CAMP REGISTRATION 2015 - YMCA of Western … Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Challenger British Soccer (Grade 3-8) Week 4 Mad Science (Grade 2-5) Week 3 Week 5 Week

Please read and initial to show approval of the following:

I understand that after the first day of camp all program changes are subjected to a $25 switch fee. I acknowledge that if my camper changes to a specialty camp program, the cost difference must be paid before the change is activated. Campers are not allowed to change programs mid-week. All requests for changes or adding more weeks of enrollment must be submitted by Wednesday of prior week’s change to avoid an additional $10 late change fee.

I am aware that no credit will be issued for vacations, incidental absences, transportation delays, withdrawals or dismissals from camp. If my child is absent and a doctor’s note is provided credit will be issued after the 5th consecutive absence minus a $25 deposit.

Camp TCamp TCamp TCamp T----Shirt Size (please circle) Shirt Size (please circle) Shirt Size (please circle) Shirt Size (please circle) Child sizes: 6-8 10-12 14-16 Adult sizes: S M L XL

Grouping Grouping Grouping Grouping (Requests to group campers must be made by both families.)(Requests to group campers must be made by both families.)(Requests to group campers must be made by both families.)(Requests to group campers must be made by both families.)

Please group my child with _________________________________________

MembershipMembershipMembershipMembership

� I have a valid membership for the YMCA of Freehold/Old Bridge. � I need a YMCA membership. Expiration Date: __________________________________ $30 charged upon registration

Emergency/ Authorized Pick up InformationEmergency/ Authorized Pick up InformationEmergency/ Authorized Pick up InformationEmergency/ Authorized Pick up Information

Name:________________________________________ Home:___________________________ Cell:_______________________ Relationship:__________________________

Name:________________________________________ Home:____________________________ Cell:_____________________ Relationship:___________________________

Please notify the camp director in writing if there is someone who should not be allowed to pick– up your child. If a family member is not permitted to pick-up your camper, a copy of the court order must be forwarded to the Camp Director’s attention. � A copy of a court order is enclosed. A copy of a court order is enclosed. A copy of a court order is enclosed. A copy of a court order is enclosed.

Unauthorized PersoUnauthorized PersoUnauthorized PersoUnauthorized Person(s) name :_____________________________________________ Relationship:___________________________________________n(s) name :_____________________________________________ Relationship:___________________________________________n(s) name :_____________________________________________ Relationship:___________________________________________n(s) name :_____________________________________________ Relationship:___________________________________________

Camp Topanemus Camp Topanemus Camp Topanemus Camp Topanemus 380 Monmouth Road, Millstone, NJ 08510 Phone: 732-294-7727 Fax: 732-294-7808 Email: [email protected]

CAMP REGISTRATION 2015CAMP REGISTRATION 2015CAMP REGISTRATION 2015CAMP REGISTRATION 2015

Camper InformationCamper InformationCamper InformationCamper Information Camper Name:______________________________________________ Gender:__________ Birthdate (mm/dd/yy):_____________________Grade (Sept 2015):___________ Address:____________________________________________________________________ City:_________________________________________ State:___________ Zip:________________

Phone:________________________________________ E-mail (required):_________________________________________________________________

Parent/ Guardian InformationParent/ Guardian InformationParent/ Guardian InformationParent/ Guardian Information

Parent One:______________________________________________Cell #:____________________________________ Work #:_______________________________________________

Employer Name:___________________________________________________________________

Parent Two:______________________________________________ Cell #:____________________________________ Work #:_______________________________________________

Employer Name: _______________________________________________________

Marital Status:_____________________ Camper Lives With: ( ) ( ) ( ) ( ) Mother ( ) ( ) ( ) ( ) Father ( ) ( ) ( ) ( ) Both ( ) ( ) ( ) ( ) Other _________________________________

Camp Topanemus has my permission to involve my child in photos and the YMCA / Camp website for publicity purposes.

