Summer Day Camp 2012-Registration Form (Each child requires a separate registration form)

GARDENA-CARSON FAMILY YMCA 1000 W. Artesia Blvd., Gardena, CA 90248 P 310 523-3470 F 310 539 6049 www.ymcala.org/gc Office Use Only Membership I.D. # Receipt # Date Packet Waiver Staff Initial Shirt Rec d Signature PARTICIPANT INFORMATION Summer Day Camp 2012-Registration Form (Each child requires a separate registration form) Child s First Name Last Name Date of Birth / / M F Address City Zip Child s School City Grade Level (Fall 12) Parent/Guardian Name Email Address Address City & Zip Home Phone Cell Phone Emergency # _ Employer Occupation Work Phone Parent/Guardian Name Email Address Address City & Zip Home Phone Cell Phone Emergency # Employer Occupation Work Phone WEEK/SESSION SELECTION A $10 deposit per week is due at registration. Deposit is applied to your camp fee. Deposit is non refundable and non transferable. Full Payment is due if registering after final payment deadline. Please select week (s) you would like your child to attend camp: Week Dates/Sessions Code Fee Amount of Deposit OR Full Payment Amount of Balance Due Final Payment Due Date (checks) Final Payment Due Date cash/credit) 1A June 20-June 22 760.ca.0405.853 $60 5/25 6/1 1 June 25 June 29 760.ca.0405.100 $100 6/1 6/8 2 July-2 July 6 760.ca.0405.101 $80 6/8 6/15 3 July 9 July 13 760.ca.0405.102 $100 6/15 6/22 4 July 16 July 20 760.ca.0405.103 $100 6/22 6/29 5 July 23 July 27 760.ca.0405.104 $100 6/29 7/6 6 July 30 August 3 760.ca.0405.105 $100 7/6 7/13 7 August.6 August 10 760.ca.0405.106 $100 7/13 7/20 Registration Fee 760.ca.0406.107 $25 Swim Lessons Please select one of the following payment options: Total Due at Registration $25 per week Total Balance Due Payment Information $ $ Office Use Only Participant is enrolling in this camp with subsidy funds paid by YMCA; No Yes % First deposit of camp per week per child is payable now. YMCA will charge my credit card by the due dates unless I cancel in writing to the YMCA 2 ½ weeks in advance. Late fee will apply; see payment and cancellation policy. First deposit of camp per week per child is payable now. I will pay by cash, check or credit card by due dates unless I cancel in writing to the YMCA 2 weeks in advance or YMCA will charge my credit card. Late fee will apply; see payment and cancellation policy. PAYMENT IN FULL. Please charge my credit card account for full payment of all weeks/camps requested and available.

