2020 CAMPER REGISTRATION FORMYMCA OF SOUTHERN MAINE - DAY CAMPSChild’s First Name: Last Name:Please note you must fill out a separate registration form for each child attending camp.

Date of Birth: Age as of 7/1/2020: Grade Entering Fall 2020: T-Shirt Size:

Gender (identifies as): Male Female Other

Ethnicity (this is used ONLY for statistical information for grants): WhiteAfrican/African AmericanLatino/Hispanic

PARENT/GUARDIANFirst Name: Last Name:

Address: City: State: Zip:

Best Phone to reach you: 2nd Best Phone:

Relationship to Child: Employer:

Email:

PARENT/GUARDIAN (Only if approved for pick up)First Name: Last Name:

Address: City: State: Zip:

Best Phone to reach you: 2nd Best Phone:

Relationship to Child: Employer:

Email:

With whom does this child live?

Please list at least one NON-PARENT emergency contact:

FIRST EMERGENCY CONTACT First Name: Last Name:

Best Phone *required: Address:

Relationship to Child:

SECOND EMERGENCY CONTACT First Name: Last Name:

Best Phone *required: Address:

Relationship to Child:

Other than those listed above, who is allowed to pick up your child?

If you would like our staff to better understand specific family structures/agreements that could affect your child’s drop-off, daily program, or pick-up, please list here in detail.

AsianPacific IslanderNative American/Alaskan Native

MultiracialOther:Prefer not to answer

Where did you hear about us? Press Herald Friends/Family YMCA Website /Facebook Online search The Sentry The Forecaster Parent & Family Magazine Maine Summer Camps Other:

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WAIVERSGeneral Waiver & Acknowledgment of Risk (Required): I, in my legal capacity as the parent/guardian of the child whose name appears on the first page of this Registration Form, do hereby acknowledge and agree that participation in day camp, full-day childcare or school-aged enrichment programs activities comes with inherent risks. I have full knowledge and understanding of the risks associated with day camp, full-day childcare or school-aged enrichment programs, participation, including but in no way limited to: trips and falls, athletic injuries, injuries from encounters with toxic plants, insects, and/or animals, or injuries related to use of playground equipment. I further acknowledge that this list is not inclusive of all possible risks associated with program participation and that said list in no way limits the operation of this agreement. In consideration of my child’s participation in the YMCA of Southern Maine’s day camp, full-day childcare or school-aged enrichment programs, I, the parent/guardian of the child who’s name appears on the first page of this Registration Form, agree to release and on behalf of myself, my child, my heirs, representatives, executors, administrators, and assigns, HEREBY DO RELEASE, AGREE TO INDEMNIFY, REIMBURSE AND HOLD HARMLESS the YMCA of Southern Maine, its officers, directors, employees, volunteers, agents and repre-sentatives from any causes of action, claims, or demands of any nature whatsoever including, but in no way limited to, claims of negligence which I, my child, my heirs, representatives, executors, administrators and assigns may have, now or in the future, against the YMCA of Southern Maine on account of personal injury, property damage, death or acci-dent of any kind, arising out of or in any way connected to the use of YMCA of Southern Maine facilities/equipment or participation in YMCA of Southern Maine programs whether that participation is supervised or unsupervised, however the injury or damage occurs, including, but not limited to the negligence of the YMCA of Southern Maine, its officers, directors, employees, volunteers, agents and representatives.

Parent/Guardian Signature: Date:

Field Trip Transportation Liability Agreement: I give permission for the YMCA to take my child on field trips(van or walking). I give my permission for my child to be transported by the appropriate YMCA of Southern Mainestaff in a YMCA approved vehicle. I assume any and all liability for damages to or caused by my child in connectionwith the transportation services offered by the YMCA, except those caused by gross negligence or intentional act ofthe YMCA. I also understand that the YMCA will not be responsible for my child between the YMCA and his/herresidence and vice versa.

Parent/Guardian Signature: Date:

Aquatic Permission Slip and Liability Agreement: I give permission for the YMCA of Southern Maine (“YMCA”) to provide scheduled, aquatic opportunities to my child. This permission covers any instructional and recreationalactivities conducted by the appropriate YMCA staff. I assume any and all liability for damages to or caused by mychild in connection with the aquatic services provided by the YMCA, and unconditionally release the YMCA from anyand all liability therefor or relating thereto, except those caused by the gross negligence or intentional wrongful actof the YMCA.

