2023 Fall New Horizons Camp Application October 9-13, 2023; 6:30 am - 5:30 pm "*" indicates required fields YMCA Membership VerficationI/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 No 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 Deselect AllTotal Applicant InformationThis 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 AgeChild must be 5½ yrs- 13 years oldDate of Birth* MM slash DD slash YYYY Current Grade* School* IEP/504*Individual Education Plan, please upload a copy if Yes Yes No 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 StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Camper Lives with:* Mother Father Grandparents Legal Guardian(s) Foster Other Situation Camper Living situationIf living with "other" please describe camper living arrangements Parental ContactsMother Name* First M.I. Last Mother Email* Mother Cell Phone*Mother Work PhoneMother Place of Employment* Father Name First M.I. Last Father Email Father Cell PhoneFather Work PhoneFather Place of Employment MedicalMedical 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 No Allergies*Including any food, environmental and medication allergies. Yes No Allergies InfoMedication* Yes No Medication ListPlease list medicationsDoes the camper have any physical limitations?* Yes No If there are physical limitations please explain:Does the camper have any behavior concerns?* Yes No If there are behavior concerns please explain:Is there anything else that we need to know to best care for your child?* Yes No 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 NameRelationshipCell PhoneWork Phone Add RemoveReleases & WaiversMEDICAL 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 agreeCONTRABAND & SEARCHES*With reasonable suspicion of withheld contraband, the YMCA reserves the right to search child's personal belongings/pockets/backpacks, etc. I agreePHOTO/ 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 agreeEXCURSION 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 agreeREFUND 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 agreeYMCA 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. CostCamp CostYMCA Lifetime MembershipYMCA 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 CostWe 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 No Please complete the Financial Assistance Request form. Financial Assistance FormChild Care ConnectionThe 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 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 YMCAHousehold 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. I understand this application does not guarantee placement into the program.Signature
