Programs are Enrollment Dependent Parent Registration Checklist
HOW TO REGISTER for summer programs Register online at www.wisconsinyouthcompany.org Registration forms may be requested through your administrative office or downloaded from our website. Parent Registration Checklist Please complete all forms entirely for each child or registration may be delayed as we will need to contact you to collect this required information. Parts IA, IB, III, IV and V are carbon copy forms (white & yellow), please return all carbon copy forms to the administrative office. Parts IA & IB - Registration & Program Selection Forms Complete both parts entirely. Part IA: be sure to select your program and check the desired arrival/departure procedure for your child and list persons other than parents who are authorized to pick up your child. Part IB: indicate the weeks and programs for which you are registering your child. Part II - Health History & Emergency Care Plan Form In compliance with state licensing requirements, children’s health history and emergency care plans must be periodically reviewed and updated by parents or guardians. Part III – Payment of Fees & Security Policies Form This form must be completed in order to protect the privacy of your account. Your account access password will be required for all account inquiries and requests to change account information. Part IV – Swim and Aquatic Activity Permission Form Check the appropriate swimming level for your child. Part V – Summer 2014 Agreement Form Be sure to read thoroughly before signing. Enrollment and Fees Weekly fees include activities and special events, supplies, equipment, staff, field trips with related transportation and admissions, snacks, facilities and the full range of available program hours. Specialty unit/ club fees (if applicable) are noted in the unit/club descriptions and on the part IB program selection form. A one-time summer processing fee of $25 is charged, part of which pays for your child’s program shirt. A $25 deposit per week is due at the time of registration. This deposit and processing fee is non-refundable and non-transferable. The deposit is applied toward the weekly/course fee. The remaining amount of fees are due by the end of the business day Friday (5:30 p.m.) six business days prior to the start of program. Fees may be paid by cash, check, money order, VISA or MasterCard. Make checks payable to Wisconsin Youth Company. A $20 fee will be assessed if your payment is late. Enrollment Deadline You may register or add weeks any time until the end of the business day on Friday (5:30 p.m.) six business days prior to the week being requested, provided space is available. Programs are Enrollment Dependent In order to provide a quality experience for your child, we need to have sufficient enrollment to operate a program and offer specific age groups within each program. If we are unable to offer the specific age group or program you registered for we will contact you to discuss available alternatives. Confirmation Process Families registering online and providing an email address will receive an emailed confirmation of their child’s registration, a welcome packet and a link to their program’s parent handbook. Families who register using paper forms who don’t provide an email address will be mailed confirmation of their child’s registration along with a welcome packet and parent handbook. Cancellation/Change Policy A written advance notice from the account holder (please include password) must be received by the WYC administrative office to cancel or change the program location or specialty unit/club of any week. This written notice must be received no later than the end of the business day Friday (5:30 p.m.) six business days prior to the week being cancelled or changed. If we don’t receive your written cancellation in time you will be liable for the remainder of the weekly fee. Financial Assistance Child care funding may be available from the city or county for licensed day camps. Parents are responsible for initiating and managing their funding source transactions. Families must obtain authorization prior to the child’s first day of program or will be responsible for making payments in accordance with the payment schedule. Once authorization is received from a funding source, our accounts receivable department will work with the parent to manage their account. It is the parent’s responsibility to follow program billing and funding activity and make timely payments for any remaining balances. Limited scholarship funds through Wisconsin Youth Company may be available on a first-come, first-served basis. In order to provide an enriching experience for as many eligible children as possible, partial scholarships are given. For scholarship information, please contact the administrative office. Contact Information: Dane County Wisconsin Youth Company 1201 McKenna Blvd. Madison, WI 53719 Waukesha County Wisconsin Youth Company 1800 Dolphin Drive Suite 200 Waukesha, WI 53186 608-276-9782 or 800-238-1174 Fax: 608-276-4050 262-547-8770 or 800-552-8878 Fax: 262-547-0394 Program related questions: Dane: info@wisconsinyouthcompany.org Waukesha: waukesha@wisconsinyouthcompany.org Billing and account information questions: Dane & Waukesha: registration@wisconsinyouthcompany.org Part IA WYC Summer 2014: Registration Form Program Attending in Summer 2014: ________________________________________________________________ __________________________________________ Child’s Name ______________ Birthdate ______ Age ________ _________________ _________________________ Gender __________________________________________________________________________ Mother / Father / Guardian (Circle one.)Primary Account Holder Grade in Fall 2014 School Attending in Fall 2014 _________________________________________________________________________ Mother / Father / Guardian (Circle one.) Secondary Contact Person ___________________________________________________________________________ _________________________________________________________________________ AddressAddress _____________________________________________ City/State/Zip ___________________________ Home Phone ___________________________________________ City/State/Zip ____________________________ Home Phone Cell Work Home ________________________ ________________________ _______________________ Work Phone Cell Phone Best Phone # During Program Hours Cell Work Home _________________________ ________________________ _______________________ Work Phone Cell Phone Best Phone # During Program Hours ___________________________________________________________________________ Best Address During Program Hours __________________________________________________________________________ Best Address During Program Hours ___________________________________________________________________________ E-mail Address __________________________________________________________________________ E-mail Address Child resides with: Mother Father Guardian Child’s program shirt size: (wicking sport/swim shirt) Youth: S M L Adult: S M L Purchase an additional t-shirt $12? Yes No Child previously attended a: WYC summer 2013 program? Yes No AFTER SCHOOL 2013-2014 program? Yes No Invoices and program information will be emailed. I prefer for the information to be mailed. AFTER SCHOOL Summer Day Camp & Immersion Camp Only: State statutes require any child under the age of 8 years old and under 80lbs. be transported in a booster seat while in any vehicle with seat belts. My child weighs less than 80 lbs.? Yes No Arrival / Departure Authorization: (For safety, any changes during the summer must be made in writing to the administrative office.) Arrival: (When child is not attending summer school) I acknowledge my child will arrive with a parent or another adult authorized to sign-in my child. I acknowledge that my child will arrive independently by walking or biking. (This includes walking independently from the parking lot.) Anticipated Morning Arrival Time: ___________________ Departure: I acknowledge my child is to wait for an authorized pick-up person (list additional authorized pick-up persons other than parents below). Unless otherwise noted, persons listed above are considered authorized pick-up and emergency contact persons. I acknowledge that my child will depart independently by walking or biking. (This includes walking independently to the parking lot.) Specific Afternoon Departure Time: ___________________ Summer School - Camps Pleasant Valley, Oaks, Wildcat, Connection and Glacier Creek Only: (WYC does not provide transportation.) My child will go directly to his/her summer school program from home. Yes No Arrival Time to WYC Program: ______________ My child will depart his/her WYC summer program to attend his/her summer school program. Yes No Departure Time from WYC: ________________ My child will arrive at his/her WYC summer program from his/her summer school program. Yes No Arrival Time back to WYC: ______________ Emergency Contact/Pick-up Authorization Information: (For safety, any changes during the summer must to be made in writing to the administrative office.) Authorized pick-up persons may be asked to present a photo I.D. All individuals authorized to pick up must be 18 years of age. Parents wanting anyone under 18 years of age to pick up their child must select the independent departure option above. Primary and secondary contacts listed above are considered authorized pick-up persons and emergency contacts unless otherwise noted. In addition to primary and secondary persons listed above, list one emergency contact (REQUIRED). In an emergency, if no contact can be made to those listed here, the police department may be notified. Add additional authorized pick up persons here, if applicable. Name (First & Last) Best Phone # During Program Hrs Complete Address Relationship to Child Emergency Contact Person Authorized Pick-up Person Office Use Only - Fees: Processing _______________ Deposit ______________ Amt Pd ______________ Ck #______________ Date Received ______________ Received by _______________ Start Date _______________ White: Administrative Copy Yellow: Confirmation Mailing Process Copy 2014 WYC - Summer Registration Form_Part IA.indd Ages (based on grade entering in fall 2014): Grades K-2 Grades 3-5 Grades 5-7 TNT (Camp of the Oaks ONLY) Child’s Name___________________________________________ Date of Birth__________________________ Construction Zone June 23-27 County Fair Splish Splash July 14-18 July 21-25 All-Stars Splish Splash Passport to Adventure Camp Finale $155 Half Day $155 Half Day $155 Half Day Full Day Only Full Day Only Full Day Only $205 Full Day $205 Full Day $205 Full Day $205 Full Day $205 Full Day $240 Full Day Construction Zone County Fair $155 Half Day $205 Full Day Animal Kingdom July 4th Week Full Day Only $120 Half Day $240 Full Day $205 Full Day $205 Full Day $205 Full Day $205 Full Day $205 Full Day $205 Full Day $165 Full Day Full Day Only Full