Required Information Name on Card Visa MasterCard Discover American Express Debit Address City & Zip Card Number Expiration Date Signature CAMP PAYMENT AND CANCELLATION/TRANSFER POLICY * I understand that camp deposits are nonrefundable. The deposits for programs are as follows: $10 per week. Weekly payments in full are due 2 1/2 weeks before each session. * I understand my registration may be cancelled if the balance is not paid 2 1/2 weeks before the start of each camp session. If space is available, I may reregister with a new $10 deposit. Payments made after the due date are charged an additional $10 per week. * A valid credit card is mandatory for security deposit for all camps and programs. Credit cards will be charged to recover unpaid amounts due to: checks returned for non-sufficient funds; rejected ATS drafts; unpaid fees; YMCA late fees and bank charges or other fees; and/or damages to facility and/or property. * Cancellations may be made in writing up to 2 1/2 weeks prior to the start of the session to receive a refund less deposit and $10 processing fee. Otherwise, payments made will not be refunded. * NSF payments are assessed a $25 fee per check as well as applicable late fees. * Late pick up fees are $1.00 for every 1 minutes or portion thereof per child. By completing this registration form, I allow my child(ren) to attend all field trips and I acknowledge my responsibility to be aware and follow all policies (including refund and enrollment policies) for programs. If I fail to follow all policies and procedures, my enrollment will be cancelled. Please make sure you receive and read your parent manual, which is full of details about our day camp. By signing up for the programs indicated above, I understand and accept the above policies and I am responsible for payment: Parent/Guardian s Signature Date YMCA OF METROPOLITAN LOS ANGELES RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT IN CONSIDERATION for being permitted to utilize the facilities, services, and programs of the YMCA (or for my children to so participate) for any purpose, including, but not limited to observation or use of facilities or equipment, or participation in any off-site program affiliated with the YMCA, the undersigned, for himself or herself and such participating children and any personal representatives, heirs, and next of kin (hereinafter referred to as the undersigned ) hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating will, inspect and carefully consider such premises and facilities and/or the affiliated program. It is further warranted that such entry into the YMCA for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgement that such premises and all facilities and equipment thereon and such affiliated program have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use or participation by the undersigned and such children. IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY ON-SITE OR OFF-SITE PROGRAM AFFILIATED WITH THE YMCA, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING: 1. THE UNDERSIGNED, ON HIS OR HER BEHALF AND BEHALF OF SUCH CHILDREN, HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the YMCA, its directors, officers, employees, volunteers and agents (hereinafter referred to as "releasees") from all liability to the undersigned or such children and all personal representatives, assigns, heirs, and next of kin of the undersigned for any loss or damage, and any claim or demands on account of injury to the person or property or resulting in death of the undersigned or such children whether caused by the negligence, active or passive, of the releasees or otherwise while the undersigned or such children is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the YMCA. 2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees, and each of them, from any loss, liability, damages or costs they may incur, whether caused by the negligence, active or passive, of the releasees or otherwise while the undersigned or such children is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the YMCA. 3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR, AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE to the undersigned or such children due to negligence, active or passive, of releasees or otherwise while in, about or upon the premises of the YMCA and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the YMCA. THE UNDERSIGNED further expressly agrees that the foregoing RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made. I HAVE READ THIS RELEASE THIS AGREEMENT DOES NOT APPLY TO LICENSED CHILD CARE SERVICES. Printed Name: Signature of Applicant/Guardian: Date: Name(s) of Child(ren) in Program and/or YMCA Facility

GARDENA-CARSON FAMILY YMCA 2012 Summer Day Camp FINANCIAL POLICY REGISTRATION FEE: PAYMENT SCHEDULE: CANCELLATIONS: PENALTIES: A non-refundable and non-transferrable registration fee of $25.00 is required at the time of registration If your child will not be attending a week where a deposit has been paid, the YMCA Child Care/Camp Office MUST be notified in writing before 4:00 PM on the Thursday before the week of camp. All registration handled by Walk-in or Mail will receive a camp packet and receipt in the mail within two (2) weeks. All forms must be completed and returned to the Camp on the first day of your camp. All cancellation must be made in writing to the YMCA, not a camp. Any payment made beyond the non-refundable deposit will be refunded minus a $25 processing fee. DELINQUENT PAYMENTS: There is a late charge of $25.00 for rejected credit cards or late payments by cash, check or credit card. RETURNED CHECKS: All returned checks will be charged a handling fee of $25.00 LATE CHARGES: There is a charge of $1.00 per child for each 1-minute increment or portion there of that you are late in picking up your child after 6:00 PM. Emergencies called in by telephone will be taken into account. When late, you will be required to sign and date the late log. The late charge will need to be paid when you pick up your child. Failure to abide by all policies and procedures can result in termination from the program. THESE POLICIES WILL BE STRICTLY ENFORCED. I have read the Summer Day Camp Financial Policy Agreement and understand that failure to follow the above will result in cancellation from the Summer Camp Program. Signature of Parent Date Name of Child/Children

