Celebration: 4-6:00pm Pool Time: 6-7:30pm Lock-In Events:8-11pm Midnight Swim: 11pm Breakfast: 7:30am Pick-up: 8:30am

Size: px

Start display at page:

Download "Celebration: 4-6:00pm Pool Time: 6-7:30pm Lock-In Events:8-11pm Midnight Swim: 11pm Breakfast: 7:30am Pick-up: 8:30am"

Bethany Foster
6 years ago
Views:

1 Come rock out the night with the Swim Team! In our old fashion, swimmers are invited to spend the night with their teammates playing games, competing, and doing what we love most swimming. New for 2014, we invite the parents and siblings to join us for this FANTASTIC event! This will Celebration: 4-6:00pm Pool Time: 6-7:30pm Lock-In Events:8-11pm Midnight Swim: 11pm Breakfast: 7:30am Pick-up: 8:30am be the last big hoorah of the year and we want EVERYONE to be a part of it. See you poolside! Per Family: 1st Athlete $45 2nd Athlete $35 Addl. Athlete $25 ALL 9&Over RY swimmers in good-standing are invited. Maximum enrollment is dependant on parental attendance (ratio of 1:12 must be kept outside of sleeping hours). Swimmers whose parents are staying the night (11pm-6am) will have priority registration. Siblings are only invited with overnight parent. All participants (including siblings) must be 9 years of age or older. All participants are expected to act according to YMCA values.

2 2014 Rockin' Lock-In May 3-4, 2014 Time Activity Location 4:00-6:00pm Team Barbeque Pavilion 6:00-7:30pm Practice/Play Pool 8:00-9:00pm Team Events School-Age 9:00pm-8:00am YMCA Closed Facility 9:00pm Move bags to Studios, Setup Sleeping areas School-Age & Studios 9:30-11:30pm Music, Relays, Special Event Facility Pool Time or Movie for those not getting in pool 11:00pm- 12:00am 11:30pm 10 & Unders 11: :00 13 & Over 12:20 Get ready for bed Pool/Studios Studios / Bathrooms 12:00am Bed time Studios 7:15am Wake Up!! Studios 7:00-7:45am Swimmers pack and move to School Age Room Studio / School- Age 8:00am YMCA Opens Facility 8:00am Aerobics Class in Studios Studios 8:00am Breakfast Conference Room 8:30-9:00am Swimmer Pickup Conference Room For Emergencies Only: Coach Andrew Cell: - YMCA Main Line:

3 Clothing Athletic Clothing Socks and Underwear Tennis Shoes Pajamas Slippers or Flip-Flops Sweatshirt / Hoodie Sleeping Necessities 2014 Rockin' Lock-In May 3-4, 2014 Sleeping Bag or Blankets Sleeping Pad or air matress twin size only, unless sharing Pillow/s What TO bring Toiletries, etc. Toothbrush/paste Floss Shampoo/Conditioner Glasses case and/or contact kit if needed Soaps/facewash if needed Deodorant No smelly kids Other What NOT to bring Nintendo DS, PSP, etc. Smartphones for gaming purposes Weapons including any kind including ALL knives Anything you don't want possibly lost Flashlight Cameraphone not to be used in bathrooms or changing areas Crazy clothing/costumes For Emergencies Only: Coach Andrew Cell: - YMCA Main Line:

4 Water Wolves Lock-In Registration Please print clearly. Please complete all blanks on this form. Incomplete forms cannot be accepted and we are unable to provide care until all paperwork has been submitted. Child(ren)'s Information: Multiple children must be siblings of athlete or another family-member athlete Child's Full Name Nickname Age Date of Birth Child's Full Name Nickname Age Date of Birth Child's Full Name Nickname Age Date of Birth Primary Secondary City State Zip Home Phone Payment Information and Authorization: First Child: $45 Second Child: $35 Third Child: $25 Please complete payment authorization below. (Please check method of payment) I authorize the YMCA to charge my credit card for lock-in payments. I understand that I must provide written notice of cancellation. CREDIT CARD AUTHORIZATION PLEASE USE CREDIT CARD ON FILE AUTHORIZED SIGNATURE: AMEX MC NAME AS IT APPEARS ON CARD CARD ISSUER VISA DISCOVER CREDIT CARD NUMBER EXP. DATE SIGNATURE OF CARDHOLDER BILLING ADDRESS OF CARDHOLDER: CITY: STATE: ZIP:

