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SPENDING THE
SUMMER WITH
FRIENDS!
Callahan Family Branch
2015 SUMMER DAY CAMP
ENROLLMENT PACKET
KENOSHA YMCA
Spending the Summer
With Friends!!!
Dear Parents,
WOW!!! It’s time to make plans for Summer Day Camp already! The school year has gone by quickly!
In this packet are the forms necessary to begin the enrollment process.
It contains:
Enrollment/Medical Form
Registration Form
Dates of Service & Payment Due Dates
Transportation Agreement
Immunization Record
CACFP / Food Program Information
Parent Policy Book
Your child(ren) will officially be enrolled when ALL forms are completed and turned in along with payment in
full for the first week (session) of attendance. If you want to reserve a place for other sessions, there is a
$15.00 deposit for each session to be attended. The deposit is non-refundable and is applied to the payment due for the scheduled session. No child may attend a session without it being paid in full.
Payments can be made via check, on-line (requires email contact information), at the Callahan Family
Branch front desk, and set up as automatic withdrawal (please indicate on Registration Form so that we can
get this set up for you).
If you have any questions, please do not hesitate to contact either myself or Malinda Sliger (Office Assistant
msliger@kenoshaymca.org or 262.654.9622 ext. 236).
We look forward to building relationships with your kids and helping to meet the needs of your family.
Please start planning to attend our Summer Day Camp Orientation, Saturday, June 6th, 10:00-12:00.
Everyone will have the opportunity to meet the staff, sample some of the lunches on our SDC Menu (we
serve am snack, lunch, & pm snack with no additional cost), ask questions, and experience some of the SDC
games and activities being planned.
Dr. M. Rachel Burton
Youth and Family Director
rburton@kenoshaymca.org
262.654.9622 ext. 238
DIRECTIONS
Below you will find our Summer Camp Enrollment Packet. This packet must
be completed and turned in when registering your child for the Kenosha
YMCA Summer Camp Program. Please insure that all forms are filled out
completely, please sure to sign and date each form and return them to:
1) Kenosha YMCA – Callahan Family Branch
2) Before & After School Program Staff
Should you have any specific questions or concerns please contact:
Malinda Sliger
via email at msliger@kenoshaymca.org. OR 262.654.9622 ext. 236
Thank you and we look forward to serving your family!
Kenosha YMCA Summer Camp
Callahan Family Branch
7101 53rd St. Kenosha, Wi. 53144
262-654-9622
Please fill out in Blue or Black Ink ONLY!
Child's Full Name
kenoshaymca.org
First Day of
Attendance
Gender (circle)
M/F
Address (City, State & Zip code required)
Grade: (based on grade JUST completed, CIRCLE one)
K - 1st
2nd - 3rd
/
Telephone #
Last Day of
Attendance
/
/
DOB
/
Age
T-Shirt Size (circle)
4th - 5th
6th - 9th
Adult S
Adult M
Youth S
Adult L
Youth M
Youth L
Parent or Guardian (provide the information requested for EACH parent or guardian.)
**NOTE: All parents/guardians will be permitted to visit during center hours unless access is prohibited or restricted by a court order**
Legal Guardian #1 First and Last Name
Address (City, State & Zip code required)
Home #
Cell #
Work Name & Address
Work #
Legal Guardian #2 First and Last Name
Email Address
Address (City, State & Zip code required)
Home #
Cell #
Work Name & Address
Work #
Child lives with :
Both Parents
Mother
Special Custody Concerns:
Email Address
Father
Grandparent(s)
Guardian
→ This Section MUST be signed even if there are NO concerns ←
Are there any custody concerns regarding this child that we need to be aware of while the child is in our care?
Please Attach any documentation (court order, etc.) to back up all custody concerns.
⃝ Yes ⃝ No If YES, please explain:
Signature of Parent or Guardian
Physician & Medical Facility Information
Physician Name
Address
Date
Phone #
Preferred Medical Facility - Please Circle one or select other:
Aurora Medical - 100400 75th St.
Kenosha Hospital - 6308 8th Ave.
St. Catherine's - 9916 75th St.
⃝ Other _________________________
Signature of Parent or Guardian
Date
I hereby give my consent for emergency medical care or treatment, to be used ONLY if I cannot be immediately reached.
