Camp Wewa Winter 2017/Spring 2018 RegistrationCAMPER'S INFORMATIONFirst Name:*Middle Initial:Last Name:*Gender:*BOYGIRLDOB:* Age*Grade:*Are you a Y Member?*YESNOIf YES, what is your YMCA Member Number?*T-Shirt Size:*YSYMYLASAMALAXLAddress* Street: City: State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip: Cabin Mate Request:(2 per camper guaranteed, must be less than one calendar year difference in age, will try to accommodate all other requests)Authorized Parties able to pick up my camper:*PARENT/GUARDIAN'S INFORMATIONName:*Cell Phone:*Employer:*Work Phone:*Email* Legal Guardian?*YESNOAddress (if different than above):EMERGENCY CONTACTS:Authorization to release child from program:*If NO, documentation must be provided at time of registration.Mother:YESNOFather:YESNOEMERGENCY CONTACTS:*Name:Relationship:Phone: PLEASE CHECK THE SESSION(S) YOU ARE REGISTERING FOR. Winter Break CampWHENDecember 31st 2017- January 5th 2018COSTMember Cost: $695Non-Member Cost: $765 Spring Break 2018 CampWHENMarch 18th - 23rd, 2018COSTMember Cost: $695Non-Member Cost: $765Refunds/Charges & Cancellations Policy: All balances for all sessions must be paid in full at the time of registration. All cancellations must be made at least 2 weeks prior to the start of camp. Any changes made after that day will forfeit all camp fees. A one time session transfer is allowed 2 weeks prior to the start of camp and subject to a $25 processing fee.*** IMPORTANT ***All changes and cancellations must be made by Email. "Responsible Party" will be accountable for the balance of their session if they do not follow the cancellation policy stated on previous page. If you have any questions call the camp office at 407-886-1240 or email email@example.com.I UNDERSTAND I WILL NEED TO COMPLETE THE 4 PAGE HEALTH HISTORY FORM AND RETURN BY FRIDAY DECEMBER 15th, 2017; FRIDAY MARCH 2nd, 2018 FOR SPRING CAMP.I hereby state that my child is physically and mentally capable of safe participation in YMCA activities. I understand and expressly acknowledge that participation at camp is a privilege, and I release the Central Florida YMCA, its agents, contract services, servants, and employees from all liability for any injury, illness, loss or damage connected in any way to my child's participation in YMCA activities, whether on or off YMCA premises. I agree to have my child examined within one year of attendance prior to the camp session attending by a licensed physician stating that he/she is free from communicable disease and has not been exposed to such. Health History forms, Physical Examination and Immunization records are required, and are due by December 15th, 2017 or March, 2nd, 2018. I also agree to have the camp staff perform a general health check of my camper at the time of arrival.I hereby give permission to the camp to provide routine health care, administer prescribed medications and medications according to Standing Orders by a licensed physician, and seek emergency medical treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for insurance purposes. I give permission to the camp to arrange necessary related transportation from me/my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips out of camp. The Central Florida YMCA reserve the right to remove any camper who, according to the Director’s discretion, is judged detrimental to the general welfare of the camp, program, staff and/or other campers. I give my permission to the Central Florida YMCA to use, without limitation or obligation, photographs, film footage, or tape recording which may include my/my child's image or voice for the purposes of promoting or interpreting Central Florida YMCA programs. The right is reserved to search any camper’s belongings, according to the Director’s discretion, when reasonable information is available that illegal substances and/or objects (according to the Parent Handbook and/or that may cause harm to self or others) may be present. No refunds or prorates will be given.Accommodation Clause:The YMCA of Central Florida will provide reasonable accommodation to students with disabilities, provided these accommodations do not pose undue hardship on the organization or jeopardize the safety of other students or employees. Management reserves the right to make all program-related decisions on reasonable accommodations.The YMCA of Central Florida’s goal is to be as inclusive as possible in providing recreational opportunities for all youth. By enrolling your child in the program, you agree your child is physically fit, has the skill level required to participate, is able to use restroom facilities with minimal assistance, and is able to eat meals and snacks unassisted. If there are questions regarding your child’s ability to participate in the program, the YMCA of Central Florida may require an individualized assessment. Please note that we are not able to provide one-on-one supervision of your child.I have read and understand the Parent Handbook. I understand and agree to abide by the policies stated within.(Please contact the camp office for a copy)Camp Fee Information:I understand that all campers are required to pay a $25 one-time, non-refundable registration fee. YMCA Camp Wewa must receive an application, camp selection form, and payment in order to register a camper for any sessions. Payment in full for all fees and balances due is required at time of registration. Failure to pay full balances due in a timely manner will result in the release of my reservation and forfeiture of program registration. A one-time session transfer is allowed, and any additional transfers may require a $25 processing fee. Cancellations made prior to two weeks ahead of program date are eligible for a full refund of fees paid, not to include the registration fee. Cancellations made within 2 weeks of session start date will result in the loss of all fees paid. I also understand no credits are given for late arrival, missed days, or early departure for any camp sessions.Responsible Party Signature:*Date* YMCA Mission: The purpose of this Association is to improve lives of all in Central Florida by connecting individuals, families and communities with opportunities based on Christian values that strengthen Spirit, Mind and Body.NameThis field is for validation purposes and should be left unchanged.