I have read and had the opportunity to ask questions, understand and agree to abide by the camp policies including Expulsion Policy, as outlined in

the Online Parent Handbook and give my child permission to participate.

I understand a $25 per week non-refundable deposit is due upon registration. Tuition will be charged two weeks prior to my camper’s attendance. All payments are refundable prior to the date that your camper’s tuition is due, this does not include the $25 per week deposit. After the date your camper’s tuition is due, no tuition will be refundedAfter the date your camper’s tuition is due, no tuition will be refundedAfter the date your camper’s tuition is due, no tuition will be refundedAfter the date your camper’s tuition is due, no tuition will be refunded. Any reduction in weeks attending will result in a credit within the YMCA facilities valid for one year, less a $25 per week deposit.

I understand that I am financially responsible for all payments from my account. If my payment is not honored by my bank or credit card account for any reason, I agree that I am responsible for the payment plus a $25 service fee applied by the Camp. This is in addition to any service fee that my bank or credit card may charge.

I understand that my child(ren)’s participation in all camp activities is dependent on full-time enrollment and weather.

2016 COMING SOON

Please circle the days that you would like you child to attend. If attending 5 dayPlease circle the days that you would like you child to attend. If attending 5 dayPlease circle the days that you would like you child to attend. If attending 5 dayPlease circle the days that you would like you child to attend. If attending 5 dayssss mark with an X.mark with an X.mark with an X.mark with an X.

WeeksWeeksWeeksWeeks

5 5 5 5 DayDayDayDay Mohawk/Cayuga Mohawk/Cayuga Mohawk/Cayuga Mohawk/Cayuga

$310$310$310$310 5 5 5 5 Day SenecaDay SenecaDay SenecaDay Seneca

$3$3$3$325252525 (WK 9 Seneca is $310)

4 Day 4 Day 4 Day 4 Day Mohawk/Cayuga Mohawk/Cayuga Mohawk/Cayuga Mohawk/Cayuga

$290$290$290$290 4 Day Seneca 4 Day Seneca 4 Day Seneca 4 Day Seneca

$305$305$305$305 (Cayuga & Seneca -Monday must

be an enrollment day) (WK 9 Seneca is $290)

3 Day 3 Day 3 Day 3 Day Mohawk/Cayuga Mohawk/Cayuga Mohawk/Cayuga Mohawk/Cayuga

$230$230$230$230 3 Day Seneca 3 Day Seneca 3 Day Seneca 3 Day Seneca

$26$26$26$261111 (Cayuga & Seneca -Monday must

be an enrollment day) (WK 9 Seneca is $230)

Week 1 (6/22-6/26)

M T W R F

M T W R F

Week 2 (6/29-7/03)

M T W R F

M T W R F

Week 3 (7/06-7/10)

M T W R F

M T W R F

Week 4 (7/13-7/17)

M T W R F

M T W R F

Week 5 (7/20-7/24)

M T W R F

M T W R F

Week 6 (7/27-7/31)

M T W R F

M T W R F

Week 7 (8/03-8/07)

M T W R F

M T W R F

Week 8 (8/10-8/14)

M T W R F

M T W R F

Week 9 (8/17-8/21)

M T W R F

M T W R F

Please check off the weeks your child will be attending:Please check off the weeks your child will be attending:Please check off the weeks your child will be attending:Please check off the weeks your child will be attending:

Magic Camp (Grade 3-8) (Magic Bag of Tricks - $35.00)

Week1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8

Challenger British Soccer (Grade 3-8)

Week 4

Mad Science (Grade 2-5)

Week 3 Week 5 Week 7

Sports Agility (Grade 3-5)

Week 6 Technology Camp (M-R,

remain at camp on Fri)

Week 4 (Grade 3-5) Week 7 (Grades 6-8)

Traditional Day CampsTraditional Day CampsTraditional Day CampsTraditional Day Camps Mohawk (Grade KMohawk (Grade KMohawk (Grade KMohawk (Grade K----2), Cayuga (Grade 32), Cayuga (Grade 32), Cayuga (Grade 32), Cayuga (Grade 3----5) & 5) & 5) & 5) &

