New Horizons Fall Break Day Camp 2023

Options	Rates	Dates of Care	Due Date for Payment
*Daily	$50 per day	Any day(s): October 9, 10, 11, 12 or 13	September 29, 2023
Weekly	$250	October 9, 10, 11, 12 & 13	September 25, 2023

*NOTE: for daily drop-ins -child must be pre-registered online with required documentation. $25 registration fee is waived for returning campers. YMCA membership required.

2023 Fall New Horizons Camp Application

October 9-13, 2023; 6:30 am - 5:30 pm

"*" indicates required fields

YMCA Membership Verfication

I/We are YMCA member:*

YMCA General Membership is a one-time lifetime payment of $50.00 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

You must have a current YMCA Lifetime membership for your household in order to enroll in YMCA programs. YMCA Membership is $50 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*

Please select dates of attendance, or select all for the full week.

Mon, October 9

Tues, October 10

Wed, October 11

Thurs, October 12

Fri, October 13

Total

Applicant Information

This form will require file uploads of the following items. Please take a moment to gather and image the required documents.

A current portrait photo of your camper
School IEP Plan (if you have one)
Medical Insurance card (first time campers only)
Birth certificate or proof of attendance at any public or private school (first time campers only)

Participant Name*

Age

Child must be 5½ yrs- 13 years old

Date of Birth*

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*

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*

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

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*

Including any food, environmental and medication 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.)

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.

Cost

Camp Cost

YMCA Lifetime Membership

YMCA General Membership is a one-time lifetime payment of $50.00 which covers all household members.

Price:

Application Fee

$25 application processing fee for first time campers only

Price:

Total Cost

We will contact you for payment after review and confirmation of your application. Tuition must be paid in full prior to start of camp. Payment options available.

Financial Assistance Needed?*

Yes

Please complete the Financial Assistance Request form. Financial Assistance Form

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

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, 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

New Horizons Fall Break Day Camp 2023

2023 Fall New Horizons Camp Application

YMCA Membership Verfication

Applicant Information

Parental Contacts

Medical

Releases & Waivers

YMCA COMMITMENT:

Cost

Child Care Connection

Camp Information

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