Fall Break – 1st Responder Day Camp

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Step 1 of 8

12%

First Responder Verification

This application is only for children of first responders.

Please select parent's first responder occupation:*

Police

Fire

Paramedic

Commitment Fee

Price:

Camp Cost

Total

Applicant Information

Participant Name*

First M.I. Last

Age

Child must be 5½ yrs- 13 years old

Date of Birth*

MM slash DD slash YYYY

Current Grade*

School*

IEP/504*

Individual Education Plan, please upload a copy if Yes

Yes

Unsure

IEP File Upload*

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

Ethnicity*

For statistical and grant application purposes. Please select up to three (3) choices.

Part-Hawaiian

Hawaiian

Asian

White

Part African-American

African-American

Pacific Islander (Micronesian, Polynesia, Samoa, Tahiti, Tonga)

Physical Address*

Street Address Address Line 2 City State ZIP Code

Camper Lives with:*

Mother

Father

Grandparents

Legal Guardian(s)

Foster

Other Situation

Camper Living situation

If living with “other” please describe camper living arrangements

Parental Contacts

Mother Name*

First M.I. Last

Mother Email*

Mother Cell Phone*

Mother Work Phone

Mother Place of Employment*

Father Name

First M.I. Last

Father Email

Father Cell Phone

Father Work Phone

Father Place of Employment

Medical

Medical Insurance*

Policy Number*

Policy Holder*

Medical Insurance Card*

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

Camper's Doctor*

Doctor's Phone*

Preferred Health Care Center*

Has camper received COVID vaccinations?*

Yes

Allergies*

Include any food, environmental or medical allergies.

Yes

Allergies Info

Medication*

Yes

Medication List

Please list medications

Does the camper have any physical limitations?*

Yes

If there are physical limitations please explain:

Does the camper have any behavior concerns?*

Yes

If there are behavior concerns please explain:

Is there anything else that we need to know to best care for your child?*

Yes

Additional care information:

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

MEDICAL RELEASE/WAIVER:*

In the event of a medical emergency if neither the parent/ legal guardian nor emergency contact persons cannot be promptly reached, I hereby authorize the YMCA staff to take my child to the nearest medical facility for care.
INSURANCE DISCLAIMER: IT IS THE MEMBER AND/OR PARTICIPANTS RESPONSIBILITY TO PROVIDE HIS/ HER OWN ACCIDENT AND HEALTH INSURANCE. THE ISLAND OF HAWAII YMCA DOES NOT CARRY HEALTH AND ACCIDENT INSURANCE FOR MEMBERS OR PARTICIPANTS.

I agree

CONTRABAND & SEARCHES*

With reasonable suspicion of withheld contraband, the YMCA reserves the right to search child’s personal belongings/pockets/backpacks, etc.

I agree

PHOTO/ VIDEO RELEASE/ WAIVER:*

The Island of Hawaii YMCA has my permission to use my child’s photograph, video, artwork, profile and/or story and any likeness in any of its publication’s web pages, and other promotional materials produced, used by, and representing the YMCA. I understand that the circulation of the materials could be worldwide and that there will be no compensation to me or my child for this use. This includes photographs, videos, and artwork during program hours as well as special events, camps, and other YMCA related outings outside of regular hours.

I agree

EXCURSION RELEASE WAIVER:*

I hereby give permission for my camper to leave the Island of Hawaii YMCA without a parent/ guardian on all day camp field trips. All campers will be under direct care of camp staff during field trips. By signing below, I give the YMCA permission to travel to the locations of these excursions and allow for my camper to participate at these excursions.

I agree

SUNSCREEN POLICY:*

I understand that it is my responsibility to apply sunscreen to my child before sending my child to the YMCA Day Camp Program on days that I feel my child needs to be protected from the sun. This may or may not include days of planned excursions to beaches or parks. I understand that it is my responsibility to send sunscreen with my child.

I agree

REFUND POLICY:*

REFUND POLICY: NO REFUND ON YMCA GENERAL MEMBERSHIP
Refund may be available 3 workdays before the start of camp. Once camp has begun, NO REFUNDS. A $50.00 processing fee will be assessed, and the remainder may be refunded. The request for a refund must be completed in writing indicating amount paid, child’s name, parent’s name, and reason for cancellation. Refunds will not be honored for enrollment in another program.

I agree

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.

Legal Guardian*

Cell Phone*

Home Phone

Address*

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

Driver's License or State ID*

Accepted file types: jpg, png, gif, pdf, Max. file size: 128 MB.

Household Income Size (Optional)

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

$0 – $24,000

$25,000 – $36,000

$37,000 – $50,000

$51,000 – $74,000

$75,000+

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, png, gif, 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*

Acknowledgement*

Submitting this application does not guarantee acceptance into the program. Please submit all the requested information, we will review your application and contact you.

I understand this application does not guarantee placement into the program.

Signature