Seneca (Grade 6Seneca (Grade 6Seneca (Grade 6Seneca (Grade 6----8, Seneca includes 1 day trip every Thursday)8, Seneca includes 1 day trip every Thursday)8, Seneca includes 1 day trip every Thursday)8, Seneca includes 1 day trip every Thursday) Options:Options:Options:Options:

Travel Camp (Grade 6Travel Camp (Grade 6Travel Camp (Grade 6Travel Camp (Grade 6----9) 9) 9) 9) (Campers Travel Tues, Weds, Thurs, Fri & remain at Camp on Mon)

5 days only 5 days only 5 days only 5 days only ---- $$$$400400400400

Week 1 (6/22-6/26) Week 2 (6/29-7/03) Week 3 (7/06-7/10) Week 4 (7/13-7/17)

Week 5 (7/20-7/24) Week 6 (7/27-7/31) Week 7 (8/03-8/07) Week 8 (8/10-8/14)

Leadership Training (Grade 9Leadership Training (Grade 9Leadership Training (Grade 9Leadership Training (Grade 9----10) (includes a trip every 10) (includes a trip every 10) (includes a trip every 10) (includes a trip every TuesdayTuesdayTuesdayTuesday))))

Week 1 thru Week 8 - $2,300

Tuition includes 1 trip per week and transportation. Leadership is a full 8 wk program. Separate application must be completed and returned along with 3

references, which can be downloaded from the camp website.

Specialty Camps (5 Day only)Specialty Camps (5 Day only)Specialty Camps (5 Day only)Specialty Camps (5 Day only) ** Weekly Tuition $330 **

2016 COMING SOON

Please check all appropriate boxes.Please check all appropriate boxes.Please check all appropriate boxes.Please check all appropriate boxes.

WeeksWeeksWeeksWeeks

Bus AM Only Bus AM Only Bus AM Only Bus AM Only (per week)(per week)(per week)(per week)

3 day3 day3 day3 day---- $$$$12121212 4 day4 day4 day4 day---- $$$$16161616 5 day 5 day 5 day 5 day ---- $20$20$20$20

Bus PM Only Bus PM Only Bus PM Only Bus PM Only (per week)(per week)(per week)(per week)

3 day3 day3 day3 day---- $$$$12121212 4 day4 day4 day4 day---- $$$$16161616 5 day 5 day 5 day 5 day ---- $$$$20202020

LuLuLuLunchnchnchnch $6 per day$6 per day$6 per day$6 per day

Week 1 3 day 4 day 5 day

3 day 4 day 5 day

M T W R F


3 day 4 day 5 day

M T W R Cook out


3 day 4 day 5 day

M T W R F


3 day 4 day 5 day

M T W R F Week 5 3 day 4 day 5 day

3 day 4 day 5 day

M T R F Week 6 3 day 4 day 5 day

3 day 4 day 5 day


3 day 4 day 5 day


3 day 4 day 5 day

M T W R F Week 9 (only Freehold Bus (only Freehold Bus (only Freehold Bus (only Freehold Bus AvailableAvailableAvailableAvailable

3 day 4 day 5 day

3 day 4 day 5 day

M T W R F

WeeksWeeksWeeksWeeks CampCampCampCamp AM OnlyAM OnlyAM OnlyAM Only (per week)(per week)(per week)(per week)

3 3 3 3 daydaydayday---- $39 4 day$39 4 day$39 4 day$39 4 day---- $52$52$52$52 5 day 5 day 5 day 5 day ---- $65$65$65$65

Camp PM OnlyCamp PM OnlyCamp PM OnlyCamp PM Only (per week)(per week)(per week)(per week)

3 day3 day3 day3 day---- $39$39$39$39 4 day4 day4 day4 day---- $52$52$52$52 5 day 5 day 5 day 5 day ---- $65$65$65$65