Day Only Full Day Only Full Day Only Full Day Only Full Day Only $120 Half Day $100 Half Day $140 Half Day** $205 Full Day $60 Additional $205 Full Day Total campout fees, if applicable Total cost $ One-time summer processing fee of $25 $ $ Total weekly deposits ($25 x number of weeks) $ Yellow: Confirmation Mailing Process Copy **Camp of the Oaks Only: Friday, June 27 will be a full day camp for summer school students. White: Administrative Copy Camp Finale Splish Splash Construction Zone All-Stars Animal Kingdom County Fair Live Your Dreams Into the Outdoors Optional Campout Live Your Dreams Full Day Only Full Day Only Stoughton’s Camp of the Oaks Camp Finale Animal Kingdom Live Your Dreams All-Stars Passport to Adventure County Fair Into the Outdoors Optional Campout July 4th Week Splish Splash $145 Half Day $165 Half Day Full Day Only Full Day Only Full Day Only Full Day Only $165 Half Day $165 Half Day $165 Half Day 2014 WYC - Day Camp Reg Part IB_Dane.indd Reminder - The remaining amount of fees is due Friday (5:30 p.m.) six business days prior to the start of the program week. $240 Full Day $210 Full Day $210 Full Day $210 Full Day $210 Full Day $210 Full Day $210 Full Day $165 Half Day $60 Additional $170 Full Day $210 Full Day $210 Full Day Waunakee’s Camp Pleasant Valley Construction Zone ALL CAMPS: located at Lussier Family Heritage Center, 3101 Lake Farm Rd., Madison. (No after camp care on Friday, August 29. All campers will be picked up by 4 p.m.) Mt. Horeb $ 230 Encore! $240 $205 $205 $205 $205 $205 $205 $60 $165 Full Day $205 $60 Into the Outdoors Optional Campout July 4th Week $205 Full Day Passport to Adventure (Half-day applies to Verona campers only) Mt. Horeb* & Verona’s Camp Wildcat ALL CAMPS: no after camp care on Friday, August 22. All campers will be picked up at 4 p.m. Camp Finale Mt. Horeb $240 Camp Finale Construction Zone Animal Kingdom All-Stars Live Your Dreams Parent pick-up p.m.: $205 $205 Passport to Adventure Live Your Dreams $205 All-Stars $205 County Fair Into the Outdoors Optional Campout $165 $205 Passport to Adventure July 4th Week $205 Splish Splash Middleton’s Camp of the Trails *Camp Wildcat ONLY - Parent drop-off a.m.: August 25-29 August 18-22 August 11-15 August 4-8 July 28–August 1 $205 $60 Into the Outdoors Optional Campout July 7-11 $205 $165 $205 $205 July 4th Week June 30 - July 3 (No camp 7/4) Animal Kingdom Madison’s Camp of the Lakes June 16-20 Dates Directions: For each week you would like your child to attend: 1) check the box above that applies to the grade your child will be entering in fall 2014, 2) check the box next to the camp fee under your camp location column, choosing full-day or half-day if applicable. Half-day options are only available to summer school students. Dane County Day Camps Part IB WI Youth Company Summer 2014: Program Selection Form Part II WYC Health History & Emergency Care Plan Form Page 1 of 2 Directions: Please complete this form entirely. A review by parents/guardians and staff is required annually. This form remains with your child’s program during the hours your child is present in the care of Wisconsin Youth Company staff. Child Information: ___________________________________________________________________________________________________ _________________________________________ Child’s Name (Last) (First) (Middle) Birthdate (MM / DD / YYYY) ___________________________________________________________________________________________________ _________________________________________ Home Address (Street, City, State, Zip Code) Date – First Day of Attendance (MM / DD / YYYY) ___________________________________________________________________________________________________ _________________________________________ Parent Name (Last) (First) Best Phone # During Program Hours ______________________________________________________________________________________________________________________________________________ Address (if different from child’s) Physician / Medical Facility Information: _________________________________________ ___________________________________________________________________________________________________ Name of Physician Name, Address and Phone Number of Medical Facility Sunscreen/Insect Repellent Authorization: Sunscreen (Check 1 box) - Wisconsin Youth Company will provide Rocky Mountain SPF 30 sunscreen. I authorize the use of Rocky Mountain SPF 30 sunscreen for my child to self-apply to the extent possible, and WYC staff is authorized to provide assistance in applying sunscreen as necessary to ensure adequate coverage. I will provide sunscreen for my child to self-apply to the extent possible, and WYC staff is authorized to provide assistance in applying sunscreen as necessary to ensure adequate coverage. I do not authorize my child to use sunscreen during program hours. Insect Repellent (Check 1 box) - Wisconsin Youth Company will provide Cutter All Family Pump Spray 7% deet. I authorize WYC staff to apply Cutter Family Pump Spray (7% Deet) to my child. I will provide insect repellent for WYC staff to apply to my child. I do not authorize the use of insect repellent on my child during program hours. Immunization History: List the month/day/year the child recieved each of the following immunizations. Please fill in all empty boxes required by state law. If you do not have an immunization record for your child, contact your doctor or local public health department to obtain the records. Visit https://www.dhfswir.org/PR/clientSearch.do?language=en and enter your child’s name and social security number for a state immunization record for your child. Vaccinations - required for 5 years and older 1st 2nd 3rd 4th 5th Vaccinations - required for 4 year olds DTP Diphtheria, Tetanus, Pertussis DTP Diphtheria, Tetanus, Pertussis Polio (IPV) Polio (IPV) Hepatitis B Hepatitis B Measles, Mumps, Rubella (MMR) Measles, Mumps, Rubella (MMR) Varicella (Chicken Pox) Has the child had Varicella (chicken pox) disease? If yes, vaccine not required. Year: _________ If no or unsure, vaccine required. Varicella (Chicken Pox) Has the child had Varicella (chicken pox) disease? If yes, vaccine not required. Year: _________ If no or unsure, vaccine required. 