Flatbush YMCA SUMMER CAMP REGISTRATION FORM

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Chastity Norris
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1 Flatbush YMCA SUMMER CAMP REGISTRATION FORM Branch: Flatbush Camp Site: Branch Camp Type: Day Camp PARTICIPANT INFO Child s Name Age _ of Birth _ Grade in September 2017 Gender School Mailing Address_ Apt.# City State Zip Home Phone () Address _ My child will: Be picked up Walk home (Only 10 yrs. or older, please sign bottom of page 2) T-Shirt Size Child: S M L XL Adult: S M L XL PARENT/GUARDIAN INFO Name of Parent/Guardian registering child Home Phone (_)_ Work Phone ( ) Cell Phone ( ) _ EMERGENCY CONTACT INFO Please list two (2) contacts not already listed on this form, to be used if the parents/guardians cannot be reached 1. Name _ Relation _ Home Phone ( )_ Work Phone ( ) Cell Phone ( )_ Name _ Relation _ Home Phone ( )_ Work Phone ( ) Cell Phone ( ) PHYSICIAN INFO Name Telephone Number (_) Address _ City State AUTHORIZATION / CONSENT EMERGENCY AUTHORIZATION: I understand that in the event of an emergency affecting my child while participating in a YMCA program, a designated employee of the YMCA will attempt to contact me and inform me as soon as possible. In the event I cannot be reached, I hereby give permission for my child to be treated by a medical professional or hospitalized by hospital selected by the YMCA. Child s Name Parent/Guardian s Name

Flatbush YMCA SUMMER CAMP REGISTRATION FORM PERMISSION FORM I hereby grant permission for my child to use all equipment and participate in all activities of the FLATBUSH YMCA.

2 Flatbush YMCA SUMMER CAMP REGISTRATION FORM PERMISSION FORM I hereby grant permission for my child to use all equipment and participate in all activities of the FLATBUSH YMCA.I hereby grant permission for my child to leave the FLATBUSH YMCA premises, under proper supervision of FLATBUSH YMCA staff, for neighborhood walks, park activities, Swimming (Ages 7 and up) and field trips. It is my understanding that these trips will be taken over the camp session without further consent from me. _ Child s Name Parent/Guardian s Signature Contact Telephone Number AUTHORIZED PICK-UP FORM The following individuals are 18 years old or older and are allowed to pick up my child from the FLATBUSH YMCA Programs. Please include the Parents/Guardians. Those authorized to pick up your child, will be asked for photo ID for verification. NAME RELATIONSHIP PHONE NUMBER I understand that no one else will be allowed to pick up my child unless I notify the FLATBUSH YMCA in advance and in writing. This person will also be asked for their photo ID for verification. Parent/Guardian s Signature UNESCORTED DISMISSAL AUTHORIZATION My child is 10 years of age or older and may sign themselves out and go home without an escort at the end of the day. Parent/Guardian s Signature Contact Telephone No.: ( )

2017 Flatbush YMCA SUMMER CAMP FEE SCHEDULE * Session dates DO NOT include Saturday and Sunday.

5 to 5 NON- DATES July 3- July 14 August 14 - August 25 Day Camp Ages 6 to 11 NON- DATES July 3- July 14 August 14

DATES July 3 - July 14 August 14 - August 25 Extended Camp Hours Ages 4.5 to 14 FEE TIME AM Session $50.

3 2017 Flatbush YMCA SUMMER CAMP FEE SCHEDULE * Session dates DO NOT include Saturday and Sunday. * Kinder Camp Ages 4.5 to 5 NON- DATES July 3- July 14 August 14 - August 25 Day Camp Ages 6 to 11 NON- DATES July 3- July 14 August 14 - August 25 Teen Camp Ages 12 to 14 NON- DATES July 3- July 14 August 14 - August 25 Sports Camp Ages 9 to 11 NON- DATES July 3 - July 14 August 14 - August 25 Extended Camp Hours Ages 4.5 to 14 FEE TIME AM Session $ :00-9:00 am PM Session $ :00-6:00 pm (Check Session) Camp Fees DEPOSIT/ FEE EXTENDED FEES DISCOUNTS TOTAL _ + AM/PM - _ = _ + _ AM/PM - _ = _ + _ AM/PM - _ = + AM/PM - _ = _ Session Total + _ Total - Total _ = Grand Total _