AUTHORIZED PEOPLE TO CALL & EMERGENCY CONTACT FOR YOUR CHILD. (Provide additional names & information for people authorized to: Contact when parent/guardian
cannot be reached who can receive information on your child and are authorized as a pick-up person that staff can release your child into his/her care)
Contact #1 First and Last Name
Home #
Address (City, State & Zip code required)
Contact #2 First and Last Name
Cell #
Relationship to child
Home #
Address (City, State & Zip code required)
Cell #
Relationship to child
I have had an opportunity to review the policies of the day care center and a summary of the Wisconsin Rules for Licensed Day Care Centers. ⃝ YES
⃝ NO
I have been informed of pets in the center and their degree of contact with the enrolled children. ⃝ YES ⃝ NO
Note: If pets are added after a child is enrolled, parents shall be notified in writing prior to the pet’s addition to the center.
I give permission for my child to participate in Field Trips and other activities during operating hours. Walking ⃝ YES
*Transported Field Trips always require an additional permission slip. This slip will include all details of the field trip.
Signature of Parent or Guardian
⃝ NO Transported* ⃝ YES
Date Signed
⃝ NO
HEALTH HISTORY & EMERGENCY CARE PLAN
1. Check any special medical condition that your child may have:
⃝ None
⃝ Physical Handicaps
⃝ Epilepsy / Seizure Disorder
⃝ Asthma
⃝ Diabetes
⃝ Cerebral Palsy / Motor Disorder
⃝ Emotional / Behavior Disorder including ADD, ADHD or ODD (Please Circle)
⃝ Gastrointestinal or Feeding Concerns Including Special Diet and Supplements
⃝ Other condition(s) requiring special care (Specify):____________________________________________________________________________________________________
2. Does your child have any allergies?
Food Allergies - ⃝ No ⃝ Yes - Specify food(s):___________________________________________________________________________________________________________
Non Food Allergies - ⃝ No ⃝ Yes - Specify:______________________________________________________________________________________________________________
If Yes, Fill out a - e. Attach additional information if needed. If No, skip to #3.
a. Triggers that may cause problems - Specify:_____________________________________________________________________________________________________________
b. Signs or Symptoms to watch for - Specify:_______________________________________________________________________________________________________________
c. Steps the child care provider should follow:_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
d. When to call parents regarding symptoms or failure to respond to treatment: ____________________________________________________________________________________
e. When to consider that the condition requires emergency medical care or reassessment: ___________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
3. Is there additional information that may be helpful to the child care provider? ⃝ None ⃝ Yes
Specify: ____________________________________________________________________________________________________________________________________________
4. Does your child take any medication (this information is needed whether they take medicine while in the program or at another time of the day, in
case of emergency) If yes, what is the medication? _________________________________________________________________________________________________________
SUNSCREEN & BUG REPELLANT
5. I will provide sunscreen & insect repellant for my child when applicable (I give permission to the Kenosha YMCA staff to apply/assist in applying
sunscreen & insect repellant to my child daily)
__________________________________________________________________________ Brand_______________ SPF_____________ ⃝ Yes
Signature of Parent or Guardian
Date
⃝ No
INSURANCE INFORMATION
6. Insurance Company: _____________________________________________________________________
Policy # _______________________________________________________________
7. Name of person holding insurance policy:_____________________________________________________
Group # ______________________________________________
MEDIA RELEASE
8. I hereby irrevocably release, consent and authorize the Kenosha YMCA and its agents to use my child’s photograph, likeness/voice as it pertains to his/her
participation with the YMCA in any manner for promotional efforts without exception of or right to any reimbursement in connection with its use.
______________________________________________________________________________________
Signature of Parent or Guardian
Date
⃝ Yes
⃝ No
HOW DID YOU HEAR ABOUT US?
9. To better serve our community we would like to know how you heard about our program.
Please circle one:
Word of Mouth
Newspaper
YMCA Flyer
Mail
School
Telephone Book
YMCA Staff
Other: _____________________________________________________________________________________________________________________________________________
Summer Day Camp Policy & Transportation Agreement
Youth & Family Department 2015
Child’s Name: _____________________________________________________________________________
A. Policy Agreement
(initials)
I have read the Kenosha YMCA Program Policy booklet and agree to abide by the policies stated therein. This includes paying
weekly fees 2 weeks BEFORE services are rendered OR Wisconsin Shares copays. I understand services will be declined
without payment.
