New Horizons Winter Break Day Camp 2023/2024

Options	Rates	Dates of Care	Due Date for Payment
*Daily	$50 per day	Any day(s): December 22, 26, 27, 28, 29, 2023; January 2, 3, 4 or 5, 2024	December 11, 2023
Week 1	$250	December 22, 26, 27, 28, 29, 2023	December 1, 2023
Week 2	$200	January 2, 3, 4, 5, 2024	December 12, 2023
Weeks 1 & 2	$450	December 22, 26, 27, 28, 29, 2023, January 2, 3, 4, 5, 2024	December 1, 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 Winter New Horizons Camp Application

December 22, 2023 - January 5, 2024; 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.

Week 1: Dec 22, 26, 27, 28, 29

Week 2: Jan 2, 3, 4, 5

Fri. Dec 22

Tues. Dec 26

Wed. Dec 27

Thurs. Dec 28

Fri. Dec 29

Tues. Jan 20

Wed. Jan 3

Thurs. Jan 4

Fri. Jan 5

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*

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.)

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

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.

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

Child Care Connection Application Requirements*

**NOTICE** If you are seeking funds from the Child Care Connection (CCC) Program through DHS, all CCC applications must be signed by the YMCA 60 days prior to the start of camp. The YMCA will not sign CCC applications after 60 days prior to the start of camp.

I will bring my completed CCC application to the YMCA

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*

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.

New Horizons Winter Break Day Camp 2023/2024

2023 Winter 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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