FFFFreehold AM onlyreehold AM onlyreehold AM onlyreehold AM only (Per Week (Per Week (Per Week (Per Week Transportation included)Transportation included)Transportation included)Transportation included)


FFFFreehold PM onlyreehold PM onlyreehold PM onlyreehold PM only (Per Week (Per Week (Per Week (Per Week Transportation included)Transportation included)Transportation included)Transportation included)



3 day 4 day 5 day

3 day 4 day 5 day

3 day 4 day 5 day


3 day 4 day 5 day

3 day 4 day 5 day

3 day 4 day 5 day


3 day 4 day 5 day

3 day 4 day 5 day

3 day 4 day 5 day


3 day 4 day 5 day

3 day 4 day 5 day

3 day 4 day 5 day


3 day 4 day 5 day

3 day 4 day 5 day

3 day 4 day 5 day


3 day 4 day 5 day

3 day 4 day 5 day

3 day 4 day 5 day


3 day 4 day 5 day

3 day 4 day 5 day

3 day 4 day 5 day


3 day 4 day 5 day

3 day 4 day 5 day

3 day 4 day 5 day

Week 9 (only Freehold (only Freehold (only Freehold (only Freehold Bus availableBus availableBus availableBus available

3 day 4 day 5 day

3 day 4 day 5 day

3 day 4 day 5 day

3 day 4 day 5 day

A valid credit card must be on file in order to register for camp. If your camper incurs any incidental charges during camp sA valid credit card must be on file in order to register for camp. If your camper incurs any incidental charges during camp sA valid credit card must be on file in order to register for camp. If your camper incurs any incidental charges during camp sA valid credit card must be on file in order to register for camp. If your camper incurs any incidental charges during camp season eason eason eason (lunch, canteen, etc), we have the right to charge your credit card for any and all su(lunch, canteen, etc), we have the right to charge your credit card for any and all su(lunch, canteen, etc), we have the right to charge your credit card for any and all su(lunch, canteen, etc), we have the right to charge your credit card for any and all such expenses. ch expenses. ch expenses. ch expenses. M I elect to leave a deposit, and understand that my credit card will be charged the tuitions balance two weeks prior to the camper’s attendance of the enrollment week.

M I am eligible for a 5% sibling discount on traditional day camp only. M I elect to pay in full upon registration and receive a 5% discount on traditional camps only. (offer expires 5/4/15) (can be combined with sibling discount)

M I am eligible for a 10% After School Care discount if registered 4 or more weeks of traditional day camp only.

Payment: Check Visa Mastercard American Express Discover Payment: Check Visa Mastercard American Express Discover Payment: Check Visa Mastercard American Express Discover Payment: Check Visa Mastercard American Express Discover Name on Card: ______________________________________________________________ Credit Card #: ________________________________________________________________

Expiration Date:____________________

I have read and agree to the terms of payment and understand the refund policy.

Transportation and Lunch OptionsTransportation and Lunch OptionsTransportation and Lunch OptionsTransportation and Lunch Options

Extended CareExtended CareExtended CareExtended Care

Parent Transport (NO FEE) Parent Transport (NO FEE) Parent Transport (NO FEE) Parent Transport (NO FEE)

Transportation Information:Transportation Information:Transportation Information:Transportation Information: Bus # _____________________ Stop # ___________________________________Bus # _____________________ Stop # ___________________________________Bus # _____________________ Stop # ___________________________________Bus # _____________________ Stop # ___________________________________ (Please refer to bus schedule on website for bus and stop #)

Authorization to Walk Home from Bus Stop Authorization to Walk Home from Bus Stop Authorization to Walk Home from Bus Stop Authorization to Walk Home from Bus Stop I GIVE_____/ DO NOT_____ give my camper permission to walk home from their designated bus stop. I understand that if my child is under the age of ten (10) that a parent, legal guardian, or designated authorized pick-up MUST be at the bus stop 15 minutes prior to the bus’MUST be at the bus stop 15 minutes prior to the bus’MUST be at the bus stop 15 minutes prior to the bus’MUST be at the bus stop 15 minutes prior to the bus’ scheduled return.scheduled return.scheduled return.scheduled return.

