YMCA Camp Pokamoke Registration Form

YMCA Camp Pokamoke Registration FormPlease mail completed forms & payments to the Sarpy YMCA Camp Office: 1111 E First St, Papillion, NE 68046.CAMPER’S NAME _________________________________________ MALE ___ FEMALE __________________________ BIRTHDATE _______________________ AGE ________________SCHOOL __________________________________________ GRADE IN FALL _____ BUS STOP USED (Location-Not Color-See back) ___________________________________PARENT/GUARDIAN ___________________________PHONE (W) _____________ (H) _________________________ E-MAIL ADDRESS ________________________________________ADDRESS ______________________________________________________________________ CITY ___________________________________ STATE ______ ZIP ______________________________Checkmark theweek(s) your childwill attend CampWeek 1 - (May 31- Jun 3)Week 2 (Jun 6-Jun 10)Week 3 (Jun 13-Jun 17)Week 4 (Jun 20-Jun 24)Week 5 (Jun 27-Jul 1)Week 6 - (Jul 5-Jul 8)Week 7 (Jul 11-Jul 15)Week 8 (Jul 18-Jul 22)Week 9 (Jul 25-Jul 29)Week 10 (Aug 1-Aug 6)Week 11 (Aug 8-Aug 12)2ND CHOICECOST PER SESSIONADVENTURERS $150ARCHERY CAMP 11-14 yrs 8-10 yrs 8-10 yrs 11-14 yrs 11-14 yrs 8-10 yrs 8-10 yrs 11-14 yrs 11-14 yrs 8-10 yrs 8-10 yrs $165ARTS & CRAFTS CAMP $150CRITTERS & TADPOLES $150INTRO TO JUNIOR HORSE $190JUNIOR COUNSELOR $250MOUNTAIN BIKE $150OUTBACKERS $150PALEONTOLOGY/ARCHAEOLOGY $165PATHFINDERS $150WRANGLERS/ROUGH RIDERS $190SHOOTING SPORTS 8-10 yrs 11-14 yrs 11-14 yrs 8-10 yrs 8-10 yrs 11-14 yrs 11-14 yrs 8-10 yrs 8-10 yrs 11-14 yrs 11-14 yrs $165SOCCER CAMP $150SPORTS $150TRAILBLAZERS $190TREKKERS $150CSI CAMP $170RETURNING JR. COUNSELOR Call the camp office for trainign times. Open to the first 12 participants.$150INDICATE APPROPRIATE PAYMENT DETAILSCash Check MasterCard Visa DiscoverAm ExpAmount enclosed / Charge to credit card $ _______________________Card # _____________________________________________________________________Signature _________________________________________________________________Exp. Date _________________________________________________________________Subtotal from AboveNon-refundable $5 or $10Camp Store punch cardFamily Night Meals ($6 per person)T-Shirt ($12)Strong Kids Campaign gift ($5 or more)to help a child go to camp (optional)Total of all lines added togetherDeposit Option ($50 per session) *$++++$$* A minimum $50 deposit per session is required to secure your registration. You may also choose to pay the remaining balance in fullor in part. Fees owed for each session must be paid 3 weeks prior to the start of the session.