1st 2nd 3rd 4th Hib (Haemophilus Influenzea Type B) Pneumococcal Conjugate Vaccine IF THE CHILD MEETS ALL REQUIREMENTS sign at arrow below and return this form to Wisconsin Youth Company, OR IF THE CHILD DOES NOT MEET ALL REQUIREMENTS check appropriate box below, sign and return this form to Wisconsin Youth Company. 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 the child WITHIN ONE YEAR and to notify Wisconsin Youth Company in writing as each dose is received. NOTE: Failure to stay on schedule or report immunizations to Wisconsin Youth Company may result in court action against the parents and a fine up to $25.00 per day of violation. For health reasons this child should not receive the following immunizations, (List in chart above any immunizations already received.): ________________ Physician’s Signature: _________________________________________________________ For religious reasons this child should not be immunized. (List in chart above any immunizations already received.) For personal conviction reasons this child should not be immunized. (List in chart above any immunizations already received. ___________________________________________________________________________________________________ _______________________ Signature of Parent / Guardian Date WYC Health Histrory & ER Care Plan Form_Summer 2014 & Sch Yr 14-15.indd Page 2 of 2 Directions: Please complete this form entirely. A review by parents/guardians and staff is required annually. This form remains with your child’s program during the hours your child is present in the care of Wisconsin Youth Company staff. Child Name: ________________________________________________________________________ 1. Special Health Information: Please check yes or no for each statement. General Health - Does your child: Have asthma? Yes No Have diabetes? Yes No Have epilepsy/seizures? Yes No Date of last seizure: __________________________________________________________________________ Have cerebral palsy/motor disorder? Yes No Details: ______________________________________________________________________________________ Wear glasses or contacts? Yes No Have ADD/ADHD? Yes No Details: ______________________________________________________________________________________ Have Autism Spectrum diagnosis? Yes No Details: ______________________________________________________________________________________ Have emotional/behavioal health issues? Yes No Details: ______________________________________________________________________________________ Have cognitive/learning disabilities? Yes No Details: ______________________________________________________________________________________ Have diet restrictions or special food needs? Yes No Details: ______________________________________________________________________________________ Other conditions that may require special care? Yes No Details: ______________________________________________________________________________________ Food/Milk Yes NoDetails: ______________________________________________________________________________________ Medication(s) Allergies - My child is allergic to: Yes NoDetails: ______________________________________________________________________________________ Environmental allergens (Insect stings, hay fever) Yes NoDetails: ______________________________________________________________________________________ Other Yes NoDetails: ______________________________________________________________________________________ My child will have an Epi Pen at site. Yes No My child will have an inhaler at site. Yes No My child will have other medication at site. Yes No Medications: Medication name(s): _________________________________________________________________________ 2. Signs or symptoms to watch for, please specify. 3. Specify triggers that may cause problems and steps WYC staff should follow in response. 4. Identify any WYC program staff to whom you have given specialized training/instructions to help treat symptoms. 5. I have reviewed the activities of the program and feel my child can participate without restrictions: If no, my child can participate with the following restrictions or accommodations. Yes No 6. Medications (prescribed and over-the-counter) your child takes regularly between the hours of 6:30 a.m. and 6 p.m. Please list the name of medication and the time of day to be administered. 7. When to call parents regarding symptoms or failure to respond to prescribed treatment: 8. When to consider that the condition requires emergency medical care or reassessment. 