Fillable Mankato Family YMCA Summer Camp 2022 School-Age Registration

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Mankato Family YMCA Summer Camp 2022 School-Age Registration

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  • 30 check-boxes
  • 52 other fields

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Page 1/4 ONLINE DOWNLOAD
Mankato Family YMCA Summer Camp 2022
School-Age Registration Form
Staff Initial
CAMPER NAME PHONE BIRTH DATE
ADDRESS CITY ZIP
AGE AT CAMP SCHOOL GRADE IN FALL (22) GENDER: M F
MOTHER/GUARDIAN NAME: DAYTIME PHONE:
FATHER/GUARDIAN NAME: DAYTIME PHONE:
EMAIL ADDRESS
IN CASE OF ACCIDENT OR ILLNESS NOTIFY
(Parents will be notied rst, please list an alternative contact):
NAME RELATIONSHIP PHONE #’s
Please list below individuals whom you give your permission to pick up your child on any given day
without prior notication:
Names & Relationship:
Is there anyone whom you do not wish to pick up your child under any circumstances?
Check One:
Y N
If you have a court order prohibiting contact by a parent, include a copy with your paperwork
Name & Explanation:
Extended Care
Extended Care will be offered from 4:30pm - 5:30pm.
Pre-registration is required.
CIRCLE
YOUR
CAMPS
SUMMER
CAMP
MANKATO FAMILY YMCA
2021
*RESIDENT CAMPERS ONLY
Are there any cabin mate requests?
If yes, please list
Should your child be given a lower bunk bed
because of restless sleeping, bedwetting,
medication, etc?
Check One:
Yes No N/A
Explain:
June
6-10
June
13-17
June
20-24
June 27
- July 1
July 5-8
(T-F)
July
11-15
July
18-22
July
25-29
Aug
1-5
Aug
8-12
Aug
15-19
Aug
22-26
Kindergarten
Clubhouse
Explorers
Voyagers
Pre-Teen
Teen
Adventure
Chesley Camp
Equestrian
Camps
Sports Camp
LIT & CIT
*Sunday-Friday
Camp
Patterson
1
HC 1
Gr 2-5
HC RES 1
Gr 3-5
HC 2
Gr 2-5
HC 3
Gr 2-5
HC 4
Gr 6-9
HC 5
Gr 2-5
HC 6
Gr 2-5
1 LIT
2 LIT
3 LIT
4 LIT
1 CIT
2 CIT
3 CIT
4 CIT
1
June
12-17
2
June
19-24
3
Jun 26
- July 1
4
Jul 31 -
Aug 5
1
2
3
4 4 4
5 5 5
6 6 6
7 7 7
8 8 8
9 9 9
10 10 10
11 11 11
Color
Wars
Gr 2-5
Speed,
Strength,
Agility
Gr 2-5
Soccer
Gr 2-5
Dance
Gr 2-5
Flag
Football
Gr 2-5
Multi-
Sports
Gr 2-5
Volleyball
Gr 2-12
Basketball
Gr 2-5
STRIDE
Gr 3-6
SPLASH
Gr 6-8
1 1
2
3
2
2
1
3
2
6
5
4
4
5
3
7
3
SCHOOL AGE DAY CAMPS
RESIDENT
CAMP
Gr 3-8Gr 9-10Gr 6-8Gr 2-8Gr 1-8Gr 2-12Gr 4-5Gr 1-3ENT K
Gr 9-12
1
Gr 1-5
2
Gr 6-8
3
Gr 1-5
4
BMX
Gr 3-6
5
Gr 1-5
6
Gr 1-5
7
Gr 1-5
8
Gr 6-8
9
Gr 1-5
10
Scooters
Gr 3-6
11
Just Girls
Gr 1-5
12
Gr 1-5
Page 2/4
2. HEALTH
Does child suffer from any allergies (medication, food, insect stings, other)?
Check One: YES NO
Please list and describe the reaction and management.
Has child ever been stung by a bee?
Check One: YES NO
If Yes, explain reaction:
Has child had a recent illness or been exposed to a contagious illness?
Check One: YES NO
If Yes, explain reaction:
Are child’s immunizations up to date as required by the State Health Dept?
Check One: YES NO
If not, please indicate reason:
Is child well enough to take part in all activities?
Check One: YES NO
If no, explain:
Does child have any physical disabilities?
Check One: YES NO
If yes, please describe:
Does child have any mental or emotional difculties which staff should be aware of?
YES NO
If yes, please describe the main issues and any solutions:
3. SWIMMING SAFETY
Students will periodically participate in Free Swim (not swim lessons) at the Mankato Family YMCA. It will be helpful to our
staff to know more about your child’s swimming ability so that we can make the swimming experience as safe as possible for
all involved. Please take a moment to complete this survey.
Beginner Swimmer
Intermediate Swimmer
Advanced Swimmer
Swim under water
Swim length of the pool
Tread water for 1 minute or more
I consider my child to be a (check one) S/he can (check all that apply)
My child is participating in
Chesley Skate Programs
and is exempt from
swimming portion.
1. MEDICATION
Will youth need medication during the hours of programming?
Check One: YES NO
A. PARENT/GUARDIAN AUTHORIZATION FOR PRESCRIPTION MEDICATION :
If child is to receive prescription medication during programming, please complete the following and sign:
Prescribing Physician Clinic Phone
Medication Dosage & Time:
Instructions for giving medication
Diagnosis/Medical reason for medication
B. PARENT/GUARDIAN AUTHORIZATION FOR NON-PRESCRIPTION MEDICATION
If non-prescription medication is being sent with child please complete and sign:
Medication Purpose for giving medication:
Amount to be given Frequency
Page 3/4
Mankato Family YMCA Youth Program Policy Guidelines, Behavior Expectations,
Disciplinary Process and Participant Agreement
NOTICE: THIS IS A LEGALLY BINDING AGREEMENT. Read the following carefully and in entirety. By signing this agreement, you have
read and agree to follow all Mankato Family YMCA and Chesley Skate Park policies and guidelines and you have read and fully under-
