YMCA Day Camp

Complete 2020 Day Camp Forms (Required)
These forms are required for your children to attend camp. If you haven't purchased camp you can purchase camp here.
Member ID
Camper Name*

First NameLast Name
Preferred Name - What does the camper prefer to be called?*
Date of Birth*

MonthDayYear
NOTE - Campers need to have completed Kindergarten before they are eligible to participate in traditional day camp. Parents should contact their branch's Camp Director or Registrar for information regarding eligibility.
Age
Entering Grade in 2019/20
School Camper Attends
Camp Registering For?*
North Camp*

TeenTraditional
Second Camp Location if needed
Second North Camp*

TeenTraditional
T-Shirt Size
First Day at Camp

MonthDayYear
Camper Swimming Ability

Non-SwimmerBeginner Swimmer (can swim on front 20ft without flotation)Advanced Swimmer (can pass swim test)
Please provide any additional information that you think is importantant or may affect the camper's ability to fully participate in the camp program.
Please consider sharing child's Individualized Education Program (IEP) in order to to best support your child's needs

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I would like to schedule a meeting with the Camp Director or Inclusion Specialist before camp starts regarding my child's unique needs.

Yes

Parent/Guardian 1
Parent/Guardian 1*

First NameLast Name
Relationship to Child*
E-mail*
Cell Phone*
Home Phone*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Work/School Name*
Or enter N/A if not applicable
Parent's Work/School Phone
Parent's Work/School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Where would you like to be reached while your child is at camp?*

Cell PhoneWork PhoneHome Phone
Contact preference
Where can you be reached while your child is in this program?
Please indicate if this name should be released if a parent/guardian, of a child attending the center/home, requests contact information for other parents/guardians.

YesNo
Should a Second Parent be listed?*

Emergency Contacts/Authorized Pickup

Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. The first emergency contact must live no more than 1 hour away and be over the age of 18.
Emergency Contact #1 - Required
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Secondary Phone Number*
Relationship to Child*

Plan for Health Conditions
If care is provided for a child who has an ongoing health condition that requires child specific care or may require a medical procedure, the parent/guardian shall complete this form.

A separate plan must be written for each condition that requires different actions to be taken.

If the child has more than 1 medical condition that requires different actions to be taken, answer the fields below for the first condition. Additional conditions must be addressed using this separate form.

If no health plan needed, please answer n/a.
Upload additional completed care plans.

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Describe the health condition*
Describe the medical procedure to be completed and expected benefits of treatment*
List activities/foods/environmental conditions to avoid*
Symptoms to watch for and actions to be taken if the symptoms are observed.*
Is any medication required?*

YesNo
In an emergency does this child require additional assistance (more than other children of the same age or in the same group) to evacuate?*

YesNo
Please describe*
In the event that the child care program must be evacuated, are there medications or supplies that must be taken with this child?*

YesNo
Please describe*

Sunscreen
Weight*
I consent to the following administration: sunscreen - topical product or lotion, exact dosage: liberal application per exposed area, to be administered: before high sun exposure. *
Type name above to consent
For the following time range
Start Date

MonthDayYear
End Date

Additional Medication
Check all that apply

Prescription medication
Nonprescription medication
Refrigeration required
Topical product or lotion
Food supplement
Modified diet
Name of medication*
If no medication needed, please answer n/a.
Exact dosage*
If no medication needed, please answer n/a.
To be administered at the following times*
If no medication needed, please answer n/a.
For the following period of time (If no medication needed, please answer n/a.)*
If your child's medication meets any of these criteria:
1. A physician's instruction is needed for a nonprescription medication (e.g. child is underage or underweight per the label instructions); or
2. It is a sample medication without a prescription label; or
3. The nonprescription medication is to be given longer than three consecutive days within a fourteen day period or is a topical product or lotion that is being used for a skin ailment and is to be given no longer than fourteen consecutive days; or
4. The child is on a modified diet (an entire food group is eliminated); or
5. The medication contains codeine or aspirin.
***The topical product or lotion and the physician's instructions exceed the manufacturer's instructions or use

Please complete this form and Box 2 must be completed by a licensed physician, licensed dentist, or an advance practice nurse.
Upload a Scanned File of the Completed Form

Upload a File

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Parent / Guardian Statement of Understanding
The YMCA of Central Ohio has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported.*
Type first and last name above to consent
This form, after being completed and signed by the parent/guardian, must be reviewed for completeness and signed by the administrator/designee prior to the child receiving care. After the child is attending the program the administrator shall have the parent/guardian review and initial the form when any changes/updates are made and at least annually. The parent/ guardian and the administrator or designee shall initial and date the form in the section below to indicate when the form was last reviewed.*
Type first and last name above to consent
Day Camp Policies and Handbooks
Acknowledgement of Policies and Procedures I have reviewed and received a copy of the center's policies and procedures/handbook.*

YesNo
Sign Document*
Date Signed*

MonthDayYear
Camp Director Name and Contact Info
Should be Empty:

Complete 2020 Day Camp Forms (Required)