2013 Summer Camps Registration Form - YMCA of Greater Toronto

YMCA SUMMER CAMPSREGISTRATION FORM2013Thank you for choosing the YMCA! By completing this form you acknowledge that you’re giving up certain legal rights andhereby represent and warrant to the YMCA: (1) You are over the age of majority in your jurisdiction of residence. (2) You areregistering on behalf of a minor and are his/her parent/legal guardian and as such are fully authorized and entitled to enter intothis agreement on his/her behalf. Please note this agreement requires you to read the Program Agreement on pages 7 and 8.Please provide your email address below to receive up-to-the-minute camp news!YMCA CAMP REGISTRATION OFFICE HOURS:September to June 30: 9 a.m. to 6 p.m. • July to August 31: 7:30 a.m. to 6 p.m. • 647-439-6611 • 1-877-303-2267MAIN CONTACTLAST NAME: FIRST NAME: GENDER: □ M □ FHOME PHONE: WORK PHONE: CELL PHONE:ADDRESS: CITY: POSTAL CODE:EMAIL:SECONDARY CONTACT/ALTERNATELAST NAME: FIRST NAME: GENDER: □ M □ FHOME PHONE: WORK PHONE: CELL PHONE:ADDRESS: CITY: POSTAL CODE:EMAIL:CAMPER INFORMATIONLAST NAME: FIRST NAME: GENDER: □ M □ FBIRTHDATE (MM/DD/YY):ADDRESS: CITY: POSTAL CODE:Campers 11 years old and under must be signed in and signed out by a parent/guardian or a person over the age of 16.The YMCA will only release campers 12 or older from camp or a bus stop after a release form has been signed by a parent/guardian.If your child is 12 or older does she/he have your permission to be released on their own at the end of their camp day?□ Yes □ NoSignature: _______________________________________________CODE OF CONDUCTThe safety of each individual in the program is of the utmost importance to the YMCA. Each registrant must recognize a personalresponsibility to learn and follow at all times the safety and other rules established by YMCA staff. I hereby agree that any behaviourof the registrant that places him/herself or others at risk may result in the registrant’s immediate dismissal from the program.Further, if dismissed from the program, I agree to cover any expense(s) arising from such dismissal. I hereby acknowledge and agreethat no refund will be granted for dismissal or removal of the registrant at his/her request before the end of a program session. Inorder to ensure the safety and well-being of all individuals participating in the program, the YMCA reserves the right to alter theprogram at any time without notice or compensation to the Registrant.I have read and understand the Code of Conduct. Signature: _______________________________________________Are there any court orders or custody restrictions which would prevent us from communicating with either parent/guardian?□ Yes □ NoIf yes, we will contact you for additional information.Government subsidy:□ Yes □ NoAre you receiving a government child care subsidy for one or more of your children that you‘re registering?If yes, please provide more details (region, child’s name, age, daily rate, etc.):1 of 8

HEALTH HISTORY AND PERSONAL INFORMATIONThe more information you can provide, the better we can meet the needs of your child. This information will be used by theCamp Manager, Wellness Staff and your child’s counselors. If there is additional information of a sensitive nature, please feel freeto send a separate letter marked ‘confidential’ to the attention of the Camp Manager or Wellness Staff. Whatever information yousend to us will be treated with confidence and respect. We encourage, but do not require, a medical examination.□ Yes □ NoIs the participant under any form of treatment for an illness, condition or injury?If yes, please explain and detail routines, medications, adaptations etc. We will also require you to complete a MedicationDispensing Form (download from ymcagta.org/camps).Does your child require 1-1 support while at camp?If yes, we will contact you for additional information.