Child’s Name: ______________________________________________________________________________

Parent/Guardian Signature: _______________________________________ Date: _____________________________

____ I decline. Signature: __________________________________________ Date: _____________________________(Check here, sign and date if you do not wish to grant permission). 2

WAIVERS CONTINUEDWalk Home Liability Agreement (complete only if your child will be walking to/from program without an adult present): I give permission to have my child picked up and dropped off at the YMCA camp program without a parent/guardian being present. I assume any and all responsibility for my child before he/she arrives and after the YMCA dismissed my child for the day, and understand that the YMCA will not be responsible for my child between the YMCA and his/her residence and vice versa.

My child will arrive unaccompanied at: ___________________ am each day.Please dismiss my child from program at: ________________ pm each day.

Parent/Guardian Signature: Date:

Camp Handbook Agreement: The Camp Handbook can be found on our website, or can be provided by the Camp Director or Membership Team at each Branch location.

I hereby acknowledge receipt of the YMCA of Southern Maine’s Camp Handbook. I understand that the policies and procedures may be changed at any time and I will receive notification if and when these changes occur. I have had explained to me any portions of the Camp Handbook about which I did not understand. I realize that by signing I agree to comply with the noted camp policies and procedures.

Parent/Guardian Signature: _______________________________________ Date: _____________________________

Printed Name: _____________________________________________________

Camper’s Name: ___________________________________________________ Camp(s) Attending: _______________

CANCELLATION POLICYAll deposits are nonrefundable and nontransferable. Weekly program fees for campers who leave for behavioral reasons will not be refunded. For cancellations other than verifiable medical reasons, tuitions paid in advance (minus deposit) will be refunded if we receive written notice with reason for withdrawal at least two weeks before the start of the sessions.

Parent/Guardian Signature: Date:

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PHOTO/AUDIO VISUAL/NARRATIVE RELEASE

Consent. With respect to my child/children named below I hereby give my consent for the National Council of Young Men’s Christian Associations of the United States of America (YMCA of the USA), and/or the YMCA of Southern Maine (YMCA), YMCA of the USA, YMCA and collaborating third parties to make, reproduce, edit, broadcast or rebroadcast:

• video film or footage• sound track recordings• photo reproductions• any narrative account of their experience

My consent gives permission to use the above materials for publication, display, sale or exhibition in promotions, advertising, education and legitimate business uses. Use includes reproductions in any form and media, adaptations and/or revisions.

I understand and agree there may be no compensation for this, and I will not make any claim for payment of any kind. I may, or may not be, identified in such reproductions; however, my child/children’s will not be used to endorse any particular commercial products or commercial services.

Should I wish to revoke this consent at any point in the future, I may do so, but I understand that images may already have been released to the public if such a revocation occurs after publication.

Ownership, Confidentiality, and Shared Use. With respect to any of the above uses, I further agree:

• All uses shall belong to YMCA of the USA and YMCA and either may share them with others;• There is no obligation of confidentiality• YMCA of the USA, YMCA, and collaborating third parties will not be liable for any use or disclosure to a third party• YMCA of the USA and YMCA shall exclusively own all known or later existing rights to the uses worldwide.• YMCA of the USA and YMCA can use any video film, footage, sound track recordings and photo reproductions of

me and/or my narrative account for any purpose and without compensation to me.

Release from Liability. I hereby release and discharge YMCA of the USA, YMCA and their related parties from any and all claims, actions, lawsuits or demands of any kind arising out of my consent, the use, or the shared use of the above materials.

Name(s) of child/children (if applicable):

1. 2.

3. 4.

5. 6.

Signature: Date:

Printed Name:

Address:

I do not give consent. Signature: Date:

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4

CAMP 2020 REGISTRATIONStep 1: Choose Your Weeks - Check the boxes that correspond with the camp weeks for which you are registering.

