The staff reserves the right to suspend or expel a youth participant from the program at any time based
on the severity of their actions. The parent/guardian will always be contacted when this step is taken.
This policy is to ensure the safety of youth, staff members, volunteers, and the general public.
_________ I have read the Discipline Procedures and understand that if I do not follow the rules my
youth initials parent/guardian will be contacted and I will be disciplined based on the severity of my
behavior.
_________ I have read the Youth Center Rules and I agree to follow them.
youth initials
_________ I agree to listen and show respect to all Youth Center staff
youth initials
_________ I agree to respect all youth center participants
youth initials
Print Youth Name__________________________________________________
Youth Participant Signature__________________________________________