□ Yes □ NoDoes your child have any medical or behavioural conditions that we should be aware of? □ Yes □ NoIf yes please take a moment to explain:Carries Epi-pen: □ Yes □ No For: _________________________________________________Wears Medic-Alert Bracelet: □ Yes □ No For: _________________________________________________AllergiesSeasonal:Food:Drugs:Insect:Other:□ Yes □ No ________________________□ Yes □ No ________________________□ Yes □ No ________________________□ Yes □ No ________________________□ Yes □ No ________________________THIS SECTION IS TO BE COMPLETED BY CEDAR GLEN OVERNIGHT CAMPERSDietary Needs or Restrictions (please provide details below): □ Gluten free □ Lactose intolerant □ Vegetarian□ OtherVaccination: What is the approximate date of your child’s last booster shot?MM / DD / YYHistory of Communicable Diseases and Approximate Dates:Chicken pox: MM / DD / YY Measles: MM / DD / YY Scarlet fever: MM / DD / YYGerman measles: MM / DD / YY Mononucleosis: MM / DD / YY Other: MM / DD / YYHepatitis:MM / DD / YY Mumps:MM / DD / YYOther Health Issues (Please check any applicable areas):□ Asthma□ Back□ Bleeding/clotting□ Diabetes□ Ear infections□ Emotional behaviour□ Epilepsy□ Frequent cold/sinus□ Hearing□ Hypertension□ Injury□ Kidney trouble□ Knees□ Migraines□ Sight□ Skin conditionsIf appropriate, for female participants:Has she menstruated?□ Yes □ NoIf so, is menstrual history normal? □ Yes □ NoIf not, has she been told about it? □ Yes □ No2 of 8

ALTERNATE/EMERGENCY PICK UPThis is a person over the age of 16 who is authorized to pick up your child and can be contacted by YMCA staff when the parent/guardian can’t be reached.ALTERNATE CONTACT #1LAST NAME:FIRST NAME:HOME PHONE: WORK PHONE: CELL PHONE:ALTERNATE CONTACT #2LAST NAME:FIRST NAME:HOME PHONE: WORK PHONE: CELL PHONE:YMCA DAY CAMPS AND SUMMER CLUBS PROGRAM SELECTIONNOTE: New this year, campers that will be attending Cedar Glen have the option to beprovided with either a bag lunch or a swimming towel provided to them at an extra charge.DATECAMPLOCATIONPROGRAMFEEBUS STOPOR DRIVEDIRECTBUSFEEEDCLOCATIONEDC(INDICATEA.M., P.M.OR BOTH)EDCFEEADDITIONAL CEDAR GLENOPTIONSTowel$20Lunch$27Overnight$35TOTALSESSIONFEEJuly 2 – July 5*July 8 – July 12July 15 – July 19July 22 – July 26July 29 – Aug 2Aug 6 – Aug 9*Aug 12 – Aug 16Aug 19 – Aug 23Aug 26 – Aug 30*Short weeks: closed Monday, July 1, 2013, for Canada Day and Monday, August 5, 2013 for the Civic Holiday.Subtotal $TOTAL $CAMPER MATE REqUESTName of friend: _____________________ _____________________While we do our best to accommodate everyone’s needs, we are not always able to make every request work. We will try tohonour one mutual request for children within one year age difference. When making a Camper Mate Request, please ensureboth campers are registered in the same program.3 of 8

YMCA CEDAR GLEN OVERNIGHT CAMP PROGRAM SELECTIONLEADERSHIP CAMP PROGRAMS (PLEASE ADD HST TO THE BASE FEE)PROGRAM AGE DATE BASE FEEPROGRAMSELECTIONSpecialty Hiking Trip 13-16 Sunday, August 25 – Friday, August 30, 2013 $650 □Junior Leader in Training Session 1 13 Sunday, June 30 – Friday, July 12, 2013 $1,295 □Junior Leader in Training Session 2 13 Sunday, July 28 – Friday, August 9, 2013 $1,295 □Leader in Training Session 1 14 Sunday, July 14 – Friday, July 26, 2013 $1,395 □Leader in Training Session 2 14 Sunday, August 11 – Friday, August 23, 2013 $1,395 □Counsellor in Training Session 1 15-16 Sunday, June 30, 2013 – Friday, July 19, 2013 $1,595 □Counsellor in Training Session 2 15-16 Sunday, July 21 – Friday, August 9, 2013 $1,595 □Counsellor in Training Session 3 15-16 Sunday, August 11 – Friday, August 30, 2013 $1,595 □Base Fee 1 $Base Fee 2 $HST 13% $Total CampFee$CABIN MATE REqUESTName of friend: _____________________ _____________________While we do our best to accommodate everyone’s needs, we are not always able to make every request work. We will try tohonour one mutual request for children within one year age difference. When making a Cabin Mate Request, please ensureboth campers are registered in the same program.TRANSPORTATION SERVICEFor 2013 all transportation costs for Cedar Glen residential campers are included in the camp fee. Please indicate the bus stopthat your child will be utilizing if required.□ Toronto Sheppard Ave.YMCA CentreDeparture time is 2 p.m.□ Toronto Central GrosvenorSt. YMCA CentreDeparture time is 2:30 p.m.□ Mississauga BurnhamthorpeRd. YMCA CentreDeparture time is 3 p.m.□ Busing Not requiredArrival time is 2 p.m.BUS STOP TO CAMP567 Sheppard Ave. E.(Sheppard and Bayview)20 Grosvenor St.(Yonge and Grosvenor)325 Burnhamthorpe Rd. W.(Burnhamthorpe and HWY 10)I will drop off at camp□ Toronto Sheppard Ave.YMCA CentreDeparture time is 2 p.m.□ Toronto Central GrosvenorSt. YMCA CentreDeparture time is 2:30 p.m.□ Mississauga BurnhamthorpeRd. YMCA CentreDeparture time is 3 p.m.□ Busing Not requiredDeparture time is 3 p.m.BUS STOP FROM CAMP567 Sheppard Ave. E.(Sheppard and Bayview)20 Grosvenor St.(Yonge and Grosvenor)325 Burnhamthorpe Rd. W.(Burnhamthorpe and HWY 10)I will drop off at camp4 of 8