9. Does your child receive additional support services or one-on-one support during the school year? Yes No If yes, please explain. In the event my child becomes ill or injured, I understand every effort will be made to reach me or an emergency contact person on file. I give my consent for Wisconsin Youth Company to act on my behalf to obtain emergency care and treatment if it is deemed necessary. ___________________________________________________________________________________________________ _______________________ Signature of Parent / Guardian Date WYC Health Histrory & ER Care Plan Form_Summer 2014 & Sch Yr 14-15.indd Part III WYC Summer 2014: Payment of Fees & Account Security Policies Form Child’s Name ______________________________________________________________ Payment of Fees 1. I understand the one-time summer processing fee of $25 is non-refundable and non-transferable, unless a program is canceled by WYC. 2. I understand the $25 deposit towards each program is non-refundable and non-transferable, unless a program is full or canceled by WYC. ($100 deposit for Wander Wisconsin trips.) 3 I understand that full payment and all required information must be submitted at least six business days prior to the scheduled program start date, or my child’s enrollment may be cancelled. If registering within two weeks of the start of program, payment is due in full and all forms must be complete prior to the start of program date. 4. I understand that a late payment fee of $20 will be assessed for payments not received by Friday, six business days prior to the scheduled program, of a scheduled program and non-payment of fees may result in my child’s removal from the program. I understand that a $30 charge is assessed for each Non-Sufficient Funds (NSF) check or declined credit card transaction. 5. I understand written advance notice must be received by the administrative office to withdraw from or change scheduled attendance, provided space is available. Written notice must be received no later than the end of the business day six business days prior to the program start date being withdrawn from or changed. Failure to submit written cancellation on time will result in the liability of all fees paid and owed for that program. 6. I understand that no fee credit will be given if my child is absent from all or any portion of a confirmed program. 7. If a program is full or cancelled by Wisconsin Youth Company for any reason, registering families shall have no claim other than a full refund. 8. I understand I may request duplicate mailings to a second address for a fee of $15. 9. I understand early drop-off and/or late pick-up outside of program time may result in a $25 late fee per child for each 15 minute increment. Repeated infractions may result in removal from program. 10. I understand that if I am receiving assistance, I am responsible for any amount not paid by my funding source. Written verification from the funding source must be on file in the administrative office prior to confirmation of my child’s enrollment. My funding source is ___________________________________________________ Contact person _____________________________________ Phone number __________________________ Signature: __________________________________________________ (Account Holder) ______________________ Date Summer 2014 Payment Schedule Enrolled Program Date Payment Due Date Enrolled Program Date Payment Due Date Processing Fee* Upon Enrollment Deposit Balance July 14-18 July 3 June 9-13 (Camp Glacier Creek Only) May 30 July 21-25 July 11 June 16-20 June 6 June 23-27 June 13 June 30-July 3 June 20 July 7-11 June 27** July 28-August 1 July 18** August 4-8 July 25** August 11-15 August 1 August 18-22*** August 8 August 25-29*** August 15 Deposit Balance *One-time summer processing fee of $25 per child. **If enrolled in Circus Advanced and/ or Theater Immersion Camps (2 weeks), remaining amount of fees for both weeks is due Friday (5:30p.m.) six business days prior to the start of the first program week. I agree to the 2014 summer payment schedule. Signature of Parent / Guardian: ______________________________________________ (Account Holder) Reminder, subtract all deposits paid in advance. • ($25/week for day camp, Immersion Camp and Middle School U) • ($25 daily deposit if you register for less than five days: Waukesha Wander Wisconsin Travel Club) • ($100/trip for Wander Wisconsin) ________________ Date Account Access Password - Required ***Friday, August 22 & 29 - There will be no after camp care. All campers are to be picked up by 4 p.m. The security of your enrollment information is important and we’ve taken steps to help keep it secure. When enrolling your child, you are required to create a unique password and answer at least one security question listed below. This verification is REQUIRED whenever you or someone you authorize calls or emails us regarding your information (i.e. balance due, pick-up persons) and whenever account holders submit written requests and information updates so that we can protect your privacy and only give the information out to you or the person you designate. We can ONLY provide enrollment information when the correct PASSWORD and/or SECURITY ANSWER are provided by an authorized user. You may choose to keep your same password from previous Wisconsin Youth Company programs; however, you must confirm the password below. Please give us a password and the answer to at least one of the security questions listed below. Account Access Password ______ ______ ______ ______ ______ ______ (Maximum: 6 characters) Security Questions (Please answer at least one of the following.): 1. What street did you live on during high school? _____________________________________________________________ 