2023 Summer Camp Forms

Please have forms completed before the first day of camp.

Child #1 Name Child #1 Name * First Last
Child #1 age as of June 20, 2023 *
List camps for child #1 *
Child #2 Name Child #2 Name First Last
Child #2 age as of June 20, 2023
List camps for child #2
Child #3 Name Child #3 Name First Last
Child #3 age as of June 20, 2023
List camps for child #3
Child #4 Name Child #4 Name First Last
Child #4 age as of June 20, 2023
List camps for child #4
PARENT / GUARDIAN INFORMATION
Parent #1 Name Parent #1 Name * First Last
Parent #1 Email *
Parent #1 Cell Phone Parent #1 Cell Phone * - ### - ### ####
Parent #1 Work Phone Parent #1 Work Phone * - ### - ### ####
Parent #1 Home Phone Parent #1 Home Phone - ### - ### ####
Parent #2 Name Parent #2 Name First Last
Parent #2 Cell Phone Parent #2 Cell Phone - ### - ### ####
Parent #2 Work Phone Parent #2 Work Phone - ### - ### ####
Parent #2 Home Phone Parent #2 Home Phone - ### - ### ####
Please list any special medical information (conditions, allergies, medications being taken, etc...) for EACH child. If none, please write "NONE" in the box. *
EMERGENCY CONTACTS
Emergency Contact #1 Name Emergency Contact #1 Name * First Last
Emergency Contact #1 Relationship to Child(ren) *
Emergency Contact #1 Primary Phone Number Emergency Contact #1 Primary Phone Number * - ### - ### ####
Emergency Contact #1 Secondary Phone Number Emergency Contact #1 Secondary Phone Number - ### - ### ####
Emergency Contact #2 Name Emergency Contact #2 Name * First Last
Emergency Contact #2 Relationship to Child(ren) *
Emergency Contact #2 Primary Phone Number Emergency Contact #2 Primary Phone Number * - ### - ### ####
Emergency Contact #2 Secondary Phone Number Emergency Contact #2 Secondary Phone Number - ### - ### ####
PHYSICIAN / HOSPITAL / INSURANCE INFORMATION
Child(ren)'s Physician Name Child(ren)'s Physician Name * First Last
Child(ren)'s Physician Phone Number Child(ren)'s Physician Phone Number * - ### - ### ####
Preferred Hospital *
Medical Insurance Carrier *
Medical Insurance Policy Number *
Medical Insurance Phone Number Medical Insurance Phone Number * - ### - ### ####
AUTHORIZED PICK-UP LIST

The following people should be allowed to pick-up my child(ren)
Authorized Pick-up Person #1 Authorized Pick-up Person #1 First Last
Authorized Pick-up Person #2 Authorized Pick-up Person #2 First Last
Authorized Pick-up Person #3 Authorized Pick-up Person #3 First Last
Authorized Pick-up Person #4 Authorized Pick-up Person #4 First Last
Authorized Pick-up Person #5 Authorized Pick-up Person #5 First Last
UNAUTHORIZED PICK-UP LIST

The following people should NOT be allowed to pick-up my child(ren)
Unauthorized Person #1 Unauthorized Person #1 First Last
Unauthorized Person #2 Unauthorized Person #2 First Last
PARENTAL / GUARDIAN PERMISSIONS
I grant child #1 permission to leave a YCS program on their own at the end of or during the program. *

I grant child #1 permission to leave a YCS program on their own at the end of or during the program. I grant permission for child #1 to walk home alone. I grant permission for child #1 to bike home alone. I grant permission for child #1 to take the bus home. Other Other
Any special instructions to YCS staff regarding child #1 leaving a program:
I grant child #2 permission to leave a YCS program on their own at the end of or during the program.

I grant child #2 permission to leave a YCS program on their own at the end of or during the program. I grant permission for child #2 to walk home alone. I grant permission for child #2 to bike home alone. I grant permission for child #2 to take the bus home. Other Other
Any special instructions to YCS staff regarding child #2 leaving a program:
I grant child #3 permission to leave a YCS program on their own at the end of or during the program.

I grant child #3 permission to leave a YCS program on their own at the end of or during the program. I grant permission for child #3 to walk home alone. I grant permission for child #3 to bike home alone. I grant permission for child #3 to take the bus home. Other Other
Any special instructions to YCS staff regarding child #3 leaving a program:
YCS SUNSCREEN POLICY

1. YCS does not provide sunscreen for participants as it is a medication and some participants may have allergies to some ingredients in certain sunscreens. Each participant needs to bring his or her own. If a camper does not have their own sunscreen they will not be allowed to participate in outside activities.

2. Participants should arrive at programs with a thick base coat of sunscreen already applied, especially in hard to reach areas, such as their backs.

3. Staff will remind participants regularly to reapply sunscreen every 2 hours: 10 am, 12 pm and 2 pm.

4. We encourage campers to wear hats to protect their heads and shirts to protect their backs. This is especially important if your child has sun sensitivities.

REMINDER FOR PARENTS:
Please apply the first application of sunscreen at home. Sunscreen should be supplied by you, the parent.

I understand that selecting “yes” allows YCS staff to apply sunscreen to my child and if my child does not have sunscreen on they will not be able to participate in outdoor camp activities.
Do you want child #1 wearing sunscreen while outdoors? *

Do you want child #1 wearing sunscreen while outdoors? Yes No Other Other
Do you want child #2 wearing sunscreen while outdoors?

Do you want child #2 wearing sunscreen while outdoors? Yes No Other Other
Do you want child #3 wearing sunscreen while outdoors?

Do you want child #3 wearing sunscreen while outdoors? Yes No Other Other
Permission to Administer Medication

While medication should ideally be administered at home, we recognize that it is sometimes necessary for a participant to receive medication during the program. In this event, the following procedures will be followed:

1. All medications (prescribed and over-the-counter) and a signed copy of this authorization form must be deposited with Program Staff.

2. The participant must be instructed at home or by the family physician to self-administer the medication in the presence of the program staff.

3. Medication must be in an unbreakable container labeled with the participant’s name, content, dosage, and time to be administered. Medication sent to the program should not exceed the dosage for one program day.

4. Medication will be kept in a secure location and provided to your child at the appropriate time. If necessary, a program staff member will assist your child with removal of a childproof cap, but will not administer the medication. All medication brought on field trips will be kept in the possession of the Program Instructor.
Name of Medication
Reason for Medication
Are there any side effects that staff should be aware of?
Dosage and time(s) to be given
I hereby request the Yarmouth Community Services’ staff to provide the above medication at the time(s) indicated for my child to self-administer. I am aware that this medication will be dispensed by non-medical, recreation personnel. I hereby agree to release and hold the Yarmouth Community Services, its agents and employees harmless from any and all claims, including negligence, which may arise as a result of the administering of the medication.

Draw your signature into the box below.

Clear

2023 Summer Camp Forms

2023 Summer Camp Forms

PARENT / GUARDIAN INFORMATION

EMERGENCY CONTACTS

PHYSICIAN / HOSPITAL / INSURANCE INFORMATION

AUTHORIZED PICK-UP LIST

UNAUTHORIZED PICK-UP LIST

PARENTAL / GUARDIAN PERMISSIONS

YCS SUNSCREEN POLICY

Permission to Administer Medication