Cook Out

2016 COMING SOON

Signature:________________________________________________________________________ Date:____________________________________________

Health HistoryHealth HistoryHealth HistoryHealth History

Camper Name:_________________________________________________________ Gender:__________________ DOB:__________________ Age:____________ Grade in Sept:________________

Address:_______________________________________________________________________ City:_________________________________________ State:______________ Zip:______________________

Home Phone:_________________________________________

Parent Name:______________________________________________ Cell Phone:____________________________________________ Work Phone:__________________________________________

Parent Name:______________________________________________ Cell Phone:____________________________________________ Work Phone:__________________________________________

Medical History (Required by the New Jersey Department of Health & Safety)

Doctor Name:____________________________________________________________________ Phone Number:__________________________________________________

Insurance Carrier:______________________________________________ Policy #:__________________________________________________________

Immunization History: Please record the date (month and year) of the basic immunizations and most recent booster. If you have any questions, check with your doctor. Physician’s signature is NOT required unless your child needs to be administered medication. Dates are required either filled in or attached.

DBT Booster:_____________ Tetanus Booster:______________ Polio OPV (Sabin):________________ MMR:________________

Pertussis:_______________ HBV:____________________ HIB:___________________ HIB:___________________

HIB:_______________ Varicella:___________________ Tuberculin Test:_____________ Result:_____________

Date of last medical exam:__________________________

Food Allergies: _______________________________________________________________________________________________________________________________________________________________________

Medication Allergies:________________________________________________________________________________________________________________________________________________________________

Does the child carry an asthma inhaler?______________________________________________ Will you be sending an Epipen to camp?______________________________________

Operations or serious injuries (dates):__________________________________________________________________________________________________________________________________________

Chronic or recurring illness including seizure:_________________________________________________________________________________________________________________________________

List all medications that your child is currently taking:_____________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________

Please list any additional health history information we should be aware of:_________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________

Parent Authorization: This health history is correct and complete. The camper described in this form has permission to engage in all camp

activities unless otherwise noted. I hereby grant permission to YMCA Camp Topanemus to provide routine health care, administer prescribed

medications and seek emergency treatment if necessary. In the event that I cannot be reached in an emergency, I hereby grant Camp Topanemus

to secure and administer treatment.

Signature of Parent/Guardian:__________________________________________________________ Date:___________________________________________

Medication Permission Form:

I hereby request the following medication to be given to my child at the prescribed time and dosage by the camp’s Registered Nurse. This applies to over-the-counter medication. No medication will be given unless the information below is filled out in detail and signed by a licensed physician. All medication is to be brought to camp in the original contained labeled by the pharmacy. Medications must be delivered to the camp office by an adult. All medications will be kept in locked storage area. Medications will be returned only to the parent.

Medication: __________________________________ Dosage:________________________________ Specific Time:___________________________ Diagnosis:________________________

Medication: __________________________________ Dosage:________________________________ Specific Time:___________________________ Diagnosis:________________________

A physician is to sign this form if medication will be administered to your camper.

Physician Signature:__________________________________________________ Printed Name:______________________________________________ Date:________________________________

Parent Signature:____________________________________________________ Printed Name:______________________________________________ Date:________________________________

Please check if you would like to be contacted by our inclusion coordinator.

2016 COMING SOON

Responsible Camper Conduct Agreement

This form must be completed for each camper. Each This form must be completed for each camper. Each This form must be completed for each camper. Each This form must be completed for each camper. Each camper must sign his or her own name.camper must sign his or her own name.camper must sign his or her own name.camper must sign his or her own name.