Continued on page 5…

Application D

ate:

JUN

EJU

LYA

UG

UST

DAY

CAM

PSA

ges:1

52

22

96

13

20

27

31

01

72

43

1Total

Weeks:

Fee/Week*:

Total Due

(# weeks

x fee)

Camp Sokokis

5 - 8

$250

9 - 1

2$2

45

Camp O

sprey

5 - 8

$250

9 - 1

2$2

45

Camp Pineland

5 - 8

$250

9 - 1

2$2

45

Otter Pond O

utdoor Adventure Cam

p

5 - 8

$270

9 - 1

2$2

65

In-Town Cam

p

5 - 8

$250

9 - 1

2$2

45

JUN

EJU

LYA

UG

UST

SPECIALTY

CAM

PSA

ges:1

52

22

96

13

20

27

31

01

72

43

1Total

Weeks:

Fee/Week:

Total Due

(# weeks

x fee)

Outdoor A

dventure Skills9

- 12

$265

Creature Catching5

- 8$2

70

Theater Camp

9 - 1

2$2

65

JUN

EJU

LYA

UG

UST

LEAD

ER IN

TRA

ININ

G (LIT)

Ages:

15

22

29

61

32

02

73

10

17

24

31

Total Sessions

Fee/Session:

Total Due

(# weeks

x fee)

Camp Sokokis

13

- 16

Session 1

Session 2 Session 3

$39

5

Camp O

sprey1

3 - 1

6

Session 1 Session 2

Session 3$3

95

Camp Pineland

13

- 16

Session 1

Session 2 Session 3

$39

5

Otter Pond O

utdoor Adventure Cam

p1

3 - 1

6

Session 1 Session 2

Session 3$3

95

In-Town Cam

p1

3 - 1

6

Session 1 Session 2

Session 3$3

95

5

CAMP 2020 REGISTRATIONStep 1: Choose Your Weeks - Check the boxes that correspond with the camp weeks for which you are registering.

JULY

OV

ERN

IGH

TA

ges:2

91

62

33

0Total

Weeks:

Fee/ O

vernight:

Total Due

(# weeks

x fee)

Otter Pond Cam

p Overnight

9 -1

6

$90

Total weeks/sessions m

y child will be

attending this summ

er: ___________

Total Fees:$

CAMP 2020 REGISTRATIONStep 2: Calculate Camp Fees

6

1. Carry your total camp fees listed on the bottom of page 4 to line 1 of the Fee Calculator below.2. Complete the Fee Calculator below. (If you prefer, we can help you with this.)3. Proceed to payment information on page 6.

At the Y, we believe all kids should have the opportunity to discover who they are and what they can achieve through programs like summer camp. That’s why we are committed to serving everyone, regardless of ability to pay. If you have any questions about registering for camp or applying for the Y’s financial assistance or Maine State subsidies, please call us.

1. Total due for camp weeks (from page 4): $

Are you.. If yes, apply this adjustment

a. Registering before 5/1? Early Bird ($10 x ___ weeks) $

b. Registering for 7+ weeks before 6/1? Multi-week ($10 x ___ weeks) $

c. Registering siblings Sibling ($10 x # of additional siblings x ___ weeks) $

2. Total Adjustments (add up lines a through c): $

3. Total for Summer Camp 2020 (subtract line 2 from line 1): $

4. Deposit due at registration ($50 per week x ___ weeks) If receiving financial assistance, this amountwill be adjusted at the same rate. This adjusted weekly deposit is still required in advance.

$

5. Total Remaining Balance Prior to Financial Assistance (subtract line 4 from line 3): $

YMCA Financial Assistance (Please complete Financial Assistance Application) To be completed by

the YMCAASPIRE or other State Subsidy (Please complete Subsidy Application)

Adjusted Balance:

Deposit is due at registration. Weekly balances are due in full the Wednesday prior to each week of camp through an automatic draft payment. If an automatic payment is not possible, please contact your Camp Director.

Fee Calculator

Payment methods on next page…

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PAYMENT METHODS

I wish to pay my balance due in full. Total Balance Due: $_________________

I have applied for Financial Assistance (the completed application is enclosed with this registration form). (NOTE: Billing information must be completed below. No payment will be made prior to your acceptance of your awarded fee.)

The following must be completed if not paying in full.I authorize automatic payments for the amount due, as listed below: (NOTE: I understand I am responsible for payment and will be charged an additional $20 NSF charge if any payment is returned or fails to authorize.)

Visa/MasterCard/American Express Charge Name on Credit Card:Card Number: CVC Number: Exp Date:

Auto Draft from Bank Account Name on Account: Account Number: Routing Number:

I am requesting a payment plan other than the week before camp. (NOTE: The Camp Director will be in touch to set this plan up.)

If a State Agency or Independent Agency is assisting you with your child’s camp fees, please fill out the Subsidy Forms and attach it to your camp registration packet.