B. Agreement To Participate & Transportation Agreement
(initials)
(initials)
I will transport and sign my child in/out of the Kenosha YMCA Summer Program on the days I have indicated on the Summer
Camp Registration Form.
I will allow the Kenosha YMCA to transport my child to and from scheduled field trips to and from the Callahan Family
Branch/Renaissance School during the Summer Camp Program hours on the days indicated. I give permission for my child
to participate in ALL activities.
(Please check all that apply)
⃝ Callahan Family Branch: Transporting for field trips.
⃝ Renaissance School: Transporting to CFB for swimming and transporting for field trips.
⃝ Camp Adventure: To / From (school): ____________________________________________________________________________________
Session (circle one): AM / PM
Please share your email address with us for important program updates as well as online payment sign up.
Parent/Guardian Email Address: ___________________________________________________________________________________________
Signature of Parent or Guardian
Date Signed
DEPARTMENT OF HEALTH & FAMILY SERVICES
Division of Public Health
DPH 4192 (Rev. 02/08)
STATE OF WISCONSIN
ss. 252.04,Wis. Stats.
DAY CARE IMMUNIZATION RECORD
COMPLETE AND RETURN TO DAY CARE CENTER . State law requires all children in day care centers to present evidence of immunization against certain
diseases within 30 school days (6 calendar weeks) of admission to the day care center. These requirements can be waived only if a properly signed
health, religious, or personal conviction waiver is filed with the day care center. See “Waivers” below. If you have any questions on immunizations or how to
complete this form, please contact your child’s day care provider or your local health department.
PERSONAL DATA
STEP 1
PLEASE PRINT
Child’s Name(Last, First, Middle Initial)
Date of Birth (Month/Day/Year)
Area Code/Telephone Number
Name of Parent/Guardian/Legal Custodian (Last, First, Middle Initial)
Address (Street, Apartment number, City, State, Zip)
IMMUNIZATION HISTORY
STEP 2
List the MONTH, DAY AND YEAR the child received each of the following immunizations. DO NOT USE A (4) OR (X) except to indicate whether
the child has had chickenpox. If you do not have an immunization record for this child, contact your doctor or local public health department to
obtain the records.
TYPE OF VACCINE
First Dose
Second Dose
Third Dose
Fourth Dose
Fifth Dose
Month/Day/Year
Month/Day/Year
Month/Day/Year
Month/Day/Year
Month/Day/Year
Diphtheria-Tetanus-Pertussis
(Specify DTP, DTaP, or DT)
Polio
Hib (Haemophilus Influenzae Type B)
Pneumococcal Conjugate Vaccine (PCV)
Hepatitis B
Measles-Mumps-Rubella (MMR)
Varicella (chickenpox) vaccine
Vaccine is required only if the child has
not had chickenpox disease.
Has the child had Varicella (chickenpox) disease? Check the appropriate box and provide the year if known.
Yes year _____________________ (Vaccine is not required)
No or Unsure (Vaccine is required)
REQUIREMENTS
STEP 3
The following are the minimum required immunizations for the child’s age/grade at entry. All children within the range must meet these
requirements at day care entrance. Children who reach a new age/grade level while attending this day care must have their records updated with
dates of additional required doses.
AGE LEVELS
NUMBER OF DOSES
5 months through 15 months
2 DTP/DTaP/DT
2 Polio
2 Hib
2 PCV
2 Hep B
1
2
3
16 months through 23 months
3 DTP/DTaP/DT
2 Polio
3 Hib
3 PCV
2 Hep B
1 MMR
1
2
3
2 years through 4 years
4 DTP/DTaP/DT
3 Polio
3 Hib
3 PCV
3 Hep B
1 MMR
1 Varicella
4
3
At Kindergarten entrance
4 DTP/DTaP/DT
4 Polio
3 Hep B
2 MMR
2 Varicella
1
If the child began the Hib series at 12-14 months of age, only 2 doses are required. If the child received one dose of Hib at 15 months of age or
after, no additional doses are required. Minimum of one dose must be received after 12 months of age (Note: a dose 4 days or less before the
first birthday is also acceptable).