CAMPER BIRTH DATE GENDER AGE AT CAMP LIST MEDICATION ALLERGIES: PARENT OR GUARDIAN (or spouse) HOME ADDRESS BUSINESS ADDRESS SECOND PARENT/GUARDIAN or Emergency Contact HOME ADDRESS BUSINESS ADDRESS If not available in an emergency, notify: NAME Relationship DAY NAME Relationship DAY If applicable: Department of Children Services Case Worker HEALTH HISTORY: (Check, giving approximate dates) Condition No Yes Date Diseases No Yes Date Ear Infection Rheumatic Fever Heart Defect/ Disease Convulsions Diabetes Hypertension Sleepwalking Bedwetting Mononucl eosis Chicken Pox Measles German Measles Mumps Asthma Bleeding & Clotting Disorder OTHER: Allergi es Hay Fever No Yes Date Poison Ivy Insect Stings Penicill in Other Drugs NAME OF DRUGS: Immunizatio ns Measles, Mumps, Rubella(MM R) DTP Series Polio OPV (Sabin) Tetanus Others No Yes Date OTHER IMMUNIZATIONS: Operations or serious injuries (dates) Disability or Illness Dietary modifications Current medication (send with instructions) IMPORTANT: Labeled medication and instructions must be sent to camp/caravan with campers. Other disease or details of above Name of dentist/orthodontist Phone Name of family physician Phone Doctors suggestions or health related information for camp personnel (For Female) Has this person menstruated? If not, has she been told about it? If so, is her menstrual history normal? Special considerations Signature Date

Acceptance of Policies & Procedures I have received and will read a copy of the Gardena-Carson Family YMCA s Summer Camp information regarding the policies, procedures, and the financial policy. I understand that it is my responsibility to be aware of these policies. I understand that failure to abide by all policies can result in termination of camp or program. Signature of Parent: Child s Name: Child s Name: Date: YMCA Camp/Program Site: Gardena-Carson Summer Camp

Gardena-Carson Family YMCA PROGRAM ENROLLED IN FOR OFFICE USE ONLY SITE CHILD S NAME AM K PM LAST FIRST NICKNAME M T W TH F ADDRESS MEMBER DATE STREET CITY ZIP FEE GRADE BIRTHDATE SEX HOME ( ) START DATE MOTHER OR GUARDIAN HOME ( ) HOME ADDRESS CELL ( ) PLACE OF EMPLOYMENT AND CITY WORK ( ) FATHER OR GUARDIAN HOME ( ) HOME ADDRESS CELL ( ) PLACE OF EMPLOYMENT AND CITY WORK ( ) EMERGENCY CONTACT NAME ( ) RELATIONSHIP NAME OF OUT-OF-STATE CONTACT ( ) RELATIONSHIP DOES YOUR CHILD KNOW HOW TO SWIM? YES NO THE FOLLOWING INDIVIDUALS HAVE MY UNRESTRICTED PERMISSION TO PICK UP AND SIGN OUT THE ABOVE CHILD FROM THE YMCA PROGRAM WITHOUT ANY FURTHER CONFIRMATION FROM ME: 1. 2. 3. 4. NAME HOME WORK RELATIONSHIP MULTIJURISDICTIONAL AUTHORIZATION AND RELEASE FOR MEDICAL AND DENTAL TREATMENT (IMPORTANT - This Section Must Be Completed For Attendance*) Doctor Phone ( ) Please specify any medical problems: allergies, past operations or treatment of serious illness: Specify allergic reactions to medications and/or foods: I hereby grant permission for my child to use all of the play equipment and participate in all of the activities of the YMCA Program. I hereby grant permission for my child to leave the YMCA Program premises under the supervision of a staff member for neighborhood walks or field trips in an authorized vehicle. I hereby grant permission for my child to be included in evaluations and pictures connected with YMCA Program. The undersigned, as the parent(s), or legal guardian(s), of the above-named person, (the minor ) hereby authorize YMCA of Metropolitan Los Angeles and its employees, directors and adult volunteers (collectively YMCA ) to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care (collectively medical care ) to be rendered to the minor under the general or special supervision and upon the advice of a physician or surgeon licensed under the laws of the state or other jurisdiction in which medical care is sought, and to consent to any x-ray, anesthetic, dental or surgical diagnosis or treatment and hospital care (collectively dental care ) to be rendered to the minor by a dentist licensed under the laws of the state or other jurisdiction in which dental care is sought. For the purpose of medical care or dental care obtained outside of California, this authorization is given with the intent that any consent given pursuant to this authorization shall be the consent of each of the undersigned. The undersigned understand and agree that YMCA shall not be legally or financially liable for any bill or medical expense incurred, or for any cause of action or claim arising from any medical care or dental care provided, or the lack of medical care or dental care. The undersigned hereby agree to indemnify, defend, and hold YMCA harmless from any claim made by or on behalf of the minor person or the minor s heirs or parents or guardians arising out of any medical care or dental care provided. SIGNED: DATE:, 201 SIGNED: DATE:, 201 MEDICAL INSURANCE COMPANY POLICY NUMBER EXPIRES: Note: The YMCA requests that, if the minor is in the custody of both parents or more than one legal guardian, both or all sign this authorization. The YMCA understands that the minor is in the custody only of the person(s) who have signed this authorization. *If for religious reasons you cannot sign this, the branch must be contacted for a legal waiver which must be signed for attendance.

