Fall Break Camp 2024 Registration

OST Fall Break Camp 2024
Fall Break Camp runs Oct. 21-25, 2024 from 6:30 AM - 6:00 PM. Structured activities will run from 9:00 AM - 4:00 PM. Fall Break Camp is held at the Delmar E. Demaree Family YMCA (Downtown Y).

Rates:

Y-Member: $150.00

Community Participants: $175.00

YMCA Contact:

A.J. Edwards

aj.edwards@kokomoymca.org

765-457-4447

Field Trip Schedule:

Monday, Oct. 21st at 10:00 AM: Police Station (Downtown) Tour

Monday, Oct. 21st at 12:00 PM: KHCPL Pumpkin Painting

Tuesday, Oct. 22nd at 9:40 AM: Howard County Courthouse Tour

Wednesday, Oct. 23rd at 10:00 AM: Fire Station #1 (Downtown) Tour

All field trips are walking trips with YMCA staff. By registering your child for OST Fall Break Camp, you authorize your child to participate in Fall Break Camp activities, including all field trips.

Camper Information
Camper Name*

First NameLast Name
Gender*
Camper's Date of Birth*

MonthDayYear
Ages 7-12
Age*
Ages 7-12
Grade in 2024-2025*
School*
Camper's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Camper Resides With*
Parent/Guardian Marital Status & Custody of Child*
IF THERE ARE ANY LEGAL DOCUMENTS PERTAINING TO THE CUSTODY OF YOUR CHILD, PLEASE SUBMIT THOSE WITH THIS FORM.

Health Information
Please Note: If your child has an EpiPen, you will need to have our Anaphylaxis Emergency Care Plan filled out by your child's physician. Please click here to download this form. In the event of an allergic reaction that requires the use of an EpiPen, 911 will be called.

If your child has any medications that will need to be taken during our program, you will need to fill out a Medication Administration Authorization form for each medication. Medications must be turned in to YMCA staff in the original container that has the original pharmacy labels identifying the child as the recipient of the medication, as well as the dosage, prescription number, and the treating physician's name. The YMCA will not administer over the counter medications.
Please describe any allergies, dietary restrictions, or special needs of your child:*
Does your child have a communicable disease or condition which may prove to be a risk to others? If Yes, please comment:*
Insurance Carrier*
Policy Number*

Parent/Guardian Information
Parent/Guardian #1 Name*

First NameLast Name
Relationship to Child*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Parent/Guardian Email*
example@example.com
Parent/Guardian #2 Name

First NameLast Name
Relationship to Child
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com

Emergency Contacts & Alternate Pick-Up List
The following individuals are authorized to pick up my child from the YMCA program, in addition to the parent/guardian(s). Anyone coming to pick up a child from the YMCA should be prepared to show valid photo ID. Any changes to this authorized pick-up list must be submitted to the YMCA program office in writing by the child's parent/guardian.
Emergency Contact #1 Name*

First NameLast Name
Relationship to Child*
Phone Number*
Please enter a valid phone number.
Emergency Contact #2 Name

First NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.
Emergency Contact #3 Name

First NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.

Program Policies & Authorizations
Please read and initial the following program policies and authorizations.
Initial: I give permission for my child to participate in the YMCA's Out of School Time Program Fall Break Day Camp and program activities. Camp activities will run from 9:00 AM - 4:00 PM each day.*
Initial: I understand that the YMCA of Kokomo's responsibility for my child begins when my child is signed in to the program by the parent or guardian. Campers must be walked into the YMCA facility and be dropped off by 9:30 AM.*
Initial: I understand that the YMCA of Kokomo's responsibility for my child ends when an authorized adult (over the age of 18) or myself has signed-out my child. I understand that the YMCA will only release my child to the parent/guardian(s) and emergency contact(s) listed on this form. Photo ID will be required. I understand that I must notify the YMCA in writing of any changes to my child's authorized pick-up list. Campers must be picked up by 6:00 PM.*
Initial: I understand that YMCA of Kokomo staff and volunteers are not allowed to communicate with, babysit, or transport children at any time outside of the YMCA program.*
Initial: I understand that the YMCA of Kokomo is mandated, by state law, to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation.*
Initial: I understand that should a person arrive to pick up my child appear to be under the influence of drugs or alcohol, for my child's safety, YMCA staff may have no recourse but to contact the police department.*
Initial: I acknowledge it is my responsibility to keep the YMCA of Kokomo advised of any changes to my child's registration form so we can best serve your family.*
Initial: The YMCA of Kokomo agrees to keep the parent/guardian informed of any incidents, injuries, exposure to communicable diseases, and behavioral concerns.*
Initial: I understand that neither the YMCA of Kokomo, nor its agents, officers, directors, employees, or volunteers, can be held responsible in the event of an accident, injury, or death. I understand that all precautions will be taken to ensure the safety and health of my child.*
Initial: I understand that if, after a reasonable period (at the administration's discretion) it is found that my child is unable to adjust to the program, the YMCA of Kokomo reserves the right to dismiss my child from the program.*
Initial: I understand that the YMCA of Kokomo is not responsible for any lost, stolen, or damaged personal items. If your child brings any belongings from home, please be sure to label all items with your child's first and last name.*