CONFIRMATION, PAYMENT, CANCELLATIONS AND REFUNDSYou will receive confirmation of registration within two weeks of receipt of your completed forms. If you have not received yourconfirmation of registration within two weeks please contact our Camp Registration Office at 647-439-6611 or 1-877-303-2267to make sure your registration was received. A 10% initial payment is due per camp program when you register online. Fullpayment is preferred when registering by phone or mail, although you can make an initial payment of $50 for each camper atthe time of registration. All balances must be paid in full by June 2, 2013, and registrations processed after that date must be paidin full. If full payment is not received prior to the camp start date, the YMCA reserves the right to cancel the registration withoutnotice, and cancellation charges will be applied.Requests for cancellations or refunds must be made in writing and submitted to the YMCA Camp Registration Office. Requestsfor refunds received prior to 28 days will receive a refund minus an administration fee of $25 or 10% of the total fee — whicheveris greater. Refund requests received with less than 28 days notice are subject to an administration fee of 50% of the total fee. Refundrequests that are received after 12 p.m. on the Friday before the camp session starts will not qualify for a refund. Any refundrequests are considered on an individual basis by the YMCA Manager. A doctor’s note is required for cancellations due to medicalreasons. Refunds are not granted for inclement weather. Refund requests received after August 31, 2013, will not be grantedPAYMENT METHODPlease ask about our convenient payment plans. Your balance will be due on June 2, 2013, or at the time of registration if after June 2.Initial payment (minimum $50 per camper): $ _________________________Initial method of payment: Please indicate your payment method below.□ CREDIT CARD - Please complete credit card # below dotted line: (check one) □ AMEX □ VISA □ MASTERCARDNAME ON CREDIT CARD:____________________________ CARDHOLDER SIGNATURE: _________________________________LAST FOUR DIGITS OF CREDIT CARD #: _____________________ EXPIRY DATE: MM / DD / YY□ Cheque - Please make cheque payable to YMCA of Greater Toronto□ Money Order - Please make payable to YMCA of Greater TorontoPRE-APPROVED PAYMENT/DEBIT AUTHORIZATIONIf there is someone other than you paying for care (e.g. grandparents, shared between parents, business/organization), aseparate Pre-Approved Payment/Debit Authorization form from all payers is required before a new registration will be processedor the current payment agreement can be amended. (This does not include government subsidy.) All paying parties may benotified of a possible termination of camp session after the first declined payment. Important: All payers excluding abusiness/organization will receive a tax receipt for their portion of fees paid.I hereby authorize the YMCA of Greater Toronto to withdraw my equalized Day Camp/Summer Club/Overnight Camp balance asdetailed below. I understand and agree that full payment of fees is required on the scheduled monthly draw date. During or aftermy registration period, the YMCA will reschedule a declined payment from my bank account, plus any administrative charges.RECOURSE STATEMENT:“I have certain recourse rights if any debit does not comply with this agreement. For example, I have the right to receivereimbursement for any debit that is not authorized or is not consistent with this PAD Agreement. To obtain more information onmy recourse