2
If the child began the PCV series at 12-23 months of age, only 2 doses are required. If the child received the first dose of PCV at 24 months of
age or after, no additional doses are required.
3
st
MMR vaccine must have been received on or after the first birthday (Note: a dose 4 days or less before the 1 birthday is also acceptable).
4
th
rd
th
th
Children entering kindergarten must have received one dose after the 4 birthday (either the 3 , 4 or 5 ) to be compliant (Note: a dose 4 days or
th
less before the 4 birthday is also acceptable).
COMPLIANCE DATA AND WAIVERS
STEP 4
IF THE CHILD MEETS ALL REQUIREMENTS (sign at STEP 5 and return this form to the day care center), OR
IF THE CHILD DOES NOT MEET ALL REQUIREMENTS (check the appropriate box below, sign and return this form to day care center).
Although the child has not received all required doses of vaccine for his or her age group, at least the first dose of each vaccine has been
received. I understand that it is my responsibility to obtain the remaining required doses of vaccines for this child WITHIN ONE YEAR and to
notify the day care center in writing as each dose is received.
NOTE: Failure to stay on schedule or report immunizations to the day care center may result in court action against the parents and a
fine of up to $25.00 per day of violation.
For health reasons this child should not receive the following immunizations __________(List in STEP 2 any immunizations already received)
______________________________________________________________________
Physician’s Signature Required
For religious reasons this child should not be immunized. (List in STEP 2 any immunizations already received)
For personal conviction reasons this child should not be immunized. (List in STEP 2 any immunizations already received):
SIGNATURE
STEP 5
To the best of my knowledge this form is complete and accurate.
____________________________________________________________________________
______________________________________
SIGNATURE - Parent, Guardian or Legal Custodian
Date Signed
Summer Camp @ Callahan Branch
2015 SDC REGISTRATION FORM
Childs Full Name
Todays Date
Grade (based on grade JUST completed CIRCLE ONE):
K - 1st
2nd - 3rd
4th - 5th
6th - 9th
I would like to purchase a Student Membership at the KENOSHA YMCA: $143.00 (6 month) or $180.00 (1 year) (Please complete a membership application) ⃝ YES ⃝ NO
Member / Multiple Child Rates
General Public Rates
SDC 2015 FEES
1-2 Days per session = $90.00
1-2 Days per session = $105.00
3 days per session = $132.00
3 days per session = $155.00
4-5 days per session = $175.00
4-5 days per session = $205.00
SESSION 1 MUST BE PAID IN FULL.
Non-Refundable Deposit of $15 per child/per additional session will hold a place for your child
There are no refunds or credits issued for unused days.
Parent is responsible for paying balance by due date. There will be a $5.00 late fee for each payment received late.
⃝ 1-2 Days
Session 6
REGISTRATION DIRECTIONS:
→ Place checkmark to select number of days needed per week.
→ Circle specific weekdays child will be attending.