stand the Liability Agreement. You agree to give up your right and the named minor’s right to bring a court action to recover com-
pensation or obtain any other remedy for any personal injury or property damage however caused arising out of the named minor’s
participation in YMCA Programs, now or any time in the future.
Policies & Guidelines
1. In the event that my child needs immediate medical attention for injuries while participating in a YMCA program, or when a
parent cannot be reached or is delayed, I authorize the YMCA staff to give my child reasonable rst aid, and to arrange
transportation of my child to a health care facility for emergency services as needed.
2. I give permission to the medical personnel selected by the YMCA to order x-rays, routine tests, and to secure and administer
treatment including hospitalization; releasing any records necessary for insurance purposes.
3. If non-prescription/prescribed medication is to be given during YMCA program, I hereby authorize YMCA staff to administer
this medicine. I release YMCA personnel from any liability in relation to the administration of this medicine and understand I
must provide this medication in the original properly labeled bottle/container with enough to last the duration of the program
session.
4. If my child requires use and administration of an Epi-pen, it is my responsibility to ensure that the Epi-pen is given to YMCA
staff by the rst day of the Youth Program. If YMCA staff is required to administer and use the Epi-pen, I agree to forever
release and discharge the YMCA and its directors, ofcers, and employees from any and all liability arising out of or resulting
from use or administration of the Epi-pen.
5. I give my permission for the YMCA staff to administer sunscreen, bug spray, Vaseline, lip balm and hand sanitizer as needed.
6. I give permission for the YMCA to transport my child as needed for Youth Programming and eld trips. I also give permission
for my child to participate in walking eld trips.
7. I understand that if my child receives any special services in school (Para Assistance, Behavior, etc.), I am required to arrange
for assistance for the Youth Program, unless approved by the Program Director.
8. I agree to the Behavior Expectation Policy and Disciplinary Process stated below. I understand that I will not receive a refund if
my child is suspended or dismissed.
9. I authorize the reproduction, publication, and use by the YMCA for promotion, public relations, or social media use of any
picture or video footage of my child taken in this program. (Program guide, yers, ads, YMCA website, social media, etc.)
If no, explain: _______________________________________________________________________________________________________________________________________________
Behavior Expectation:
The Mankato Family YMCA staff works proactively with your child to follow the mission of the YMCA of the USA: “To put Christian
principles into practice through programs and services that build healthy spirit, mind and body for all” as well as apply the ve core
values of Caring, Honesty, Respect, Responsibility and Faith. We expect all participants to treat others with these principles and val-
ues in mind. If a child’s behavior deems unsuitable for the program, we will respond with those same principles.
The YMCA does not tolerate physical ghting, inappropriate language and/or touch, disruptive behavior, profanity, blatant disrespect,
violation of rules or illegal activity. If this should occur, parents will be notied and may be asked to pick up their child, dependent on
the circumstances. If behaviors continue or escalate, the child may be suspended from the program depending on the severity and/or
frequency of behavior. Our goal is to provide positive growth opportunities for all in a safe, healthy, nurturing environment. Refunds
will not be given if a child is sent home because of a behavioral problem.
Disciplinary Process:
Most disagreement situations are minor and can be resolved with minimal corrections. YMCA staff use disagreements as a learning
opportunity for the children and try to integrate problem-solving skills into the discussion. However, if the negative behavior contin-
ues the following steps may be instituted:
1. Discussions between child and staff to set goals and objectives.
2. Discussion between child, staff and Program Director to clarify goals and objectives previously set by the parties involved.
Documentation will be kept of the negative behavior and parents/guardians will be made aware of the situation.
3. If the conduct continues, the Program Director will contact the parent/guardian to inform them of the situation and discuss
possible options to correct the behavior. This will be recorded in the form of a Behavior Contract signed by the child, staff,
parent and Program Director.