rights, I may contact my financial institution, or visit www.cdnpay.ca.”CANCELLATION OF AGREEMENT:“I may revoke my authorization at any time, subject to providing notice of 15 days. To obtain a sample cancellation form, or formore information on my right to cancel a PAD Agreement, I may contact my financial institution, or visit www.cdnpay.ca.”Do you have a pre-existing payment plan for other YMCA services? □ Yes □ NoPlease check your preferred pre-approved payment method: Check your preferred monthly draw date: □ 2 nd □ 16 th □ 20 th□ CREDIT CARD: (check one) □ AMEX □ VISA □ MASTERCARDNAME ON CREDIT CARD:___________________________________LAST FOUR DIGITS OF CREDIT CARD #: ______________EXPIRY DATE: MM / DD / YY□ BANKING DETAILSSAVINGS ACCOUNT: (Attach bank verification form)CHEQUING ACCOUNT: (Attach void cheque)ACCOUNT HOLDER NAME: __________________________CARDHOLDER/ACCOUNT HOLDER SIGNATURE: __________________________________________ TODAY’S DATE:MM / DD / YYCREDIT CARD #: ____________________________________EXPIRY DATE: MM / DD / YYCARDHOLDERSIGNATURE: ____________________________________5 of 8

PROGRAM AGREEMENTPHOTO AND VIDEO CONSENT, ASSIGNMENT AND RELEASE FORMPURPOSES: For marketing, advertising, promotional and/or communication purposes, the YMCA may, from time to time, takephotographs and/or video recordings of YMCA based activities or events that include real people, which photographs and videorecordings will be placed in the YMCA National Photo Bank and which may be used by any YMCA in Canada (the “Purposes”).For purposes of this Form, “YMCA” refers to the local YMCAs and YMCA-YWCAs in Canada and to YMCA Canada, the nationalassociation of local YMCAs and YMCA-YWCAs across Canada.By signing this Form, you are consenting to the taking of photographsand/or video recordings of you by the YMCA for the Purposes, you areassigning to the YMCA, and waiving any rights you have related to, anysuch photographs and/or video recordings, and you are consenting to theuse of any such photographs and/or video recordings, in whole or in part,by the YMCA for the Purposes.For valuable consideration received but without any promise of remuneration, I hereby agree to allow photographs and/orvideo recordings to be taken of me, whether posed or candid, while I am on YMCA property and/or participating in YMCAactivities or events, to be used by the YMCA in connection with the Purposes, whether on the YMCA’s internet web site, inYMCA printed materials, or in any other medium (the “Work Product”). I confirm that the YMCA shall not be obligated to use theWork Product.I understand that the Work Product is being created under the direction and control of the YMCA. I hereby irrevocably assignto the YMCA any and all rights, including copyright, financial or moral, that I may have in the Work Product. I agreethat the YMCA has the sole worldwide ownership and rights in and to the Work Product, including copyright interests, and Iacknowledge that I have no interest or ownership in the Work Product or its copyright. Photos and/or video recordings will notbe sold to third parties and will not be used by third parties except in cases where a third party has been contracted by the YMCAto create the Work Product.I agree that I will not bring or consent to others bringing a claim or action against the YMCA on the grounds that anythingcontained in the Work Product, or in the manner in which the Work Product is used, is defamatory, reflects adversely on me, orviolates any other right whatsoever, including, rights of privacy and publicity. I hereby release and forever discharge each ofthe YMCAs, its officers, directors, employees, agents, partners and affiliates, and their respective heirs, executors, personal legalrepresentatives, successors and assigns, as applicable, from all actions, claims, causes of action, suits, demands, liabilities anddamages whatsoever, in law or equity, which I may have against any of them in connection with the Work Product.I confirm that I am over the age of 18 and am competent to execute this Form and to participate in the development of the WorkProduct; or, to the extent that I am under the age of 18, have had my parent or guardian review this Form and consent to myparticipation in the creation of the Work Product on my behalf.Any inconsistency between this Form as expressed in English and any other language shall, to the full extent permitted by applicablelaw, be resolved by reference to the English version. Les parties ont convenu de rediger cette entente en anglais.6 of 8