5 Emergency Information Parent/Guardian and Medical information: In the event of an emergency, please number, in order of priority (1-6), which phone to contact. Parent/Guardian Name Cell Phone/Pager Priority City State Zip Home Phone Priority Place of Employment Work Phone Priority Parent/Guardian Name Cell Phone/Pager Priority City State Zip Home Phone Priority Place of Employment Work Phone Priority Doctor's Name Medical Insurance Provider Doctor's Phone Policy# Emergency contact name, address and phone numbers of TWO people to be called in the event that we cannot reach either parent/guardian: Emergency Contact Name Cell Phone City State Zip Home Phone Emergency Contact Name Cell Phone City State Zip Home Phone Additional Information: Authorized Person for pick-up (in addition to parents and emergency contacts) Authorized Person for pick-up (in addition to parents and emergency contacts) Authorized Person for pick-up (in addition to parents and emergency contacts) Authorized Person for pick-up (in addition to parents and emergency contacts) Phone Phone Phone Phone Does your child have any special needs, medical conditions, birth marks and/or allergies or intolerances to food, medication or other substances? Yes or No Check here if your child has any allergies. Types of Allergies: If epinephrine is required, please complete EPINEPHRINE FORM Check here if your child has Asthma. If child requires inhaler, please complete INHALER FORM. Check here if your child will be required to take medication during the Lock-In. Please complete MEDICATION AUTHORIZATION FORM. What are the symptoms and action to be taken If any?

6 Health Information Form Please fill out one form per child Child's Full Name Nickname Age Date of Birth Sex State or Country of Birth Language Spoken City State Zip Home Phone Health Conditions Condition Yes Comments Condition Yes Comments Allergies (food, insects drugs latex) Allergies (seasonal) Asthma or breathing problems Attention- Deficit/Hyperactivity Disorder Behavioral problems Developmental problems Bladder problem Bleeding problem Bowel problem Cerebral Palsy Cystic Fibrosis Dental problems Diabetes Head injury, concussions Hearing problems or deafness Heart problems Lead poisoning Muscle problems Seizures Sickle Cell Disease (not trait Speech problems Spinal injury Surgery Vision problems Describe any other important health-related information about your child (for example, feeding tube, hospitalizations, oxygen support, hearing aid, etc.) List all medications your child takes regularly (including prescription, over-the-counter and herbal) Please provide the following information: Name Phone Date of last Appointment Pediatrician/primary care provider Specialist Dentist Case Worker{if applicable) Child s health insurance: None FAMIS Plus (Medicaid) FAMIS Private/Commercial/Employer sponsored I, _, (do ) (do not ) authorize my child s health care provider and designated provider of health care in the lock-in setting to discuss my child s health concerns and/or exchange information pertaining to this form. This authorization will be in place until or unless you withdraw it. You may withdraw you authorization at any time by contacting the Aquatics Department at the YMCA. When information is released from your child s record, documentation of the disclosure is maintained in your child s health or scholastic record. Signature of Parent or Legal Guardian: _ Date: / /

Parent Statement of Understanding The following information is important for the safety and protection of your child. Please read this information and sign below.

7 Parent Statement of Understanding The following information is important for the safety and protection of your child. Please read this information and sign below. I understand that my child will not be released to any person(s) not listed on the enrollment form. I understand that my child will not be released to any person(s) who seems to be under the influence of drugs or alcohol. I understand that I am not to leave my child at the YMCA or program site unless a YMCA staff member or volunteer is there to receive and supervise my child. I understand that it is my responsibility to sign my child in upon arrival and sign my child out before leaving the program. Sign-in/out sheets are available as you arrive at the program area. I understand that my child will not be allowed to leave the program with an unauthorized person. Any person authorized to pick up my child must be listed on their form. Authorization by telephone will not be accepted. I understand that the YMCA is mandated to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation. I understand that YMCA staff and volunteers are not allowed to babysit or transport children at any time outside the YMCA facilities and program. If a violation of this policy is discovered, the YMCA will take immediate disciplinary action toward staff and volunteers. I have read and understand the statements above regarding YMCA policies and procedures. Parent/Guardian Signature Date Statement of Authorization 1. My child has permission to participate in swimming activities. Assess your child s swimming abilities here if not a member of the swim team: NON-SWIMMER INTERMEDIATE BEGINNER SWIMMER ADVANCED SWIMMER 2. In the case that your child becomes ill during the program, you will be contacted as soon as possible. If the parent or guardian is unable to be reached, the child s emergency contact will be notified. It is the responsibility of the parents or guardians to arrange for the child to be picked up from the center as soon as possible. 3. In the case that your camper or anyone in the immediate household of the camper develops a reportable communicable disease as defined by the State Board of Health, it is the responsibility of the parent to notify the YMCA within 24 hours of the next business day in order for the YMCA to take proper action, except in the case of life-threatening diseases which must be reported immediately. 4. My signature authorizes the management and staff of the YMCA of Metropolitan Washington to act for me according to the best judgment in the event of a medical emergency and/or routine medical care. I/we grant permission for emergency medical treatment and/or routine medical care by the YMCA staff, a rescue squad, or private physician and/or hospital or emergency health care facility staff, under the same circumstances as above, if needed. Any such action will be taken in the best interest of the child and will be reported to me/us as soon as possible. My signature waives and/or releases the YMCA of Metropolitan Washington form any and all liability and/or financial responsibility for any medical expenses incurred. By signing below, you are authorizing all of the above. Parent/Guardian Signature Date

