Camp Enrollment Form

YMCA Summer Camp Enrollment Form

Please print neatly

1st Day of Enrollment    Kinder Camp    Fun Club    Adventure Club

Session: (Circle only those attending)

June 8 – 12    June 15 – 19    June 22-26    June 29 – July 3    July 6 – 10

July 13 – 17    July 20 – 24    July 27 – 31    Aug 3 –7    Aug 10 – 12

Child’s Name:    DOB:    Grade    Gender: M F

Address

Mother’s Name:    Home Phone:

Address: City: Zip Code:

Place of Employment: Work Hours: Work Phone:

Employment Address:

Cell Phone: Email:

Father’s Name:    Home Phone:

Address: City: Zip Code:

Place of Employment: Work Hours: Work Phone:

Employment Address:

Cell Phone: Email:

Guardian’s Name:    Home Phone:

Address: City: Zip Code:

Place of Employment: Work Hours: Work Phone:

Employment Address:

Cell Phone: Email:

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Emergency Contact Persons

FIRST

Name: Phone Number

Address: City: Zip Code:

Relationship to Child:

SECOND

Name: Phone Number

Address: City: Zip Code:

Relationship to Child:

Persons Authorized to Pick Up Your Child

(Other Than Parents)

Name: Phone Number:

Address: City: Zip Code:

Relationship to Child:

Name: Phone Number:

Address: City: Zip Code:

Relationship to Child:

Name: Phone Number:

Address: City: Zip Code:

Relationship to Child:

Are there any persons who are not permitted to pick up your child?

1. Relationship to Child

2. Relationship to Child

Doctor’s Name Doctor’s Phone Number

Dentist’s Name Dentist’s Phone Number

1st Choice of Hospital Phone Number

Address City Zip Code

Health Insurance Information Policy Number

If Physician cannot be reached, what action should be taken call emergency hospital other explain

Additional Information

Any Medical Problems

Any Known Allergies

Any recent injuries or hospitalizations

Current Medication

Any additional information

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T-Shirt Order Form

(Circle the correct size)

Child: S    M    L    XL      Adult: S    M    L    XL

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Authorization Release

Authorization to take pictures:

The parent of the above registered child gives authorization allowing the child to be photographed, and the photos to be used in the promotion of the YMCA.

Transportation Authorization:

The parent of the above registered child gives authorization allowing the child to be transported to and from school. Furthermore the parent gives authorization to transport the child on YMCA scheduled field trips.

Have received a copy of the Parent Handbook including discipline policies and I understand that these policies apply to all child care programs at the YMCA.

Insurance Information

Medical Insurance Co. Name

Group Number Policy Number

Medical Release

I hereby give my permission to the YMCA staff to seek medical treatment (private physician or hospital) or transportation for my child should any emergency arise. I understand that a conscientious effort will be made to locate me or my spouse before any action will be taken.

I/We have been personally advised of, and received a copy of the personal rights contained in the California Code Regulations, Title 22, at the time of admission. (Included in Parent Handbook)

I, the parent/authorized representative of , have received a copy of the “CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS” and the CAREGIVER BACKGROUND CHECK PROCESS from the licensee.

Name of Child Care Center

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Policies and Agreement Contract

Please read and initial

I understand that I will be required to pay for all sessions that I check unless I give a two weeks written notice. Failure to comply will result in cancellation of all future sessions.

I understand that whenever I drop off or pick up my child, I must enter the Day Camp site to sign the roll sheet and write down the time I dropped my child off or the time I picked my child up. I understand that the person picking up my child, including parents, may have to provide a photo ID if not recognized by staff.

Tuition payment may be made by check (please write your child’s name on your check), credit card or cash. Cash payments must be made at the Diamond Bar. Payment will be due on Wednesday prior to the week of attendance.

A late fee of $15.00 per 15 minutes will be collected for any child picked up after 6:30 p.m. Parents who chronically leave their children after the 6:30 p.m. closing hour will be terminated from this program. Any child who has not been picked up by 7:30 p.m. will be turned over to local authorities if an emergency contact cannot be located.

The YMCA is not responsible for a child’s lost or broken articles. Please remember to label your child’s belongings. Children are not allowed to bring possessions from home (i.e. toys, Game Boys, action figures, etc.).

I understand by signing this form, I agree to abide by these policies and all policies contained in the Summer Day Camp Handbook.

YMCA of Pomona Valley Media Waiver

I give my permission for the YMCA of Pomona Valley to use without limitation or obligation, photographs, film footage, or tape recordings which may include my or my children's image or voice for the purpose of promotion or interpreting YMCA programs.

Childs Name:

Parent(s) Signature:

Date:

Diamond Bar YMCA
Child Care Center
909.860.9622
22600 Sunset Crossing Rd.
Diamond Bar, CA 91765
www.pomonaymca.org

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