Summer Camp2025 Summer New Horizons Camp ApplicationJune 2 – August 1, 2025 6:30am – 5:30pm"*" indicates required fieldsStep 1 of 911%YMCA Membership VerficationI/We are YMCA member:*YMCA General Membership is a one-time lifetime payment of $75.00 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 NoYou must have a current YMCA Lifetime membership for your household in order to enroll in YMCA programs. YMCA Membership is $75 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 CamperSession* Session #1 Session #2 Early Bird #1 Early Bird #2 Specific Day Weekly RateSpecific Day* MM slash DD slash YYYY Specific Week (Mon – Fri)* MM slash DD slash YYYY YMCA Lifetime MembershipYMCA General Membership is a one-time lifetime payment of $75.00 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: Total Applicant InformationParticipant 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 UnsureIEP 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 SituationCamper Living situationIf living with “other” please describe camper living arrangementsParental 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 EmploymentMedicalMedical 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 NoAllergies*Include any food, environmental or medical allergies. Yes NoAllergies InfoMedication* Yes NoMedication ListPlease list medicationsDoes the camper have any physical limitations?* Yes NoIf there are physical limitations please explain:Does the camper have any behavior concerns?* Yes NoIf there are behavior concerns please explain:Is there anything else that we need to know to best care for your child?* Yes NoAdditional care information:Emergency ContactsPlease 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 & 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 agreeSUNSCREEN 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 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 $75.00 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.Payment via Credit Card will include a 3.5% processing fee Financial Assistance Needed?* Yes NoLegal Guardian*Cell Phone*Home PhoneAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Employment* Employed UnemployedCurrent Employer*Occupation*Monthly Salary / Wages / Tips*Hours Worked per Week*Other Sources of IncomeHousehold 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*Max. file size: 128 MB.Last 2 Months of PaystubsMax. file size: 128 MB.Proof of IncomeMax. file size: 128 MB.Previous Year Tax ReturnMax. file size: 128 MB.Verification of DHS Assistance (If Applicable)Max. file size: 128 MB.Child 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 NoChild 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 InformationCamp Hours: 6:30am -5:30 pmBreakfast, Lunch, and 2 snacks includedIf your child requires a special diet, you must provide it. If you bring home lunch please remind child NO SHARINGBring a flask with water daily, refills availableLabel child’s belongings (water flask, backpack, etc.)Child must be potty trainedNo Participation, No PlayJournal Writing, Arts & CraftsOrganized physical activitiesDrama, Cultural dancingCalming EnvironmentLearning Center 1 Hour dailyCursive WritingCurrent 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 certificateProof of attendance at any public or private schoolLetter of acceptance to any public or private schoolParent/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