Waivers
I authorize the YMCA of Kokomo to use photos, images, and video of my child in any publication affiliated with the YMCA or with any news service for publicity, including, but not limited to, program newsletters, fundraising brochures, press releases to newspapers, social media, and the YMCA of Kokomo’s website and SmugMug page. I understand and agree that there will be no compensation for use of these materials. This release shall continue in full effect until I send in written notice to terminate the use of any photo, image, or video of my child. Such termination shall not affect the use of photos, images, or videos before the notice of termination. LEAVE BLANK IF AUTHORIZATION NOT GRANTED.
Photo/Video Release (Optional)
I hereby certify that my child (named in this enrollment form) is in normal health and capable of safe participation in the program in which he or she is enrolling. I further give permission for my child to be given emergency medical treatment by a Young Men’s Christian Association of Kokomo, Indiana (“YMCA”) staff member until parents can be reached and be present and/or emergency care arrives for treatment. In case of emergency, I understand that my child will be transported to Ascension Saint Vincent Hospital or Community Howard Regional Health Hospital by local emergency ambulance services for treatment, if YMCA staff deem it necessary. In the event that I cannot be contacted, I further consent to the medical, surgical and/or hospital care to be performed for my child by a licensed physician or hospital when deemed immediately necessary by the physician to safeguard my child’s health. It is understood that some medical situations will require YMCA staff to contact local emergency resources before the parent(s), child’s physician and/or adults acting on the parent’s behalf. I understand any costs incurred related to my child’s medical treatment are not the financial responsibility of the YMCA. *

Clear
Emergency Medical Treatment Authorization
I, in my legal capacity as parent/guardian of the minor named below (“Minor”), acknowledge and agree that any use of Young Men’s Christian Association of Kokomo, Indiana (“YMCA of Kokomo”) facilities, services, equipment and premises (“Facilities”) and any participation in YMCA of Kokomo programs and activities (“Programs”) comes with inherent risk including, but in no way limited to: (1) moderate and severe personal injury, (2) property damage, (3) disability, (4) death, and (5) sickness or disease, including, without limitation, COVID-19. I voluntarily, for myself and Minor, accept and assume full responsibility for these risks as well as any and all other risks of the use of Facilities and participation in Programs. I agree that I have full knowledge of the nature and extent of all such risks and am not relying on all such risks being described in this document. Waiver, Release, Indemnification and Covenant Not to Sue In consideration of Minor’s use of Facilities and participation in Programs, I, in my legal capacity as parent/guardian of Minor, agree on behalf of myself and Minor that the YMCA of Kokomo, its officers, directors, agents, employees, volunteers, insurers and representatives (“Releasees”) will not be liable for any personal injury, property damage, disability, death, sickness or disease incurred by Minor, however occurring including, but not limited to, the negligence of Releasees. I understand that Minor and I will be solely responsible for any loss or damage, including personal injury, property damage, disability, death, sickness or disease sustained from the use of Facilities and participation in Programs. I further agree, in my legal capacity as the parent/guardian of Minor, on behalf of Minor, myself, and any and all legal successors and proxies, to release and HEREBY DO RELEASE, WAIVE AND COVENANT NOT TO SUE Releasees from any causes of action, claims, suits, liabilities or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which Minor, myself, and any and all legal successors and proxies may have, now or in the future, against Releasees on account of personal injury, property damage, disability, death, sickness, disease, or accident of any kind, arising out of or in any way related to the use of Facilities or participating in Programs, whether that participation is supervised or unsupervised, however the injury or damage occurs, including, but not limited to, the negligence of Releasees. In further consideration of the use of Facilities and participation in Programs, I, in my legal capacity as parent/guardian of Minor, agree on behalf of myself and Minor to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, suits, liabilities or costs of any nature whatsoever, including claims of negligence, arising out of or in any way related to the use of Facilities and participation in Programs. *

Clear
Minor Participant Liability Waiver

Required Documents
A picture of these documents will work for our purposes.
Birth Certificate

Cancelof
Immunization Records

Cancelof
Custody/Court Decrees (If Applicable)

Cancelof
Kokomo Family YMCA | 114 N Union St. Kokomo, IN 46901 | kokomoymca.org
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OST Fall Break Camp 2024