8 YMCA OF METROPOLITAN WASHINGTON ("YMCA") PARTICIPANT WAIVER FORM ACKNOWLEDGEMENT I expressly acknowledge that there are certain dangers, risks, illnesses and personal injuries inherent in participating in the YMCA's programs, events, classes, and/or other activities, which may result from unavoidable accidents or injuries, athletic activities, sports programs/classes, the use of any equipment, exercise, or other activities or from my or my minor child(ren)'s or ward(s)' physical condition. I understand that the YMCA and its employees, agents, counselors, teachers, trainers, representatives, successors and assigns assume no responsibility for loss, damage, illness or injury to person or property that I or my minor child(ren) or ward(s), if applicable, may sustain as a result of my or their physical condition or resulting from my or their participation in any activities, programs, events, classes, the use or non-use of any equipment, exercise, horseback riding, archery, field trips, waterfront and pool activities, canoeing/boating, campfires, Hiking, high ropes and other challenge courses, or any other activities, classes, events, or programs at and/or sponsored by the YMCA. I expressly acknowledge, on behalf of myself and my minor child(ren) and ward(s), heirs and executors, that I voluntarily assume the sole risk for any and all dangers, illnesses and personal injuries that may result from my or my minor child(ren)'s or ward(s)' participation in any events/activities/programs/classes while at the YMCA and/or sponsored by the YMCA. I also acknowledge that the YMCA often uses photographs, videotapes, television programs, motion pictures, tape recordings, or other similar media for promotional purposes. I hereby consent to the use of my and/or my minor child(ren)'s or ward(s)' name(s) and/or likeness(es) in such materials to be exhibited and used for advertising, trade purposes, solicitation of patronage, promotional purposes, or other similar purposes, even if my and/or my minor child(ren)'s or ward(s)' name(s) and/or likeness(es) are an integral part of such photograph, videotape, television program, motion picture, tape recording, or other similar media. RELEASE In consideration of the YMCA allowing me and/or my minor child(ren) or ward(s) to attend and/or participate in any programs, events, classes, or other activities at the YMCA and/or sponsored by the YMCA, I hereby, for myself, my minor child(ren) or ward(s), heirs, and executors, waive, release and forever discharge the YMCA and its employees, agents, counselors, teachers, trainers, representatives, successors and assigns, from and against any and all rights and claims for any loss, damage, illness or injuries to person or property sustained as a result of my attendance and/or participation in any such programs, events, classes, and other activities, whether or not such loss, damage or injury results from, the negligence of the YMCA and its employees, agents, or representatives or from some other cause. My agreement to release the YMCA does not include any loss, damage or injury that results from the YMCA's gross negligence or willful, wanton, or reckless misconduct. I further waive any and all rights to inspect or approve the photograph, videotape, television program, motion picture, tape recording or other use of my and/or my minor child(ren)'s or ward(s)' name(s) and/or likeness(es), including any written article, script, caption or other writing that may accompany such use of my and/or my minor child(ren)'s or ward(s)' name(s) and/or likeness(es). I hereby, for myself, my minor child(ren) or ward(s), heirs, and executors, waive, release and forever discharge the YMCA and its employees, agents, counselors, teachers, trainers, representatives, successors and assigns, from and against any and all liability, claims, losses, costs, expenses or damages for libel, slander, invasion of privacy, conversion, defamation, appropriation of likeness or any other claim based on the use of my and/or my minor child(ren)'s or ward(s)' name(s) and/or likeness(es) in any such materials. INDEMNIFICATION I hereby represent and warrant to the YMCA that I have the authority to execute this Participant Waiver Form on behalf of myself and/or on behalf of my minor child(ren) or ward(s) as parent, guardian and/or next friend, if applicable. In the event of any misrepresentation or breach of the foregoing warranty by me, or in the event that I, my minor child(ren) or ward(s),or any other person nevertheless asserts any claim against the YMCA arising out of my or my minor child(ren)'s or ward(s)' participation in any program, event, class or other activity as set forth herein, I agree to indemnify, hold harmless and defend the YMCA from and against any and all liability, claims, losses, costs, expenses or damages resulting therefrom, including, but not limited to, claims of loss, damage, illness or injury to person or property whether or not such loss, damage, illness or injury results from the negligence of the YMCA or from some other cause. ACCEPTANCE I expressly acknowledge and agree to the terms and conditions set forth on this Participant Waiver Form. Signature of Participant of Parent/Guardian of Participant(s) under the Age of 18 Date Name(s) and Age(s) of Participant(s) under the Age of 18, If Any

ST. CLOUD AREA FAMILY YMCA SUMMER CAMP WAIVERS

ST. CLOUD AREA FAMILY YMCA SUMMER CAMP WAIVERS Parent Statement of Understanding The following information is important for the safety and protection of your child. Please read this information and sign