ASSUMPTION OF RISK AND INDEMNIFYING RELEASEWhile YMCA staff and instructors will make every reasonable effort to minimize exposure to known risks associated with eachRegistrant’s (defined below) participation in a YMCA program (“Program”), I hereby acknowledge that I and/or my child if I amregistering on his/her behalf (collectively, the “Registrant”) may be required, depending on the nature of the Program, toparticipate in various physical activities that may involve risk of injury. In this regard, I agree that I have provided (if required) acomplete and accurate health history and hereby permit the Registrant to participate in the full range of Program activities, exceptas specifically noted by me in the health information section of the Program registration (where applicable).In consideration forthe Registrant’s opportunity to participate in the Program, the receipt and sufficiency of which is hereby acknowledged, I herebyrelease and forever discharge the YMCA of Greater Toronto (“YMCA”), its respective officers, directors, employees, volunteersand agents, and their respective successors and assigns, from any and all liability for damages sustained in consequence of loss,injury or damage to the Registrant, and from all other actions, causes of action, claims, demands or damages of any kind withrespect to death, injury, loss or damages to any person or property arising out of or connected with preparation for, or participationin, the Program.MEDICAL EMERGENCIESIn the event of an accident, injury or illness involving the Registrant, and immediate contact by the YMCA with a designatedcontact cannot be made, I hereby authorize and grant permission to YMCA staff to secure proper medical treatment and authorizeon the Registrant’s behalf all procedures, including, without limitation, admission to an emergency unit, hospital and treatmenttherein, ordering of x-rays, tests or treatment, injections, anesthesia and/or surgery, as deemed necessary by the attending medicalprofessional(s). I agree not to hold the YMCA responsible for any costs or injury arising out of an emergency situationCOMMITMENT TO PRIVACYThe YMCA of Greater Toronto is committed to protecting personal information by following responsible information handlingpractices. We collect and use information you volunteer when you access or register for a YMCA program, in order to better meetyour service needs, to ensure a safe environment, for statistical and assessment purposes, to inform you about the Program inwhich you are registered, and to satisfy government and regulatory requirements. You may also hear from us periodically aboutother YMCA programs, services and opportunities that may interest and benefit you. For more information on our commitmentto privacy, or if you do not wish to receive such communications from the YMCA, please visit our website at ymcagta.org andclick on “Privacy” or call the YMCA Camp Registration Office at 416-928-9622 or 1-800-223-8024.DISCLAIMERAll programs and busing are subject to change or cancellation due to low enrolment orother unforeseen circumstances that are prohibitive to the operation of the program or bus.REGISTRATION AGREEMENTBy signing my name, I (or my legal guardian) acknowledge that I (or we) have carefully read andunderstand the Photo and Video Consent, Assignment and Release Form, Recourse Statement,Cancellation of Agreement statement, Assumption of Risk and Indemnifying Release statement,Medical Emergencies statement, Commitment to Privacy statement and Disclaimer.Date:Camper name:Name of parent or guardian:Parent or guardian signature:7 of 8

8 of 8YMCA CAMP REGISTRATION OFFICEYMCA of Greater Toronto2200 Yonge Street Suite 300, Toronto, ON M4S 2C6647-439-6611 • 1-877-303-2267 • Fax: 416-928-2030ymcagta.org/campregistersummer.camp@ymcagta.org