⃝ 3 Days
⃝ 4-5 Days
$_____________
Amnt Due
Payment Due & Registration Deadline: June 5th or 6th
⃝ 3 Days
⃝ 4-5 Days
$_____________
Amnt Due
Payment Due & Registration Deadline: June 12th
⃝ 3 Days
⃝ 4-5 Days
$_____________
Amnt Due
Payment Due & Registration Deadline: June 19th
⃝ 3 Days
⃝ 4-5 Days
$_____________
Amnt Due
Payment Due & Registration Deadline: June 26th
⃝ 3 Days
⃝ 4-5 Days
⃝ 3 Days
⃝ 4-5 Days
$_____________
Amnt Due
Child will attend: Mon / Tue / Wed / Thurs / Fri
August 10-14
⃝ 1-2 Days
⃝ 3 Days
⃝ 4-5 Days
$_____________
Amnt Due
Child will attend: Mon / Tue / Wed / Thurs / Fri
August 17-21
⃝ 1-2 Days
⃝ 3 Days
⃝ 4-5 Days
$_____________
Amnt Due
Child will attend: Mon / Tue / Wed / Thurs / Fri
Session 11
⃝ 1-2 Days
July 13-17
⃝ 1-2 Days
Payment Due & Registration Deadline: August 7th
Child will attend: Mon / Tue / Wed / Thurs / Fri
Session 5
August 3-7
Session 10
⃝ 1-2 Days
July 6-10
$_____________
Amnt Due
Payment Due & Registration Deadline: July 31st
Child will attend: Mon / Tue / Wed / Thurs / Fri
Session 4
⃝ 3 Days
⃝ 4-5 Days
Child will attend: Mon / Tue / Wed / Thurs / Fri
Session 9
⃝ 1-2 Days
June 29 to July 3
⃝ 1-2 Days
Payment Due & Registration Deadline: July 24th
Child will attend: Mon / Tue / Wed / Thurs / Fri
Session 3
July 27 to July 31
Session 8
⃝ 1-2 Days
June 22-26
$_____________
Amnt Due
Payment Due & Registration Deadline: July 17th
Child will attend: Mon / Tue / Wed / Thurs / Fri
Session 2
⃝ 4-5 Days
Child will attend: Mon / Tue / Wed / Thurs / Fri
Session 7
⃝ 1-2 Days
June 15-19
⃝ 3 Days
Payment Due & Registration Deadline: July 10th
→ Make check/money order out to “Kenosha YMCA”
Session 1
July 20-24
$_____________
Amnt Due
Payment Due & Registration Deadline: July 3rd
August 24-28
⃝ 1-2 Days
⃝ 3 Days
⃝ 4-5 Days
$_____________
Amnt Due
Payment Due & Registration Deadline: August 14th
Child will attend: Mon / Tue / Wed / Thurs / Fri
Child will attend: Mon / Tue / Wed / Thurs / Fri
Payment Option: (choose one)
Online Payment
Check
Credit Card
E-Payment
Receipt # ________________________________________________________
Staff Name
TOTAL AMOUNT PAID FOR ALL SESSIONS
(Include each session that is paid in full, each session that a deposit has been
applied to, late registration fees, and membership fees.)
$_____________
Total Paid
AUTHORIZATION TO ADMINISTER MEDICATION
Youth & Family Department
I HEREBY AUTHORIZE ADMINISTRATION OF THE FOLLOWING MEDICATION(S) TO MY CHILD BY STAFF OF THE KENOSHA YMCA YOUTH & FAMILY DEPARTMENT.
(INSTRUCTIONS: Place form in child's file when medication is no longer required.)
Child's Name: ___________________________________________________________________________
D.O.B: _____________________________
Name of Medication
Dosage
Time
Dates for Medication to be given
Prescription
⃝ YES
⃝ NO
From:
To:
⃝ YES
⃝ NO
From:
To:
⃝ YES
⃝ NO
From:
To:
⃝ YES
⃝ NO
From:
To:
⃝ YES
⃝ NO
From:
To:
Special Instructions:
Signature of Parent or Guardian:
Date Signed:
Medication Log
Date
Time
Name & Dosage of Medication
Person Administering Medication
Date
Time
Name & Dosage of Medication
Person Administering Medication
2015 Summer Camp
Dates of Service and Payment Due Dates
Session #
Payment Due
Dates of Care
1
June 5th or 6th 2015
6/15/15 – 6/19/15
2
June 12th 2015
6/22/15 – 6/26/15
3
June 19th 2015
6/29/15 – 7/03/15
4
June 26th 2015
7/06/15 – 7/10/15
5
July 3rd 2015
7/13/15 – 7/17/15
6
July 10th 2015
7/20/15 – 7/24/15
7
July 17th 2015
7/27/15 – 7/31/15
8
July 24th 2015
8/03/15 – 8/07/15
9
July 31st 2015
8/10/15 – 8/14/15
10
August 7th 2015
8/17/15 – 8/21/15
11
August 14th 2015
8/24/15 – 8/28/15
Please Contact the Youth & Family Office Assistant
Malinda Sliger
with any billing questions or concerns
262.654.9622 ext 236
or
MSliger@KenoshaYmca.org
Thank You