DAY CAMP 2018 REGISTRATION FORM

DAY CAMP 2018 REGISTRATION FORM PARTICIPANT INFORMATION FIRST NAME M.I. LAST NAME D.O.B. GENDER Male Female PARENT / GUARDIAN INFORMATION FIRST NAME M.I. LAST NAME D.O.B. GENDER Male Female STREET ADDRESS CITY STATE ZIP PHONE NUMBER ALTERNATE PHONE E-MAIL ADDRESS PARENT / GUARDIAN INFORMATION FIRST NAME M.I. LAST NAME D.O.B. GENDER Male Female STREET ADDRESS CITY STATE ZIP PHONE NUMBER ALTERNATE PHONE E-MAIL ADDRESS AUTHORIZED PICK-UP LIST Only the parents / guardians listed above and the individuals listed below will be allowed to pickup the participant from camp (must be at least 18 years of age and present photo I.D. at pick-up): NAME OF AUTHORIZED PERSON PHONE NUMBER RELATIONSHIP TO CHILD NAME OF AUTHORIZED PERSON PHONE NUMBER RELATIONSHIP TO CHILD NAME OF AUTHORIZED PERSON PHONE NUMBER RELATIONSHIP TO CHILD NAME OF AUTHORIZED PERSON PHONE NUMBER RELATIONSHIP TO CHILD

MEDICAL INFORMATION & CARE AUTHORIZATION PARTICIPANT MEDICAL INFORMATION DOCTOR PHONE NUMBER OFFICE LOCATION (CITY OR HOSPITAL) DENTIST PHONE NUMBER OFFICE LOCATION (CITY) HEALTH INSURANCE PROVIDER POLICY NUMBER KNOWN ALLERGIES (MEDICATION, FOOD, ENVIRONMENTAL, ETC.) PRESCRIBED MEDICATION (DOCTOR S NOTE REQUIRED) OTHER NEEDS (BEHAVIORAL CONCERNS, FEARS, ANXIETIES, ETC.) The health information as written above is correct to the best of my knowledge and I permit my child to engage in all prescribed YMCA activities. In the event I cannot be reached in an emergency, I give permission to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for my child. I hereby give the YMCA staff permission to administer prescribed medication to my child and I agree to provide a note from my child s doctor outlining all prescribed medication procedures. I further acknowledge that the YMCA of Southeast Ventura County does not carry health or accident insurance on its participants and understand that all expenses incurred in the treatment of illness, injuries, or accidents will be the responsibility of the participant and his or her parents or guardians. Name of Parent / Guardian Signature of Parent / Guardian Date PARENT HANDBOOK RECEIPT & ACKNOWLEDGEMENT I have received a copy of the Conejo Valley YMCA Day Camp Parent Handbook and I understand that it is my responsibility to read and become familiar with its contents. I agree to abide by the program requirements and the parent / guardian responsibilities outlined in the handbook. I hereby give the YMCA permission to take, copyright, and publish photographs of my child for promotional purposes. I give permission for my child to be transported by the YMCA staff to field trips in buses and/or vans. Name of Parent / Guardian Signature of Parent / Guardian Date

ENROLLMENT PERIODS & PAYMENT AGREEMENT ENROLLMENT CATEGORIES CAMP WEEKS 1 2 3 4 5 6 7 8 9 10 EXPLORER (K - 3) FULL-TIME: $240 / WEEK PART-TIME: $195 / WEEK CHALLENGER (4-5) FULL-TIME: $240 / WEEK PART-TIME: $195 / WEEK ADVENTURER (6-8) FULL-TIME: $255 / WEEK PART-TIME: $205 / WEEK h h h h h h h h h h C.I.T. (9-10) FULL-TIME: $190 / WEEK DATES OF CAMP WEEKS PAYMENT DUE DATES OF CAMP WEEKS PAYMENT DUE WEEK 1: 06/11-06/15 05/28 WEEK 6: 07/16-07/20 07/02 WEEK 2: 06/18-06/22 06/04 WEEK 7: 07/23-07/27 07/09 WEEK 3: 06/25-06/29 06/11 WEEK 8: 07/30-08/03 07/16 WEEK 4: 07/02-07/06 06/18 WEEK 9: 08/06-08/10 07/23 WEEK 5: 07/09-07/13 06/25 WEEK 10: 08/13-08/17 07/30 ADD-ON ACTIVITIES SWIM LESSONS MONDAYS & WEDNESDAYS $20.00 PER WEEK CAMP WEEKS 1 2 3 4 5 6 7 8 9 10 N/A SPORTS CAMP 4:00 PM - 6:00 PM DAILY $45.00 PER WEEK N/A N/A N/A N/A I agree to pay in-full the corresponding fee listed above for each of the following enrollment dates which I have marked above. I understand that my child will not be allowed to participate in the YMCA Day Camp program if full payment is not received by the start of the camp week, and that I may not leave my child in the care of the YMCA if an overdue balance exists on my account. I also understand that no refunds or credits will be given for non-attendance without a doctor s note for illness. Name of Parent / Guardian Signature of Parent / Guardian Date