2. Who was your childhood hero? ______________________________________________________________________ 3. What is your Grandmother’s maiden name? _________________________________________________________ Account Access - Optional In order to protect your privacy, we are unable to provide information to anyone other than an account holder or authorized user. Account holders are liable for the account, are able to request information and are able to make changes to the account. Authorized users are individuals authorized by the account holder to access information only. As the account holder, you may authorize other individuals (e.g. a spouse and/or other parent) by listing their name(s) below. I authorize the following person(s) to be an authorized user, allowing him/her to access information on the account: ________________________________________________________________________________________________________________________________________________________________________ I authorize the following person(s) to become an account holder, allowing him/her to make changes to account information: ________________________________________________________________________________________________________________________________________________________________________ Authorized Account Holder’s Name and Signature - Required Primary Account Holder Name: _______________________________________________ Print Name Optional Additional Account Holder Name: _______________________________________________ Print Name Signature: __________________________________________________ (Primary Account Holder) _________________________ Date Signature: _______________________________________ (Additional Account Holder) _________________________ Date White: Administrative Office Copy Yellow: Confirmation Mailing Process Copy 2014 WYC - Summer Payment of Fees & Account Security Policies Form.indd Part IV WYC Summer 2014: Swim & Aquatic Activity Permission Form Read this swim and aquatic activity permission form completely and carefully and indicate the appropriate swim level for your child. You are encouraged to complete this form even if the program(s) you selected do not include swimming or aquatic activities, so we have the information in the event you add a program for which swimming or aquatic activity permission is necessary. Child’s Name _______________________________________________________________________________ Age ________________ (Please print) (as of 6/1/14) Day Camp Campers will participate in recreational swimming activities off-site at a designated swimming pool or beach at least once during the camp week, weather permitting. Please note: Immersion Camps in Dane County do not include swimming or aquatic activities. Wander Wisconsin and Wander Camps Programs include swimming in natural bodies of water or in swimming pools as well as other aquatic activities in a variety of settings such as canoeing, kayaking, rafting, tubing and water park attractions. A swim level of 2 or higher is required to participate in Wander Wisconsin. Specific activities, as well as the swim level required for those activities, are outlined in the program descriptions. Middle School U Some courses include swimming in natural bodies of water or in swimming pools as well as other aquatic activities in a variety of settings such as canoeing, kayaking, tubing and water park attractions. Specific activities, as well as the swim level required for those activities, are outlined in the course descriptions. I Understand: 1. There is a greater risk in having my child participate in swimming and other aquatic activities, however, I feel that the added risk is acceptable because of the benefits to my child and agree to absolve WYC of any greater responsibility by virtue of my child’s participation in swimming or aquatic activities. 2. WYC adheres to state licensing regulations, American Camp Association accreditation standards (for applicable programs), and program policies regarding supervision of children while swimming. 3. Swimming will only take place at beaches and swimming pools where there is a certified lifeguard on duty. 4. Swimmers will be supervised by camp staff at a ratio of one adult staff member for every eight swimmers. 5. At beaches, all swimmers will stay in water no deeper than chest level. (Day camp only) 6. Swim levels, as defined below, will be used to divide swim groups during swim activities and to ensure that participants are only allowed to use watercraft within their swim level classification. 7. Aquatic environments may vary and the swim levels, as defined below, will be translated accordingly. 8. Aquatic or WYC staff members reserve the right to decrease participant swimming levels for any reason. 