Signature: Date:

Weekly balances are due in full the Wednesday before camp starts through an automatic draft payment (credit card or checking account). If an automatic payment is not possible, please contact your Camp Director. We are dedicated to working with all families and will not turn a child away due to financial need. Payment schedules, options and financial assistance are available, please ask. Checks, credit card payments, and bank account drafts returned to us by the bank will incur a $20 fee. Campers cannot attend camp weeks that are not paid for in advance.

You must select one box. Registration cannot be completed (your spot will not be reserved) unless payment information is provided.

Camp PinelandKara Phillips, Camp Director25 Campus Dr., Suite 100, New Gloucester, ME 04260 kphillips@ymcaofsouthernmaine.org207-688-2255 x611

Otter Pond Outdoor Adventure CampLiza Stratton, Camp Director25 Campus Dr., Suite 100, New Gloucester, ME 04260 lstratton@ymcaofsouthernmaine.org207-688-2255 x609

In-session address:73 Chadbourne Rd., Standish, ME 04084

In-TownJoe Baty, Camp Director70 Forest Ave., Portland, ME 04101jbaty@ymcaofsouthernmaine.org 207-874-1111 x121

Camp OspreyJennifer Genthner, Camp Director14 Old S. Freeport Rd., Freeport, ME 04032 jgenthner@ymcaofsouthernmaine.org 207-865-9600 x204

Camp SokokisMeaghan Woodsome, Branch Executive 3 Pomerleau St. Biddeford, ME 04005 mwoodsome@ymcaofsouthernmaine.org 207-283-0100 x402

CONTACT US

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2020 OTTER POND TRANSPORTATION AGREEMENT YMCA OF SOUTHERN MAINE

Child’s Last Name:________________________________________ Child’s First Name:_________________________________

Transportation Waiver: I agree that the information within this registration is complete. I give my permission for mychild to be transported by the appropriate YMCA of Southern Maine staff in a YMCA approved vehicle for daily transportation, severe weather transportation, and/or field trips. I assume any and all liability for damages to or caused by my child in connection with the transportation services offered by the YMCA, except those caused by gross negligence or intentional act of the YMCA. I also understand that the YMCA will not be responsible for my child between the YMCA/YMCA approved vehicle and his/her residence and vice versa.

Signature of Parent/Guardian: __________________________________________________ Date: ______________

Please check the appropriate boxes below. Choose one stop for AM and one stop for PM bus service. If you need to change your child’s stop on a given day, please bring a signed note to the Camp Director that morning and we will be happy to accommodate your PM request. PM bus change requests cannot be received after 12:00pm.

My child will be using AM Bus Service (selected below) to Otter Pond

My child will be using PM Bus Service (selected below) from Otter Pond

My child will be dropped off at Otter Pond (7:30-9:00am Before Care)

My child will be picked up at Otter Pond (4:00-5:30pm After Care)

Please check the box next to the AM and PM bus your child will ride daily. Buses are subject to change until final enrollment is determined. We will notify you of any changes prior to the start of the camp season.

PINELAND BUS AM Bus Schedule Arrival Departure PM Bus Schedule Arrival Departure

Pineland Branch, YMCA 7:30am 7:35am Narragansett School – Gorham 4:15pm 4:20pm

Falmouth Hannaford 8:00am 8:05am Westbrook Hannaford 4:35pm 4:40pm

Westbrook Hannaford 8:20am 8:25am Falmouth Hannaford 4:55pm 5:00pm

Narragansett School – Gorham 8:40am 8:45am Pineland Branch, YMCA 5:25pm

PORTLAND BUS AM Bus Schedule Arrival Departure PM Bus Schedule Arrival Departure

Small School – South Portland

7:30am 7:35am Windham Shaw’s – (Rt. 35) 4:10pm 4:15pm

King Middle School - Portland

7:50am 7:55am Cumberland Congregational Church 4:40pm 4:45pm

Cumberland Congregational Church

8:15am 8:20am King Middle School - Portland 5:05pm 5:10pm

Windham Shaw’s – (Rt. 35) 8:45am 8:50am Small School – South Portland 5:30pm

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2020 DAY CAMP

CHILD ACCOMODATIONS FORM

YMCA OF SOUTHERN MAINE

Child’s Last Name: First Name:

This form is used to assist us in providing the best possible experience for your child while s/he attends

camp. Your signature on this form gives us permission to share this information with the counselors and

staff who will be working with your child.

Does your child have an Individualized Education Plan (I.E.P.) during the school year?

