Winter Camp 2024 Registration Form

Winter Camp 2024 Registration

The Youth Centers of Orange
The first week of Winter Camp is from December 30th - January 3rd. We will be closed January 1st. The second week of camp is January 6th - 10th.

The week will be packed with many fun games and activities!

Camp Hours: 7AM - 6PM

Ages: 5-14

Kids must bring a lunch everyday. Breakfast and snack are provided.

Winter Camp is $25 per day, per kid.

Payment is due at drop-off. Payments cannot be made at the end of the week.
Student Information
Student's Name

First NameLast Name
Birth Date

MonthDayYear
Grade
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information 1
Name

First NameLast Name
Cell Number
Home Number
E-mail
example@example.com
Parent/Guardian Information 2
Name

First NameLast Name
Cell Number
Home Number
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
Which days will your student be attending camp from December 30th-January 3rd?

Monday, December 30thTuesday, December 31stThursday, January 2ndFriday, January 3rd
Which days will your student be attending camp from January 6th - 10th?

Monday, January 6thTuesday, January 7thWednesday, January 8thThursday, January 9thFriday, January 10th
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the student prescribed any medications? An inhaler or epi-pen? If yes, please explain any instructions.
Does your child have any behavioral problems? If so please, explain.
Informed Consent and Acknowledgement

I approve my child’s application as a member of the Youth Centers of Orange (YCO) and will notify the Center when any changes such as:
authorized pick up, telephone numbers, address, and health conditions occur. My child and I agree to follow all rules and policies that embody
the YCO and understand that their membership may be terminated at any time for failure to follow the rules and policies. I am aware of the YCO’s hours of operation and the dismissal time for pick up. In addition, I understand the policies for the YCO transportation services during field trips.

I understand members are able to enter and leave as they please. I understand that once my child has entered the building, he or she will not
be able to leave the Center without a parent, guardian, or authorized adult to sign them out. Staff are not able to physically restrain members
from exiting the building without a parents permission.

I am aware that the YCO is not a licensed day care facility.
I give permission for my child to participate in activities such as surveys or discussion/focus groups in order to assist the YCO success within
the programs. I also grant permission to the Youth Centers of Orange to use photographs, recordings, and audiotapes of my child for the sole
purpose of program evaluations, public relations, and social media that belongs to the Center. The Youth Centers of Orange has permission to
share and receive information that pertains to the YCO’s needs with agencies that serve our members such as the Orange Unified School
District, Health agencies, and Health Department.

I agree to hold the Youth Centers of Orange and their fiscal sponsor The Hub OC, harmless in case of injury as a result from my child's
participation in the YCO’s programming. The Youth Centers of Orange has my permission to give access to emergency treatment by a doctor
or physician in case of an emergency or accident. I am also aware that I am accountable for any costs from medical care which the YCO/The
Hub OC will not be accountable for.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date

MonthDayYear
Date
Signature

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Winter Camp 2024 Registration

Student Information