Belle Chasse Day Camp Registration Form - Summer 2014 Please PRINT LEGIBLY & complete one form per camper.
Camper’s Last Name_______________________________________ First Name_______________________________________________ Home Address____________________________________________ City_________________________State_______Zip______________ Home Phone(_____)_______________ YMCA Member: □ Yes □ No □ Male □ Female Birthdate ____/____/______ Age at Camp ______ Fall Grade_____School Attending_____________________________ T-Shirt Size: YouthS
YouthM
YouthL
S M L XL XXL
How did you hear about us? □ Repeat Participant □ Friend □ Flier □ Other__________________________________________________ Primary Contact: □ Either □ Mother □ Father □ Other ________________________________________________________ Mother’s Full Name_________________________________________ Day Phone(____)_____________ Cell Phone(____)_______________ DOB____/____/______ Place of employment____________________ E-mail___________________________________________________ Father’s Full Name_________________________________________ Day Phone(____)_____________ Cell Phone(____)_______________ DOB____/____/______ Place of employment____________________ E-mail___________________________________________________ CHILD RELEASE AUTHORIZATION / EMERGENCY CONTACT OTHER THAN PARENTS / GUARDIANS - MUST HAVE VALID I.D. TO PICK UP Person(s) authorized to pick up child from camp and contact in case of emergency:
Name___________________________________________________ Relationship__________________________ DOB____/____/______
This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed YMCA activities, except as noted by an examining physician and me. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the YMCA staff to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above. I give permission for YMCA staff to render first aid and apply sunscreen. I give permission for my child to be transported in YMCA vehicles by certified YMCA drivers. I hereby request that my child be accepted to attend Belle Chase YMCA Day Camp program. I understand and am aware that my child will be participating in many physical activities and the potential for accidents does exist. In consideration of acceptance to Belle Chasse YMCA Day Camp: I understand that the YMCA of Greater New Orleans will not be responsible for any lost or stolen items while members and/or program participants are using YMCA facilities, on YMCA premises, or on off-site YMCA program locations. I, the undersigned, for myself and my heirs, do hereby indemnify and hold harmless the YMCA of Greater New Orleans and its employees and agents from any and all claims for injury, illness, loss, or damage I, or my child, may suffer as a result of participation, including any injury caused by the negligence, if any, of the YMCA, its officers, employees, agents, volunteers, or the negligence of anyone else. I give my permission to the YMCA of Greater New Orleans to use, for no compensation, photographs, film footage, or tape recordings, which may include my or my child’s image or voice for purposes of promoting or interpreting YMCA programs. The YMCA of Greater New Orleans is founded on Christian principles and prohibits inappropriate behavior and conduct. This includes, but is not limited to, profanity or abusive language, inappropriate attire, smoking, use of alcohol or drugs, the removal of YMCA property, physical harm to another person or threat of such actions, sexually offensive actions, confirmed listing as a registered sex offender, or criminal conduct of any type. Such inappropriate behavior or conduct is unacceptable and will not be tolerated. When the safety of others is threatened a member or anyone on YMCA property may be immediately removed and expelled from all YMCA of Greater New Orleans facilities. Deposits are non-refundable but are transferrable within the 2014 Summer Camp season. Balances must be satisfied one week prior to the intended week of participation. Late fees will be charged in the amount of $10/day that over-due balances exist. No refunds or credits will issued to anyone withdrawing once the first day of the session has begun. Cancellations or transfers must be made in writing one week in advance. Payments can be made by automatic withdraw from the account on file at the YMCA or a separate bank account or credit card. We (parent/guardian and camper) have fully and completely read this Registration Form and both agree to follow the responsibilities described throughout. We have read the parent handbook and agree to abide by the policies of the YMCA of Greater New Orleans. Parent/Guardian Signature_________________________________________________
Day Phone(____)_____________ Cell Phone(____)_______________ Name___________________________________________________ Relationship__________________________ DOB____/____/______
Camper Signature________________________________________________________ Date_______/_______/____________
PAYMENT METHOD
Day Phone(____)_____________ Cell Phone(____)_______________
□ Card on File
Please list any special considerations relevant to your child, such as
□ Bank Account Number_____________Bank Routing Number____________
medications, recent illnesses or injuries, activity restrictions, developmental
□ Credit Card: □ Visa □ MasterCard □ American Express
age, allergies, chronic health concerns, etc.:_________________________
Account Number_________________________________________________
________________________________________________________
Name on Card___________________________________________________
________________________________________________________
Signature_______________________________________________________
________________________________________________________
Exp Date (mo/yr)_________/__________
________________________________________________________
□ We would like to contribute $_________ to the scholarship program to help get kids to camp.
PAYMENT OF:
Please mail, fax or return application & payment to: 8101 Highway 23 ♦ Belle Chasse, LA 70037 Phone: 504.392.9622 Fax: 504.681.6163
Deposit( $20 for each week registered at Belle Chasse) $_________ Non-Member $25 One-TIme Registration Fee $_________ Camper Session Fee(s) $_________ Total $_________ Less enclosed payment -$_________ TOTAL DUE $_________
BELLE CHASSE DAY CAMP SCHEDULE 2014 Belle Chasse Day Camp runs Monday-Friday Note: $20 deposit is due per session upon registration
175
BC
135
175
Teen Day Camp
BC
135
175
Counselor-in-Training (CIT)
BC
165
205
Just Dance! (5-8 yrs. old)
BC
155
195
Maginficent Mess (3-6 yrs. old)
BC
155
195
Imagination Station (5-8 yrs. old)
BC
155
195
Imagination Station (9-12 yrs. old)
BC
155
195
Wacky Sports Camp (9+ yrs. old)
BC
155
195
Bull's-Eye! (9+ yrs. old)
BC
165
205
Week of August 11
135
Week of August 4
BC
Week of July 28
175
Week of July 21
135
Week of July 14
BC
Week of July 7
175
Week of June 30
135
Week of June 23
BC
Week of June 16
175
Week of June 9
Non-Member Price
135
Week of June 2
Member Price
BC
Week of May 26
Location
PLEASE MARK YOUR SELECTIONS
Adventurers (3-4 yrs. old) Day Camp Explorers (5-6 yrs. old) Day Camp Challengers (7-8 yrs. old) Day Camp
. .
Trekkers (9-10 yrs. old) Day Camp Navigators (11-12 yrs. Old) Day Camp Teens
Specialty Camps
Iron Chef Belle Chasse (9+ yrs. old)
BC
165
205
Girls Just Wanna Have Fun (7-12 yrs. old)
BC
165
205
Boys Will Be Boys (7-12 yrs. old)
BC
165
205
Swim Lessons Beginner (Polliwog/Pike)
BC
35
70
Intermediate (Guppy/Ray)
BC
35
70
Camp Hours Before Care Camp Activities
7:00 a.m. - 9:00 a.m. 9:00 a.m. - 5:00 p.m.
After Care
5:00 p.m. - 6:00 p.m.
hristian principles into practice through programs that build a healthy spirit, mind, and body for all.
Save the date for our open houses! Bring the kids to come take a tour, see what camp is all about, and meet the camp team. Saturday, April 26, 2014 - 9:00 -11:00 a.m. Saturday, May 10, 2014 - 1:00 - 3:00 p.m.