2026 Fall Break Day Camp Application

YMCA Membership Verfication

I/We are YMCA member:*

YMCA General Membership is a one-time lifetime payment of $100.00 which covers all household members. It is not willable; non-refundable. Minors who are ward of the State in foster care/guardianship shall establish individual YMCA membership. This will allow the YMCA membership to follow the minor should they transfer foster care/parents. Register online or call 808-935-3721 to check on YMCA General Membership.

Yes

No

You must have a current YMCA Lifetime membership for your household in order to enroll in YMCA programs. YMCA Membership is $100 for lifetime and covers all family members in your household. To become a YMCA member, enroll online, click here

After you have your YMCA membership, please continue to complete the application for the camp application below. YMCA membership does not guarantee acceptance into YMCA camp and summer programs.

Returning Camper*

Has this participant attended camp at Island of Hawaii YMCA before?

Yes, Returning Camper

No, First Time Camper

Session*

Full Camp (Oct 5-9)

Specific Day

Specific Day*

YMCA Lifetime Membership

YMCA General Membership is a one-time lifetime payment of $100.00 which covers all household members.

Price:

Application Fee

$25 application processing fee for first time campers only

Price:

Water Bottle Fee*

Mandatory water bottle fee. Your child will receive a bottle of water DAILY upon arrival. Refills are provided throughout the day.

Price:

Water Bottle Fee*

Mandatory water bottle fee. Your child will receive a bottle of water DAILY upon arrival. Refills are provided throughout the day.

Price:

Camp Cost

Total

Camper Lives with:*

Camper Living situation

If living with “other” please describe camper living arrangements

Parental Contacts

Mother Name*

Mother Email*

Mother Cell Phone*

Mother Work Phone

Mother Place of Employment*

Father Name

Father Email

Father Cell Phone

Father Work Phone

Father Place of Employment

Emergency Contacts

Please list at least 2 contacts. (IN ADDITION TO THE PARENTS/ LEGAL GUARDIANS, I AUTHORIZE ONLY THE FOLLOWING PEOPLE TO PICK UP MY CHILD AND/ OR IN AN EMERGENCY, BE CONTACTED IF THE PARENT/ LEGAL GUARDIAN CAN’T BE CONTACTED.)

Contact 1 Full Name*

Relationship*

Cell Phone*

Work Phone*

Contact 2 Full Name*

Relationship*

Cell Phone*

Work Phone*

Releases & Waivers

YMCA COMMITMENT:

Upon review and approval of your application, the YMCA will reserve your child’s spot in camp and guarantee childcare once payment and Y membership is established.

Financial Assistance Needed?*

Yes

No

Legal Guardian*

Cell Phone*

Home Phone

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employment*

Employed

Unemployed

Current Employer*

Occupation*

Monthly Salary / Wages / Tips*

Hours Worked per Week*

Other Sources of Income

Household Size*

If unemployed, please explain how you support yourself financially.*

If unemployed and receiving unemployment insurance compensation, when does this end?*

How much are you able to afford?*

Is there anything else we need to know about your financial situation?

Personal Statement of Hardship (Optional)

Driver's License or State ID*

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 6 MB.

Last 2 Months of Paystubs

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 6 MB.

Proof of Income

jpg, jpeg, png, pdf

Max. file size: 6 MB.

Previous Year Tax Return

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 6 MB.

Verification of DHS Assistance (If Applicable)

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 6 MB.

Child Care Connection

The State of Hawaii Child Care Connection Hawaii (CCCH) subsidy program helps low-income families to sustain their employment, educational efforts and job training by paying a subsidy for their children who are in the care of DHS-approved child care providers. Visit the DOHS site for more information on criteria and application.

Are you eligible for Child Care Connection?*

Please understand that we must receive payment before childcare is given. It is up to you to provide verification for the Child Care Connection Program. All CCC applications must be signed by the YMCA 60 days prior to the start of camp.

Yes

No

Household Income Size (Optional)

FOR STATISTICAL & GRANT APPLICATION PURPOSES ONLY. (NOTE: YOUR HOUSEHOLD INCOME BRACKET DOES NOT DETERMINE AWARDS FOR FINANCIAL ASSISTANCE.)

Camp Information

Camp Hours: 6:30am -5:30 pm
Breakfast, Lunch, and 2 snacks included
If your child requires a special diet, you must provide it. If you bring home lunch please remind child NO SHARING
Bring a flask with water daily, refills available
Label child’s belongings (water flask, backpack, etc.)
Child must be potty trained

No Participation, No Play
Journal Writing, Arts & Crafts
Organized physical activities
Drama, Cultural dancing
Calming Environment
Learning Center 1 Hour daily
Cursive Writing

Current Photo*

Please provide a current portrait photo of your child.

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 6 MB.

Birth Certificate or Proof of School Enrollment file upload*

Proof of school enrollment includes acceptance letter or a current report card.

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 6 MB.

PLEASE ATTACH ONE OF THE FOLLOWING TO YOUR APPLICATION:

Child’s birth certificate
Proof of attendance at any public or private school
Letter of acceptance to any public or private school

Parent/Guardian Name*

Child's Name*

Submitter's Email*

Signature

YMCA Membership Verfication

Applicant Information

Parental Contacts

Medical

Emergency Contacts

Releases & Waivers

YMCA COMMITMENT:

Child Care Connection

Camp Information