Release FormIN CASE OF EMERGENCY, WE SHOULD CONTACT: (Please list names in order they are to be contacted.)Name ____________________________________________ Phone __________________ Relationship __________________________________________________________________________________Name ____________________________________________ Phone __________________ Relationship __________________________________________________________________________________PERSON(S) AUTHORIZED TO TAKE CHILD FROM SITE:Name _____________________________________________________________________ Relationship _____________________________________________________________________________________Name _____________________________________________________________________ Relationship _____________________________________________________________________________________HEALTH HISTORY: (Checkmark all applicable items and give approximate dates)Ear infection ____________ Rheumatic fever ____________ Diabetes ____________ Convulsions ____________Hay fever ___________ Insect stings ____________ Penicillin ____________ Last tetanus shot ____________ Other _________________________________Operations or serious injuries or illness ______________________________________________________________________________________________________________________________Restrictions to activities _________________________________________________________________________________________________________________________________________________Fears (insects, water, heights, animals, etc.) _________________________________________________________________________________________________________________________Recent event that could cause an emotional problem (death in family, divorce, etc) ________________________________________________________________________Behavior problems _________________________________________________________________________________________________________________________________________________________Is your child on medication? ______ Will this medication be taken during the day while the child is at camp? ___________________________________________What kind(s) of medication? ________________________________________________________________________________________________________________________________________________Possible side effects _________________________________________________________________________________________________________________________________________________________Doctor’s name and phone number _________________________________________________________________________________________________________________________________________MEDICATION: All medication must be given to counselor in its original container(s) along with a Medication Request Form (below).SWIMMING: My child has permission to swim during camp: Yes ___ No ___Child’s swimming ability: Good ___ Fair ___ Poor ___IMPORTANT (READ BEFORE SIGNING BELOW):In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure proper treatment for hospitalization,order injection, anesthesia, or surgery for my child as named on this registration form. I understand the YMCA does not carry health and accident insurance andthat I, as Guardian, will be responsible for any bills incurred. I also give permission for the YMCA camps to transport my child off camp property for the purposeof medical care and program activities. The YMCA has my permission to use any photographs or videos of my child in its promotional material. I acknowledgeand understand that participation in a camp activity and activities involving saddle and/or pack animals expose the participant to certain known and unknownhazards which could result in physical injury and/or psychological injury to the participant or death of the participant. These same hazards could result in damageto or loss of the participant’s personal property. I understand that the purpose of this release form is to totally relieve the YMCA of Greater Omaha and itsowners, agents, and employees from any and all liability for injuries, death or loss of property sustained by me or by my child or by a person in my charge as aresult of participation in a YMCA activity. Parents will be notified by phone of sickness or injury if the situation warrants.CAMPER’S NAME __________________________________________________________________________________________________________________________________________________PARENT/GUARDIAN SIGNATURE ___________________________________________________________ DATE _________________BUS STOP RELEASE FORMCrossing out items voids this form.MEDICATION REQUEST FORMCAMPER’S NAME ___________________________ AGE _________________Session name(s) ___________________________________________________Session date(s) ____________________________________________________I authorize the above-named camper to walk home from, or waitunsupervised at, the bus stop indicated on my registration form. I releasethe YMCA of any liability once my child leaves the bus. Campers willnot be dropped off at bus stops unattended without this signed release.Remaining campers end up at last scheduled bus stop.Parent’s Signature ________________________________________CAMPER’S NAME ______________________________ AGE _______________MEDICATION: _______________________________________________________AMOUNT TO BE GIVEN: ____________________________________________TIME(S) TO BE GIVEN: ______________________________________________DATE(S) TO BE GIVEN: ______________________________________________I understand that medications must be in original containers and sealed in a plasticbag, listing the doctor, pharmacy, drug, dosage and child’s name. Medicationsmust be turned into the child’s counselor and will be administered by the YMCA.Parent’s Signature ________________________________________