9. My child will receive a program shirt (the cost of which is included in the processing fee), and will be required to wear the program shirt for all program swimming activities at public facilities. The program shirt will help WYC staff and lifeguards supervise my child and has the added benefit of providing sun protection. My child will not be allowed to swim without a program shirt. (Please indicate program shirt size on part IA of the registration packet.) Please select one of the swim levels below: NO SWIMMING - My child is not allowed to go in the water but may play in a designated area away from the water. Level 1 – Beginning Swimmer: My child has little or no swimming experience. My child can enter and exit the water unassisted; put his/her face into water; and float on front and back. My child may enter the water, but must stay in water no deeper than waist level. Level 2 – Swimmer: My child has intermediate swimming skills. My child can tread water for at least 20 seconds; swim 20 yards on front with arm action and some side breathing; and has been introduced to deep water. My child may swim anywhere within the designated swim area of the swimming pool with water levels up to 6 feet. My child may participate in canoe and tubing activities if applicable. In a beach setting at day camp my child will still be expected to remain in water no deeper than chest level. Level 3 – Advanced Swimmer: My child has intermediate to advanced swimming skills. My child can tread water (without touching bottom) for at least one minute; swim front crawl for 25 yards; and is comfortable in deep water. My child may swim in the deep water area of the swimming pool. In a beach setting in day camp my child will still be expected to remain in water no deeper than chest level. My child may participate in canoeing, tubing, kayaking and rafting activities if applicable. Level 3 Swimmers ONLY - Swimming Pool Diving Board Permission: If available, my child may jump off (low) diving boards (feet first only and no flips). Flips and diving head first are not allowed. Do you have any concerns about your child participating in water activities? Comments: YES NO I give permission for my child to participate in swim and aquatic activities as indicated above. _________________________________________________________ Parent / Guardian - Please Print Name White: Administrative Copy ________________________________________________________ Signature of Parent / Guardian Yellow: Confirmation Mailing Process Copy _______________________ Date WYC - 2014 Summer Swim & Aquatic Activity Permission Form.indd Part V WYC Summer 2014: Agreement Form Please read this agreement completely and carefully, and sign below. Child’s Name ____________________________________________________________________________________________________ Please print Parental Consent 1. I give my consent for WYC staff to act on my behalf to obtain emergency care and treatment if deemed necessary for my child. 2. I give my consent as indicated on part II for the application of sunscreen and/or insect repellent. 3. I give my consent for my child’s participation in any field trips scheduled as part of his or her summer enrollment. 4. I give my consent for my child to be transported to and from any scheduled program activity for which transportation is provided. 5. I understand that WYC reserves the right to remove or suspend a child from the program if the child has needs that cannot be accommodated within the normal staffing pattern or if the safety of the child, staff or other children are jeopardized. 6. I understand I must list a minimum of one, preferably local, emergency contact other than parents on the registration form. I will inform anyone listed as an emergency contact that WYC may contact him or her in an emergency. I give permission for WYC staff to share pertinent information, including health information, with emergency contacts as necessary. 7. If severe weather, physical plant problems or other emergencies exist in the community surrounding the program location or the facility itself, program may not operate or may relocate to an alternate site. There is no credit or fee reduction for program closings. 8. I acknowledge that I have carefully reviewed and accurately completed parts IA, IB, II, III, IV and V of this registration packet. Agreement Signature - I/We understand and agree to abide by the above policies and other WYC policies as stated in the parent handbook. Handbook is available online or in print. _______________________________________________ Parent / Guardian - Please Print Name _______________________________________________ Optional Additional Account Holder - Please Print Name ____________________________________________ __________________ Signature of Parent / Guardian Date ____________________________________________ __________________ Signature of Account Holder Date Photo Release I grant Wisconsin Youth Company (WYC) permission to publish my child’s image in its newsletters, brochures, displays or other printed material and on its websites for purposes of promoting the programs. I understand that children’s names are not used when their images are displayed on our website or in widely distributed print materials. I understand that if I request, in writing, removal of my child’s image from WYC’s websites his/her image will be removed no later than 15 days from receipt of my request. Also, I release WYC, its employees, officers, directors and successors from any liability or claim related to the publication or disclosure for which I have hereby granted permission. I understand that the consent I grant here is completely voluntary. Yes, I accept the photo release. No, I do not accept the photo release. I agree to photo release for program site use only. (e.g. bulletin boards in the room, art project or newsletters) Yes, I accept the photo release. No, I do not accept the photo release. _______________________________________________________________________________________ Signature of Parent / Guardian White: Administrative Office Copy Yellow: Confirmation Mailing Process Copy ________________________ Date WYC - 2014 Summer Agreement.indd
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