1. Healthcare

BOOTHBAY REGION YMCA AND CLC YMCA
2015 SUMMER CAMP REGISTRATION
Camper’s Last Name:
First Name:
Address:
City/State/Zip:
Male
Female
Birth Date:
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Age:
Email:
Grade ENTERING September 2015
Home#
Father or Guardian Name:
Day Phone #:
Mother or Guardian Name:
Day Phone #:
Emergency Contact:
Day Phone #:
Emergency Contact:
Day Phone #:
Pick Up Authorization: All campers must be picked up by 5pm and signed out by an authorized
adult. A fee of $1 per minute will be charged for children picked up after 5pm. The following individuals
have authorization to pick-up my child. Parent/Guardian listed above do not need to be included. Please
inform anyone that you list that a photo ID will be required upon pick-up of your child.
Name: _________________________________________
Day Phone#: __________________
Name: _________________________________________
Day Phone#: __________________
Health History:
Doctor preference: _______________________________ Phone #_________________________
Please list any allergies to bee stings, food, medications, etc.: _________________________________
Please list any current medications (including inhalers) that the camper is on:_____________________
___________________________________________________________________________________
Has the camper been under medical care or hospitalized for any illness in the past year?
If the camper’s activities should be restricted in any way, please describe:
Yes
No
Bus Permission
I give permission for my child to ride on the bus for camp related activities and field trips:
Parent/Guardian Signature:
_______________________________________ Date: _________________
Waiver: Must be signed in order to participate.
I/We understand that all registration fees and deposits are non-refundable and non-transferable and fees of campers who leave
camp for behavioral reasons will not be refunded. I/We also understand that all cancellations, other than verifiable medical reasons,
require a 7-day written notice stating the reasons for withdrawal. By signing this application I/We give permission for the applicant
to participate in all of the activities for his/her age group. I/We also grant permission for the YMCA to use photographs and video of
the applicant for marketing and general public relations purposes. I/We allow camp nurse to administer Tylenol to camper. I/ We
understand that the YMCA does not provide camper accident insurance. I/We hereby give permission to the medical personnel
selected by the YMCA staff to transport the applicant to a medical facility and secure treatment for the applicant. I/We understand
that I/We will be responsible for payment of all medical bills. I/We also hold the YMCA and the staff harmless for any accident or
injury that might occur. The YMCA is not responsible for lost, stolen or damaged personal articles. I/We allow camp nurse to
administer Tylenol to camper.
Parent/Guardian Signature:
_______________________________________ Date: _________________
DESCRIPTION
15-Jun 22-Jun 29-Jun
LOCATION
CAMP KNICKERBOCKER
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CAMP K
(CIT) COUNSELOR IN TRAINING
CAMP K
ADVENTURE EXPLORERS
CAMP K
ADVENTURE NAVIGATORS
CAMP K
1/2 DAY SPECIALTY (AM) ADD PM? Y N
CAMP K
1/2 DAY SPECIALTY (PM) ADD AM? Y N
CAMP K
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6-Jul
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13-Jul 20-Jul 27-Jul 3-Aug 10-Aug 17-Aug 24-Aug
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□ 10 Week Registration Required
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SCAMPER CAMP
CAMP K
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CRITTER CAMP
BOOTHBAY Y CHILD
ENRICHMENT CENTER
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YARTS ACTING INTENSIVE
CAMP K
YARTS FOR ALL
CAMP K
YARTS MUSIC THEATRE (ADVANCED)
CAMP K
YARTS SURFIN’ SAFARI DANCE CAMP
BR YMCA ANNEX
YARTS BROADWAY DANCE CAMP
BR YMCA ANNEX
YARTS BROADWAY BABIES
CAMP K
YARTS MUSIC THEATRE CAMP
CAMP K
YARTS MUSIC VIDEO CAMP
CAMP K
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SPECIALTY - ARTS & CRAFTS CAMP
CLC YMCA
SPECIALTY - CHEERLEADING CAMP
CLC YMCA
SPECIALTY - GEOCACHING CAMP
CLC YMCA
SPECIALTY - LEGO CAMP
CLC YMCA
SPORTS - BASKETBALL CAMP
BR YMCA
SPORTS - FOOTBALL CAMP
BR YMCA
SPORTS - TENNIS CAMP
BR YMCA
SPORTS - BASEBALL CAMP
CLC YMCA
SPORTS - GYMNASTICS CAMP
CLC YMCA
SPORTS - SOCCER CAMP
CLC YMCA
SPORTS - TENNIS CAMP
CLC YMCA
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SAILING CAMP REGISTRATION FORMS WILL NOT BE ACCEPTED UNTIL APRIL 1ST.
PLEASE SEE GUIDE FOR ONLINE REGISTRATION SCHEDULE.
Sailing Camp (See registration rules)
ROUND POND
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Sailing Camp LIT’s
ROUND POND
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SUMMER CAMP PROGRAM PAYMENTS FOR MORE THAN 1 WEEK OF CAMP UNLESS PAID IN FULL MUST BE
SET UP ON A DRAFT PAYMENT. I authorize my bank to honor preauthorized Electronic Funds Transfer (EFT) or Credit/Debit Cards
against my account for payments for YMCA Summer Camp. Should any preauthorized EFT or Credit/Debit Cards not be honored by said bank
when received by them, it is understood the payment is to be made by me in the amount of said payments plus service charge. It is further
understood if such payment is not honored by the bank or credit card institution the YMCA at its discretion, may resubmit the amount due for
payment on future date. Cancellation of this agreement requires a 7 day written notice to the Camp Registrar. Payments must begin on the
Friday before the first day of camp.
Please charge my account: Visa [ ] M C [ ]
Is this account on file with the Y? Yes[ ] No[ ]
Checking [ ] Savings [ ]
If yes please enter the last 4 digits: ________________________
If we do not have your account on file please add below.
CC Number_________________________________________ Exp. Date ___/___
If you are adding a checking account, please attach a voided check.
Name______________________
Signature of Parent/Guardian _____________________________________________ Date: _________________________