PHOTO & VIDEO/AUDIO RECORDING RELEASE YMCA OF METROPOLITAN LOS ANGELES PLEASE PRINT I am eighteen years of age or older, and if not, then my Mother/Father/Legal Guardian has also signed below under my signature. With regard to my participation in activities sponsored by or related to any activity in which I participate in any way sponsored by the National Council of Young Men s Christian Associations of the United States of America, and to any YMCA of the USA Association, including the Young Men s Christian Association of Metropolitan Los Angeles (collectively, YMCA ), I hereby give my permission and consent, now and for all time (without any further compensation, claim or demand by me) to the YMCA, and to advertising agencies, agents, entities and third parties collaborating with the YMCA and their representatives, if any, (the Organizations ) to make, reproduce, edit, broadcast or rebroadcast any video, film, or digital footage and other sound track recordings, or photo reproductions of my image or voice in any form, and my narrative account of my experience with YMCA activities ( Materials ) for publication, display, sale or exhibition thereof in promotions, advertising and legitimate business uses without any further compensation to me. I may or may not be identified by name in such reproductions. However, I shall not be stated by name to have endorsed any particular commercial products or commercial services without my express written permission. I further agree to the following: Any Materials created subject to this Release shall belong to the YMCA as its property, with full right of disposition of them without my oral or written permission. The Materials will not be subject to any obligation of confidentiality and may be shared with and used by the Organizations, as well as with any third parties as the YMCA may elect. The YMCA shall not be liable for any claim arising from the use or disclosure to a third party of any of the Materials. The YMCA shall exclusively own all known or later existing rights to the Materials worldwide and shall be entitled to the unrestricted use of the Materials for any purpose without compensation to me or the provider of the Materials. AGREEMENT AND CONSENT I have read and understood the contents of this Release. I agree that my consent to this Release is irrevocable. I hereby voluntarily release and discharge the YMCA and the Organizations and their representatives from any and all claims arising out of or relating to or in connection with the uses and reproductions of my image and voice and my narrative account as described herein. I understand that the term YMCA in this Release specifically includes the YMCA of Metropolitan Los Angeles. Signature Date / / Age Email Address Phone Cell Phone Address I am the Mother/Father/Legal Guardian of. I have read and understand PLEASE PRINT the contents of this Release and hereby voluntarily consent to this Release on behalf of my minor child. Signature of Mother / Father / Legal GuardianDate / / Email Address Phone Cell Phone Address