4. If the conduct continues, the Program Director will contact the parent/guardian to arrange for the child’s discharge from the
program.
Although the above steps may be implemented in sequential order, YMCA administrative staff retains the right to take immediate
action if the child’s behavior poses a threat to their own safety, the safety of other children or staff. There will be NO REFUND OF
ANY AMOUNT for the children who are sent home because of behavior problems. Cigarettes, alcohol, illegal drugs, weapons, and
sexually explicit material and/or behavior are grounds for immediate dismissal from program.
Continued to the next page
Page 4/4
Parent/Guardian Signature Parent/Guardian Phone Number
Participant Name (Print Clearly) Participant Birthdate Today’s Date
Parent/Guardian Name (Print Clearly)
Mankato Family YMCA Minor Participant Waiver, Release,
Indemnication of All Claims & Covenant Not to Sue
PLEASE READ CAREFULLY. THIS DOCUMENT AFFECTS YOUR LEGAL RIGHTS AND IS LEGALLY BINDING. BY SIGNING THIS AGREEMENT
YOU ARE RELEASING MANKATO FAMILY YMCA FROM ALL LIABILITY AND FOREVER GIVING UP ANY CLAIMS THEREFOR
Assumption of Risk
I, in my legal capacity as parent/guardian of the minor named below (“Minor”), acknowledge and agree that any use of Mankato
Family YMCA facilities, services, equipment and premises (“Facilities”) and any participation in Mankato Family YMCA programs and
activities (“Programs”) comes with inherent risks 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. 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, Indemnication & 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 Mankato Family YMCA its ofcers, 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 participation 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.
Youth Program Policy Guidelines, Behavior Expectations, Disciplinary Processs & Participant Agreement continued
Chesley Skate Park
1. I acknowledge that my participation in skateboarding, in-line skating, BMX bicycling, scooters, or other activities or sports known as
dangerous but not mentioned above entails known and unanticipated risks that could result in physical or emotional injury, paralysis,
death, or damage to myself, to property, or to third parties. I understand that such risks simply cannot be eliminated without
jeopardizing the essential qualities of the activity. The risks include, among other things: Collision with other participants, the walls,
or other xed objects; falling down; my own equipment failure or the failure of others’ equipment; my own or others’ negligence;
and objects or conditions on the surface that may cause me to fall; broken bones, sprains, head and back injuries, abrasions, and
bruises. Furthermore, YMCA Chesley Skate Park employees have difcult jobs to perform. They seek safety, but they are not infallible.
They might be unaware of a participant’s tness or abilities. They may give inadequate warnings or instructions, and the equipment
being used might malfunction.
2. I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely
voluntary, and I elect to participate in spite of the risks. I expressly agree and promise to wear a helmet at all times during any activity
I participate in at the YMCA Chesley Skate Park.
3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless YMCA Chesley Skate Park from any and all
claims, demands, or causes of action, which are in any way connected with my participation in this activity or my use of YMCA Chesley
Skate Park equipment or facilities, including any such claims which allege negligent acts or omissions of YMCA Chesley Skate Park.
4. Should YMCA Chesley Skate Park or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this
agreement, I agree to indemnify and hold them harmless for all such fees and costs.
5. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear
the costs of such injury or damage to myself. I further certify that I am willing to assume the risk of any medical or physical condition I
may have.
6. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force
and effect.
In consideration of participant being permitted by YMCA to participate in its activities and to use its equipment and facilities I hereby certify
and agree to all of the terms of the above Release and Assumption of Risk provisions on behalf of said minor and myself. I further agree to
indemnify and hold harmless Mankato Family YMCA from any and all claims which are brought by, or on behalf of Minor, and which are in any
way connected with such use or participation by said minor. I have read, understand and agree to the policy, guidelines and participation
agreement statements above.
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Mankato Family YMCA Summer Camp 2022 School-Age Registration

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Completed 28 February 2022

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