The YMCA seeks to provide fun, safe and satisfying experiences for everyone. It is our policy that you, the camper, in turn accept responsibility for your own personal conduct. Specifically, you must agree to abide by the following rules:

1. I agree not to bring with me:

Any items which are considered inappropriate, or contribute to vandalism/graffiti. Weapons of any kind. 2. I will respect my fellow campers and counselors 3 I will stay with my group at all times. 4. I will cooperate with staff and participate in camp activities. 5. I will wear appropriate attire, based upon the Director’s discretion, at all times. 6. I will not borrow without asking. 7. I understand if I break any of the above rules, the YMCA will notify my parents, and send me home immediately. 8. I also understand that my parents will be expected to pick me up, and that no fee refund will be issued. 9. I will not use my mobile phone during camp, and if I have to bring it with me I will leave it turned off and in my bag out of site at all times.

Bullying Policy Agreement

As defined by the New Jersey Coalition for Bullying Awareness and Prevention, “Bullying is an act or threat that is unprovoked, repeated, aggressive, intended to cause fear, distress, harm, may be physical, verbal, or psychological in nature or combination, and maybe bias/ prejudice.” “Acts of bullying may include name-calling, slurs, epithets, put-downs, taunts, teasing, bodily harm, hitting, kicking, tripping, shoving, taking or damaging personal property, saying/ writing inappropriate things, starting rumors, public humiliation, deliberate exclusion, and coerced actions.” (New Jersey Coalition for Bullying Awareness and Prevention.) Any camper observed bullying another camper or campers will have their parents notified along with the camper or campers being bullied by the YMCA Camp Director. If the problem persists the YMCA of Western Monmouth County may remove the camper who has committed the act or acts of bullying from camp. Our signatures below indicate that we have read, understand and agree to abide

by the above rules and consequences. ___________________________________________________ __________________________ Camper Date _____________________________________________________ __________________________ Parent Date

2016 COMING SOON

THE YMCA OF WESTERN MONMOUTH COUNTY

RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT

IN CONSIDERATION of being permitted to utilize the facilities, services and programs of the YMCA (or for my children to so

participate) for any purpose, including, but not limited to observation or use of facilities or equipment, participation in any off-

site program affiliated with the YMCA, the undersigned, for himself or herself and such participating children and any personal

representatives, heirs and next of kin, hereby acknowledged, agrees and represents that he or she has, or immediately upon

entering or participating will, inspect and carefully consider such premises and facilities or the affiliated program. It is further

warranted that such entry into the YMCA for observation or use of any facilities or equipment of participation in such affiliated

program constitutes an acknowledgement that such premises and all facilities and equipment thereon and such affiliated

program have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and

reasonably suited for the purpose of such observation, use or participation by the undersigned and such children.

IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO

OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY OFF-SITE PROGRAM AFFILIATED WITH THE

YMCA, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:

1. THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE THE YMCA, its directors,

officers, employees and agents (hereinafter referred to as “releasees”) from all liability to the undersigned, his personal

representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefore on account

of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the

releasees or otherwise while the undersigned is in, upon, or about the premises or any facilities or equipment therein,

or participating in any program affiliated with the YMCA, without respect to location.

2.THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees and each of them

from any loss, liability, damage, or cost they may incur due to the presence of the undersigned in, upon, or about the

YMCA premises or in any way observing or using any facilities or equipment of the YMCA of participating in any program

affiliated with the YMCA whether caused by the negligence of the releasees or otherwise.

3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH, OR PROPERTY

DAMAGE due to negligence or releasees or otherwise while in, about, or upon the premises of the YMCA and/or while

using the premises or any facilities or equipment thereon or participating in any program affiliated with the YMCA.

THE UNDERSIGNED further expressly agrees that the forgoing RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be

as broad and inclusive as is permitted by the law of the State of New Jersey and that if any portion thereof is held invalid, it is

agreed that the balance shall, notwithstanding, continue in full legal force and effect.

THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT,

and further agrees that no oral representations, statements, or inducement apart from the foregoing written agreement have

been made.