Please Read Before Signing UpFOLLOW THESE STEPS TO REGISTER:1) Use ONE registration form per child.Complete both sides including the“Registration Form” and “Release Form.”2) Checkmark the camp session(s) yourchild will be attending.3) Total all fees at the bottom of theform.4) If your child has a friend or friends whowould like the same session, please submitall the registration forms together. Wecannot guarantee that multiple childrenwill be granted the same session.5) Return registration form(s) and $50deposit(s) to the Camp Office.DEPOSITS, CHANGES ANDCANCELLATIONS:Your $50 deposit fee(s) for each sessionwill be applied toward the total campfee. If you do not get into Camp, yourdeposit will be refunded. The depositwill not be refunded under any othercircumstances including disciplinaryaction or homesickness. The deposit feemust accompany the registration form.A confirmation letter will be sent to theaddress provided on the registration formafter the deposit is received. Registrationsare processed in the order received. Allsessions are filled on a first-come, firstservedbasis. If a session you select isfull, we will do our best to honor yoursecond choice. If you need to change yourchild’s camp session, the request must bemade 3 weeks prior to the start of thatsession. Before May 1st, there is a $10service charge assessed for each changerequested. After May 1st, there is a$25 service charge. Cancellations mustbe made three weeks prior to the campsession, however, you will forfeit yourdeposit. You are responsible for 100%of the camp session fee if cancellationis made less than three weeks prior tocamp session. Notify the Camp Office ifyour child is ill or will not be attendingany days during a camp session. Incase of a medical emergency where thatchild cannot attend camp he/she cantransfer to another camp session if oneis available. A refund will be given withwritten confirmation from a doctor, minusthe non-refundable deposit of $50. Ifa camper leaves before the end of thesession for any non-medical reason, allfees for that session will be forfeited.FAMILY NIGHT ON THURSDAYNIGHTS:5:30 PM- The YMCA Camp staff invitesyou to join your camper for an eveningof food, fun and family! Your child willperform songs, skits and show off theirhorse skills. Bring your own picnic dinner,or you may pre-purchase a dinnerthrough the camp office. The deadlineto pre-purchase dinners is 3:00 PM onthe Tuesday prior to Family Night. (Costis $6.00 per person). BUSES DO NOTRUN ON THURSDAY NIGHTS. YOU MUSTMAKE ARRANGEMENTS TO PICK UP YOURCHILD.CAMP STORE: You can pre-purchase anon-refundable camp store punch cardfor $5 or $10 through the Camp OfficeONLY. Cards are not sold at Camp. Punchcards enable campers to purchase itemsat the camp store. You will not receivethe punch card as the cards are kept atthe camp store.CAMP T-SHIRTS: T-shirts may bepurchased by check on Family Night orat the Sarpy Community YMCA. Cost is$12.SEVERE WEATHER OR EMERGENCIES:Our staff is trained for these situationsand we have adequate shelter for inclementweather. Please be assured we have plansand arrangements for all foreseeableemergencies.BUS ROUTES AND TIMES ARE SUBJECTTO CHANGE: Please remember pick upand return times can vary depending onsession size and traffic. If a change occursin routes, we will send a note home onthe first day of camp to notify you of thechange. If you sign the bus stop releaseform, your child will be dropped off at thedesignated bus stop without supervision.If you DO NOT sign the bus stop releaseform, your child will not be dropped offunless you are present to pick him/herup. If you arrive late at your designatedbus stop, your child will be at the last busstop on that route, waiting with the buscounselor.LOST AND FOUND: The YMCA is notresponsible for lost or stolen items.Leave valuables at home. Please labeleverything brought to camp. Lost itemswill be brought to the Camp Office (locatedat the Sarpy YMCA) every Friday. We willkeep items for 10 days only. If itemsare not claimed they will be donated toGoodwill.RAINY DAYS: Camp will be held, as rainydays do not spoil our fun! All campsoffer rainy day activities inside andoutside. Send rain gear with your camper.Horse riding and other activities may becancelled to assure your child’s safety.REDUCED CAMP RATES:1) Financial assistance is available to thosewho cannot afford to pay the full campfee. To apply for assistance, you must fillout an application available at any localareaYMCA, and include proof of income.You must then send this application andthe camp registration form(s) along with a$25 non-refundable deposit to the campoffice. Applications without the depositwill NOT be processed.2) Camp discounts are available tovolunteers who participate in a one-day“Pre-Camp Cleanup.” Contact the Campoffice at 402-339-9861 to sign up.WHAT TO BRING:- Sack lunch & drinks Monday-Friday- Water bottle and extra water- Sun block lotion- Swimsuit & towel- Jeans/long pants (for horse camp)- Boots (optional for horse camp)- White t-shirt for tye dying- Jacket/sweatshirt on cooler days- Tennis shoes needed for all camps- Bug repellentWHAT NOT TO BRING:Electronic games, radios, headsets, newclothes, expensive jewelry, money, sandalsor open shoes.