YES _________ NO __________

Does your child have any behavioral or health concerns that you want us to be aware of?

What is your recommendation for the best way for us to help your child?

Are there any specific situations that trigger this concern in your child?

What is typical and/or atypical behavior from your child?

Please note, all of our participants must be able to participate safely in our programs. We are not able

to provide one-on-one supervision and retain the discretion not to enroll or to remove a participant

from our program if that participant is not able to participate safely in the program. Open

communication is the best way to ensure a happy and safe summer for your child. Please contact your

Camp Director with any questions.

Signature of Parent/Guardian: _________________________________ Date: __________________

While your child attends school, has there been any plan of action designed to address this concern which has been effective? If yes, please explain in detail:

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2020 DAY CAMP

HEALTH HISTORY FORM

YMCA OF SOUTHERN MAINE

Child’s Last Name: First Name:

HEALTH HISTORY

Does your child have any chronic or recurring Illness? Please explain.

Does your child have any reactions to insect bites/stings? (If any, how severe is the reaction?)

Does your child have any allergies? Please explain.

Are there any camp activities your child should be exempt from because of health reasons?

Record of past medical treatment if any:

Does your child have Epilepsy: Yes No

o If yes, date of last seizure & severity ________________________________________________________________________________

Does your child have Diabetes: Yes No

o If yes, does your child take medications or insulin?

________________________________________________________________________________

Does your child have Asthma: Yes No

o If yes, does your child carry an inhaler?*** Yes No

Does your child carry an epi-pen? *** Yes No

o If yes, what for: ___________________________________________________________________

Will your child be taking medications while attending camp? Yes No

o If yes, an Authorization to Dispense Medication form is required.

Physician Name: Phone:

Address:

Dentist Name: Phone:

Address:

Hospital Preference:

Date of Birth:

(after checking the medication in with the Camp Director), will carry the medication in their bag while with the

camper, and will pass off the medication to other counselors should the camper switch groups.

If your camper will be taking medications while at camp, please send a week’s worth of medication. This will stay

on campus in a double locked cabinet for the duration of the week, and the bottle will be sent home with the child

(staff passing off to parents), on the last day of the week the camper will attend. If campers are attending multiple

weeks, the medication will need to be re-stocked and sent in with the camper on Monday.

Hospital Preference: ___________________________________________________________________________________________

HEALTH HISTORY FORM WAIVER

This health history form is correct to the best of my knowledge, and my child herein described has permission to

engage in all prescribed camp activities except as noted. I hereby give permission to the medical personnel

selected by the camp director to order x-rays, routine tests, treatment, to release any records necessary for

insurance purposes, and to provide or arrange necessary related transportation for my child. In the event I cannot

be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and

administer treatment, including hospitalization for my child named above.

My child’s immunization records are attached.

I understand the Y does not provide one-on-one supervision.

I understand the Y retains discretion to remove a child if they are unable to safely participate.

Parent/Guardian Signature: ______________________________________________ Date:________________________

NOTE: Campers/parents MUST check-in ALL medications, epi-pens, inhalers, etc. (including over the counter medications) with the Camp Director, and proper paperwork for dispensing medications must be provided.

ALL self-administered medications are to be handed to the staff leader in the campers’ group. The staff member

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2020 DAY CAMP

AUTHORIZATION TO DISPENSE MEDICATION

YMCA OF SOUTHERN MAINE

______ I hereby authorize the YMCA of Southern Maine to administer the following medication to:

Child’s Last Name: First Name:

Prescribing Physician (when applicable):

__________________________________________________________________________________________

Name of medication: __________________________________________________________________________________________

Dosage: __________________________When to give: _____________________________________________

Continue this medication until: __________________________________________________________________________________________

NOTE: ALL MEDICATIONS MUST BE IN THE ORIGINAL CONTAINER CLEARLY LABELED WITH THE

DOCTOR’S NAME AND THE CHILD’S NAME.

I have given the first dosage on: _________________________________________________________________________________________

Signature of parent/guardian: _______________________________________ Date: ___________________

RECORD OF MEDICATION The YMCA uses this to record the amount, date, time that the medication was given with staff initials.

It is a reference for sharing information with the child’s parent/guardian.

NOTE: A new form must be used for each prescribed medication.

DATE TIME AMOUNT IN

/REMAINING

AMOUNT

GIVEN

INTIALS DATE TIME AMOUNT IN

/REMAINING

AMOUNT

GIVEN

INITIALS

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