____________ ______________________________ ________________________

Date Signature (parent/guardian if under 18) Print Name

________________________________________________

Participant’s Name (Child)

2016 COMING SOON

MCA of Western Monmouth County

Freehold YMCA Branch, 470 East Freehold Road, Freehold, NJ 07728

Parent Statement of Understanding The following information is important for the safety and protection of your child. Please read the information, sign this form, and return the original to the YMCA of Western Monmouth County. A copy will be filed with your child’s records.

I understand that YMCA staff and volunteers are not allowed to baby-sit or transport children at any time outside the YMCA program. If a violation is discovered, the YMCA will take immediate disciplinary action toward staff and/or volunteers. I understand that staff and volunteers are not allowed to initiate contact with members and program participants outside the YMCA, unless necessary in certain limited cases for the smooth operation of a YMCA program. If deemed necessary, contact should be made with the program participant’s parent or guardian. Contact includes, but is not limited to, sharing of phone numbers, email addresses, personal websites and/or web logs. If a violation is discovered, the YMCA will take immediate disciplinary action toward staff and/or volunteers. I understand that I am not to leave my child* at the YMCA or program site unless a YMCA staff or volunteer is there to receive and supervise my child. I understand that my child must be escorted to and from the program area by me or another person on my authorized list. Children may not just be dropped off at the door. *Note: The YMCA’s policy is that children under the age of 9 may not be alone in our facilities/program sites. I understand children should not receive excessive gifts (e.g., toys, video games, jewelry) from YMCA staff or volunteers, and I should report this to a supervisor if they do. I understand that my child will not be allowed to leave the program with an unauthorized person. Any person authorized to pick up my child, including relatives, must be listed with the YMCA and must be of the age required by this YMCA. Any other alternate pick-up arrangements must be made in writing by a parent/guardian. Phone notification of an alternate pick-up arrangement is only accepted in an emergency. I understand that should a person arrive to pick up my child who appears to be under the influence of drugs or alcohol, for the child’s safety, staff may have no recourse but to contact the police. Please do not put staff in a position where they have to make this judgment call. I understand that I can help ensure my child’s safety by taking an active interest in his or her YMCA experience. I too will monitor volunteer and staff interactions with my child and ask my child specific questions about program activities and volunteer or staff relationships with my child. I understand that the YMCA is mandated by state law to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation.

Parent or Guardian Signature Parent or Guardian Name (Please Print)

Program Participant’s Name Program Participant’s Name


2016 COMING SOON

YMCA of Western Monmouth County Freehold YMCA Branch, 470 East Freehold Road, Freehold, NJ 07728

Parent Statement of Understanding The following information is important for the safety and protection of your child. Please read the information, sign this form, and return the original to the YMCA of Western Monmouth County. A copy will be filed with your child’s records. I understand that YMCA staff and volunteers are not allowed to baby-sit or transport children at any time outside the YMCA program. If a violation is discovered, the YMCA will take immediate disciplinary action toward staff and/or volunteers. I understand that staff and volunteers are not allowed to initiate contact with members and program participants outside the YMCA, unless necessary in certain limited cases for the smooth operation of a YMCA program. If deemed necessary, contact should be made with the program participant’s parent or guardian. Contact includes, but is not limited to, sharing of phone numbers, email addresses, personal websites and/or web logs. If a violation is discovered, the YMCA will take immediate disciplinary action toward staff and/or volunteers. I understand that I am not to leave my child* at the YMCA or program site unless a YMCA staff or volunteer is there to receive and supervise my child. I understand that my child must be escorted to and from the program area by me or another person on my authorized list. Children may not just be dropped off at the door. *Note: The YMCA’s policy is that children under the age of 9 may not be alone in our facilities/program sites. I understand children should not receive excessive gifts (e.g., toys, video games, jewelry) from YMCA staff or volunteers, and I should report this to a supervisor if they do. I understand that my child will not be allowed to leave the program with an unauthorized person. Any person authorized to pick up my child, including relatives, must be listed with the YMCA and must be of the age required by this YMCA. Any other alternate pick-up arrangements must be made in writing by a parent/guardian. Phone notification of an alternate pick-up arrangement is only accepted in an emergency. I understand that should a person arrive to pick up my child who appears to be under the influence of drugs or alcohol, for the child’s safety, staff may have no recourse but to contact the police. Please do not put staff in a position where they have to make this judgment call. I understand that I can help ensure my child’s safety by taking an active interest in his or her YMCA experience. I too will monitor volunteer and staff interactions with my child and ask my child specific questions about program activities and volunteer or staff relationships with my child. I understand that the YMCA is mandated by state law to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation.