BILLING METHOD AUTHORIZATION CONEJO VALLEY YMCA CREDIT CARD / E.F.T. AUTHORIZATION I authorize my financial institution to honor preauthorized credit card charges and/or electronic funds transfers against my account for membership, program, and/or contribution payments as indicated. When my financial institution honors the credit card or E.F.T. by charging my account, such transfer shall constitute notice of payment due and my receipt for the payment. Should any preauthorized credit card or E.F.T. not be honored by said financial institution when received by them, then it is understood that the payment is to be made by me in the amount of said payment plus a $25.00 service fee. It is further understood that the Y may resubmit the amount due for payment on a future date if such payment is not honored. I choose to utilize the Credit Card payment option (automatic direct charge to credit card): Card Holder Name: Type: AMEX VISA astercard Discover Credit Card Number: Expiration Date: Billing Address: Zip Code: I choose to utilize the E.F.T. payment option (direct debit from my checking or savings account): Name on Account: Type (Attach Voided Check): Checking Savings Routing Number: Account Number: ATTACH A VOIDED CHECK VOID ROUTING # ACCOUNT NUMBER It is my responsibility to notify the Y of any changes in address and/or billing information being used for monthly dues, including credit card expiration. I understand that all membership dues are subject to change with thirty (30) days written notice and that membership fees are not transferable. It is my responsibility to dispute any billing discrepancies within 90 days of their first appearance on my financial statements; after 90 days, I waive my right to dispute such discrepancies. I acknowledge the membership agreement set forth above and agree to adhere to these policies as stated on this form. Name of Primary Adult on Membership Signature of Primary Adult on Membership Date

SUNSCREEN PERMISSION FORM Dear Parent or Guardian, Your child is currently enrolled in our Summer Day Camp program which is mainly held outdoors. Since the weather in California is typically sunny, we encourage parents to apply sunscreen to their camper(s) before they attend camp for the day. Since sunscreen does lose its effectiveness over a period of time, we would like to make sure sunscreen is reapplied throughout the day as needed. California law requires written permission from a parent / guardian if sunscreen is applied during our programs. Our staff will only assist children that need help applying sunscreen to bare surfaces including the face, ears, bare shoulders, arms, legs, and feet. Sunscreen will be applied 15-30 minutes before an outdoor activity occurs, and then every two hours after the initial application. If a parent wishes to provide sunscreen for their camper, it must be in a Ziploc bag with the child s name clearly written on the bag. Please initial one of the following options: My child may use the sunscreen provided by the Y. I prefer that my child only use the sunscreen he/she brings to camp, but I understand that the Y will provide sunscreen in the event that the sunscreen I provided for my child runs out. I understand that sunscreen will be applied to my child before outdoor activities and throughout the day as needed. Name of Parent / Guardian Signature of Parent / Guardian Date

Dear Day Camp Parents, The Conejo Valley YMCA has partnered with Stepping Stones Riding Program to allow our campers to ride and learn about horses as part of their camp experience. The program is located at the top of the hill at the Conejo Valley YMCA branch. Both Stepping Stones and the YMCA take your child s safety very serious and have, therefore devised a set of rules/regulations that must be adhered to for your child(ren) to participate in the Horse Program. The following is that list: 1. A YMCA wavier names Member/Children Release Waiver of Liability and indemnity Agreement form must be completed prior to being allowed in the riding program. 2. A Stepping Stones wavier must be completed prior to being allowed in the riding program. 3. All riders MUST have CLOSED TOED shoes to be allowed to go up to the equestrian area and participate. Helmets will be provided. 4. A maximum of 15 campers will be allowed up at the horse facility at one time. Two staff must be present at all times. Half of the campers will be riding at one time and the other half will be seated at the picnic table area. Please be aware that these regulations are for the safety of your child(ren) and are mandatory for the use of the horses. If you have any questions, please feel free to contact me. Thank you for your time and understanding. Sincerely, Casie Cretal Day Camp Director CONEJO VALLEY YMCA 4031 N. Moorpark Road, Thousand Oaks, CA 91360 805.523.7613 F 805.523.8831 www.conejoymca.org