4 Payment Information Check Credit Card Bank Draft Money Order Credit Card # _ Exp. : Bank Name: _ Account #: Routing #: Authorized Signature: PARENT AGREEMENT I, the undersigned, give permission for my child to participate in the camp for the days he/she attends. I am aware that a completed medical form signed by a physician is required before my child may begin camp. In addition, I am fully aware that to reserve a space, I must make a deposit of $100 per two-week session and submit a registration form. I am fully aware that should my child change camps after the start of the session there is a $25 change fee. I fully understand and approve of my child being photographed for Flatbush YMCA publicity. Lastly, I fully understand that my child is responsible for his/her possessions. I have read, signed, and agreed to the registration requirements. Signature of Parent/Guardian: : _ There is a non-refundable $ deposit per session per child which is applied to session fee.

5 Flatbush YMCA SUMMER CAMP REGISTRATION FORM STANDARD RELEASE FORM From time to time, the YMCA of Greater New York (the YMCA ) takes pictures or records videos of members and non-members participating in YMCA programs, using its facilities, or attending one of its special events. Additionally, the YMCA may permit members of the media (the Media ) to take such pictures or record such videos in order to promote the YMCA s charitable mission and for other journalistic purposes. The individual person named below is signing this Release for the purposes of allowing the YMCA and the Media to use one or more such photographs, video recordings, and/or sound recordings (collectively, Recordings ) of such person for any purpose consistent with the YMCA s charitable mission, which includes, but is not limited to, the YMCA or the Media publishing such Recordings in newspapers, web sites, and other print or electronic publications, on television, or on the radio. By signing this Release, such person acknowledges that he or she has freely consented to be photographed, filmed, or otherwise recorded and has signed this Release of his or her own free will. If the person named below is under age 18, a parent or guardian of such person must sign on such person s behalf. 1. I agree that I am willing to be photographed, filmed, or otherwise recorded by the YMCA, its contractors, and the Media, either individually or as part of a group Recording, which may include my image, likeness, and/or voice. further agree that my name may be used to identify me as a subject of any Recordings featuring my image, likeness, and/or voice. 2. I understand that the YMCA will own all rights in the Recordings of me that the YMCA or a YMCA contractor takes or records ( YMCA Recordings ), and that the YMCA will have the exclusive right to use, or allow others to use, such YMCA Recordings in any medium for any purpose consistent with the YMCA s charitable mission as determined by the YMCA. 3. I understand that the Media will own all rights in the Recordings of me that the Media takes or records ( Media Recordings ), and that the Media will have the exclusive right to use, or allow others to use, such Media Recordings in any medium for any lawful purpose. 4. I understand that I am waiving any and all rights that may preclude the YMCA s or the Media s use of the Recordings as described above. 5. I acknowledge that neither the YMCA nor the Media has any obligation to use any Recordings of me or to use such Recordings for any particular purpose. 6. I understand that I will receive no monetary payment or other compensation in exchange for the rights to use Recordings of me. Child s Name Parent/Guardian s Name Parent/Guardian Signature