Parent or Guardian Signature Parent or Guardian Name (Please Print)



Date

2016 COMING SOON

2016 COMING SOON

2015201520152015 Camp Topanemus Lunch Menu ScheduleCamp Topanemus Lunch Menu ScheduleCamp Topanemus Lunch Menu ScheduleCamp Topanemus Lunch Menu Schedule

Monday Tuesday Wednesday Thursday Friday

Week 1 6/22-6/26

Chicken Fingers & Fries

Grilled Cheese

Mac and Cheese

Buttered Noodles

Pizza

Week 2 6/29-7/03


Grilled Cheese

Mac and Cheese

Pizza

CAMP COOKOUT!

Week 3 7/06-7/10


Grilled Cheese

Mac and Cheese

Buttered Noodles

Pizza

Week 4 7/13-7/17


Grilled Cheese

Mac and Cheese

Buttered Noodles

Pizza

Week 5 7/20-7/24


Grilled Cheese

CAMP COOKOUT!

Buttered Noodles

Pizza

Week 6 7/27-7/31


Grilled Cheese

Mac and Cheese

Buttered Noodles

Pizza

Week 7 8/03-8/07


Grilled Cheese

Mac and Cheese

Buttered Noodles

Pizza

Week 8 8/10-8/14


Grilled Cheese

Mac and Cheese

Buttered Noodles

Pizza

Week 9 8/17-8/21


Grilled Cheese

Mac and Cheese

Buttered Noodles

Pizza

Lunch is $6.00 and your Lunch is $6.00 and your Lunch is $6.00 and your Lunch is $6.00 and your selection should be reflected on the application.selection should be reflected on the application.selection should be reflected on the application.selection should be reflected on the application.

2016 COMING SOON

2012012012015555 Travel CampTravel CampTravel CampTravel Camp ScheduleScheduleScheduleSchedule

Monday Tuesday Wednesday Thursday Friday

Week 1 6/22-6/26

Camp Camp Camp Camp DayDayDayDay

Colonial Bowling

Six Flags Great Adventure

Sahara Sam’s Indoor Water Park

Dave and Busters

Week 2 6/29-7/03


AMC Movies Menlo Park

Hopewell Quarry

Point Pleasant Beach

Philly Duck Tours

Week 3 7/06-7/10


Combat Sports Laser Tag

The Funplex

Belmar Beach

Seaside Heights Pedals N Paddles

Week 4 7/13-7/17


Island Beach State Park

WNBA NY Liberty

Clementon Park

Breakwater Beach

Week 5 7/20-7/24


Hopewell Quarry

Indoor Roller Skating

Keansburg Amusement & Water Park

Monmouth County Fair

Week 6 7/27-7/31


Blue Claws Baseball Game

River Belle

Colonial Bowling

Turtle Back Zoo

Week 7 8/03-8/07


Sahara Sam’s Indoor Water Park

Medieval Times

Combat Sports Laser Tag

Yestercades Arcade

Week 8 8/10-8/14


NBC Studio Tour

Powerhouse Studios

Hurricane Harbor

IPLAY America

All trips are subject to change without notice Updated 5-11-15

2016 COMING SOON

2016 COMING SOON

Documents

CAMP REGISTRATION 2015 - YMCA of Western … Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Challenger British Soccer (Grade 3-8) Week 4 Mad Science (Grade 2-5) Week 3 Week 5 Week