RELEASE and WAIVER of LIABILITY and INDEMNITY AGREEMENT IN CONSIDERATION of being permitted to utilize the facilities, services and programs of the SOUTHEAST VENTURA COUN- TY 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, 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 or 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 thereof 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 LIM- ITED TO, OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY OFF-SITE PROGRAM AFFILI- ATED WITH THE YMCA, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING: THE UNDERSIGNED ON HIS OR HER BEHALF AND BEHALF OF SUCH CHILDREN, HEREBY RELEASES, WAIVES, DISCHARGES AND CONVENANTS NOT TO SUE the YMCA and all branches thereof, its directors, officers, employees and agents (hereinafter referred to as releasees ) from all liability to the undersigned or such children and all his personal representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands thereof on account of injury to the person or property or resulting in death of the undersigned or such children whether caused by the negligence 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. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releases and each of them from any, loss, liability, damage or cost they may, incur due to the presence of the undersigned or such children in, upon or about the YMCA premises or in any way observing or using any facilities or equipment of the YMCA or participating in any program affiliated with the YMCA whether caused by the negligence of the releasees or otherwise. THE UNDERSIGNED ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE to the undersigned or such children due to negligence 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 WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as 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 AND UNDERSTAND THIS DOCUMENT AND RELEASE. Name of Primary Adult on Membership Signature of Primary Adult on Membership Date Name of Second Adult on Membership Signature of Second Adult on Membership Date Name of Child Name of Child Name of Child Name of Child

ASSUMPTION OF RISK AND RELEASE OF LIABILITY I have requested to become involved and participate in the activities of Stepping Stones Riding Program (hereafter called SSRP ) as well as use the horse facility located on Conejo Valley YMCA. I am aware that being around, working with, riding, and grooming horses and general horse maintenance can be a dangerous activity. I agree to follow all rules, procedures, and instructions of SSRP and its staff. ASSUMPTION OF RISK My participation in any activity sponsored by SSRP is at my own risk, and I am voluntarily participating in the activities listed above with knowledge of the dangers involved and hereby accept any and all risks of injury or death and verify this statement by placing my initials here. RELEASE OF LIABILITY As consideration for being permitted by SSRP to use its facilities and to participate in the activities listed above, I hereby agree that I, my guardians, legal representatives, heirs, executors, successors, administrators, next of kin, spouse or assignees will not make a claim against or sue, and hereby release, SSRP, its agents, employees, officers, directors, contractors, sponsors, volunteers, event holders, and the Conejo Valley YMCA from any personal injuries, illness, death, or property damage, injury or death of horses in our care or custody, howsoever caused, or suffered by me, as a result of my participation in any of the activities listed above, whether or not said injury, death, or damage may be due to any conduct, act, omission or negligence of SSRP, its agents, employees, officers, directors, contractors, sponsors, volunteers, event holders, or members. KNOWING AND VOLUNTARY EXECUTION I have read and fully understand this document, have signed voluntarily, and understand my rights to consult with a third party/attorney prior to signing this release of liability. Date: Name: Address: City, State, Zip Code: Phone: Email: Date of Birth: Signature: If participant is under the age of 18, this agreement must also be signed by parent, guardian, or legal representative. Date: Print Name: Signature: Relationship to Participant: EMERGENCY CONTACT INFORMATION Emerg. Contact s Name: Emerg. Contact s Phone: PHOTOGRAPH RELEASE I agree to allow my photograph or video to be used by SSRP for advertising, publication, in print or on internet for educational or promotional purposes. Signature:

FRIENDSHIP SPORTSMANSHIP LEADERSHIP CONEJO VALLEY YMCA YOUTH SPORTS CAMP Grades K-8th Conejo Valley YMCA Summer Sport Camps are based on skill development and having fun. Every child plays and learns the basics of the sport, the essentials of teamwork and new skills through various activities and drills. Our sports camps are co-ed. No prior playing experience necessary! Don t miss out on an unforgettable camp experience. 6 WEEKS OF SPORTS: Location: Conejo Valley YMCA 4031 Moorpark Rd. Thousand Oaks, CA 91360 Time: 4:00pm 6:00pm Dates: June 18th -22nd Soccer June 25th -29th Soccer July 9th 13th Flag Football July 16th - 20th Flag Football July 23rd -27th Basketball July 30th -August 3rd Basketball Fees: Day Camp Add On $ 45 per week $40 Program Individual membership/ $80 Program Family Membership For more information contact Ray Cruz, Program Director, at rcruz@sevymca.org Conejo Valley YMCA 4031 Moorpark Rd. Thousand Oaks, CA 91360 Call (805) 523 7613 or visit our website www.sevymca.org The YMCA of Southeast Ventura County is not affiliated with or Moorpark Unified or C.V.U.S.D Tax I.D. 95-2305501