6 ChiLD & ADOLEsCEnT health ExAMinATiOn FORM NYC DEPARTMENT OF HEALTH & MENTAL HYGIENE DEPARTMENT OF EDUCATION TO BE COMPLETED BY ThE PAREnT OR GUARDiAn Please Print Clearly NYC ID (OSIS) Child s Last Name First Name Middle Name Sex M Female of Birth (Month/Day/Year ) Child s Address Hispanic/Latino? M Yes M No M Male Race (Check ALL that apply) M American Indian M Asian M Black M White M Native Hawaiian/Pacific Islander M Other City/Borough State Zip Code School/Center/Camp Name District Phone Numbers Number Home Health insurance M Yes (including Medicaid)? M No M Parent/Guardian Last Name M Foster Parent First Name TO BE COMPLETED BY ThE health CARE PRACTiTiOnER Birth history (age 0-6 yrs) Does the child/adolescent have a past or present medical history of the following? M Uncomplicated M Premature: weeks gestation M Asthma (check severity and attach MAF): M Intermittent M Mild Persistent M Moderate Persistent M Severe Persistent If persistent, check all current medication(s): M Quick Relief Medication M Inhaled Corticosteroid M Oral Steroid M Other Controller M None M Complicated by Asthma Control Status M Well-controlled M Poorly Controlled or Not Controlled Cell Work Allergies M None M Epi pen prescribed M Anaphylaxis M Seizure disorder M Behavioral/mental health disorder M Speech, hearing, or visual impairment M Congenital or acquired heart disorder M Tuberculosis (latent infection or disease) Medications (attach MAF if in-school medication needed) M None M Yes (list below) M Drugs (list) M Developmental/learning problem M Hospitalization M Diabetes (attach MAF) M Surgery M Foods (list) M Orthopedic injury/disability M Other (specify) M Other (list) Explain all checked items above. M Addendum attached. Attach MAF in in-school medications needed PHYSICAL EXAM of Exam: General Appearance: Height cm ( %ile) Weight kg ( %ile) BMI kg/m 2 ( %ile) Head Circumference (age 2 yrs) cm ( %ile) Blood Pressure (age 3 yrs) / M Physical Exam WNL Nl Abnl Nl Abnl Nl Abnl Nl Abnl Nl Abnl M M Psychosocial Development M M HEENT M M Lymph nodes M M Abdomen M M Skin M M Language M M Dental M M Lungs M M Genitourinary M M Neurological M M Behavioral M M Neck M M Cardiovascular M M Extremities M M Back/spine Describe abnormalities: DEVELOPMENTAL (age 0-6 yrs) Nutrition Hearing Done Results Validated Screening Tool Used? Screened < 1 year M Breastfed M Formula M Both < 4 years: gross hearing MNl MAbnl MReferred M Yes M No Screening Results: M WNL Referred 1 year M Well-balanced M Needs guidance M Counseled M Dietary Restrictions M None M Yes (list below) OAE 4 yrs: pure tone audiometry MNl MAbnl MReferred MNl MAbnl MReferred M Delay or Concern Suspected/Confirmed (specify area(s) below): Vision Done Results M Cognitive/Problem Solving M Communication/Language M Adaptive/Self-Help M Gross Motor/Fine Motor SCREENING TESTS Done Results Blood Lead Level (BLL) µg/dl <3 years: Vision appears: Acuity (required for new entrants M Nl M Abnl Right / M Social-Emotional or M Other Area of Concern: (required at age 1 yr and 2 and children age 3-7 years) Left / Personal-Social yrs and for those at risk) µg/dl M Unable to test Describe Suspected Delay or Concern: Lead Risk Assessment (annually, age 6 mo-6 yrs) M At risk (do BLL) M Not at risk Screened with Glasses? M Yes M No Strabismus? M Yes M No Dental Child Receives EI/CPSE/CSE services M Yes Hemoglobin or M No Hematocrit Child Care Only g/dl % Visible Tooth Decay M Yes M No Urgent need for dental referral (pain, swelling, infection) M Yes M No Dental Visit within the past 12 months M Yes M No CIR Number Physician Confirmed History of Varicella Infection Report only positive immunity: IMMUNIZATIONS DATES IgG Titers DTP/DTaP/DT Tdap Hepatitis B Td MMR Measles Polio Varicella Mumps Hep B Mening ACWY Rubella Hib Hep A Varicella PCV Rotavirus Polio 1 Influenza Mening B Polio 2 HPV Other _ Polio 3

7 ASSESSMENT Well Child (Z00.129) Diagnoses/Problems (list) ICD-10 Code RECOMMENDATIONS Full physical activity M Restrictions (specify) Follow-up Needed M No M Yes, for Appt. date: Referral(s): M None M Early Intervention M IEP M Dental M Vision M Other Health Care Practitioner Signature Form Completed DOHMH PRACTITIONER ONLY I.D. Health Care Practitioner Name and Degree (print) Practitioner License No. and State TYPE OF EXAM: NAE Current NAE Prior Year(s) Comments: Facility Name National Provider Identifier (NPI) Reviewed: I.D. NUMBER Address City State Zip REVIEWER: Telephone Fax CH205 Health Exam 2016_r4-16_FINAL.indd FORM ID#

SEPTEMBER 2015 MEDICAL REQUIREMENTS FOR CHILD CARE AND NEW SCHOOL ENTRANTS (PUBLIC, PRIVATE, PAROCHIAL, CHILD CARE CENTERS AND SCHOOLS)

Department of Health and Mental Hygiene Mary T. Bassett, MD, MPH nyc.gov/health Department of Education ~ Carmen Farina schools.nyc.gov/ SEPTEMBER 2015 MEDICAL REQUIREMENTS FOR CHILD CARE AND NEW SCHOOL