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YMCA FAIRFAX COUNTY RESTON

SUMMER CAMP REGISTRATION FORM

To reserve your child's summer camp experience, please note that you are required to

 Please review the Parent Handbook that is available at https://www.ymcadc.org/summer-camp-registration-forms/, which contains important information, policies and procedures related to camp and all Y Youth Development programs.

The YMCA seeks to make its’ services available to all persons regardless of their ability to pay. Please call your Y for details regarding the financial assistance / scholarship application procedures. Financial aid is awarded to applicants in need as funds are available through the support of generous donors. 

 Each year, donors that support the “Send a Kid to Camp” campaign ensure that every child in your area has access to a quality summer camp experience, regardless of financial ability. If you wish to make a contribution to the YMCA 2024 Send a Kid to Camp campaign, you may do so by clicking here: https://www.ymcadc.org/support-the-y/give/send-a-kid-to-camp/  

PARTICIPANT WAIVER FORM

ACKNOWLEDGEMENT

I expressly acknowledge that there are certain dangers, risks, illnesses and personal injuries inherent in participating in the YMCA’s programs, events, classes, and/or other activities, which may result from unavoidable accidents or injuries, athletic activities, sports programs/classes, the use of any equipment, exercise, or other activities or from my or my minor child(ren)’s or ward(s)’ physical condition. I understand that the YMCA and its employees, agents, counselors, teachers, trainers, representatives, successors and assigns assume no responsibility for loss, damage, illness or injury to person or property that I or my minor child(ren) or ward(s), if applicable, may sustain as a result of my or their physical condition or resulting from my or their participation in any activities, programs, events, classes, the use or non-use of any equipment, exercise, horseback riding, archery, field trips, waterfront and pool activities, canoeing/boating, campfires, hiking, high ropes and other challenge courses, or any other activities, classes, events, or programs at and/or sponsored by the YMCA. I expressly acknowledge, on behalf of myself and my minor child(ren) and ward(s), heirs and executors, that I voluntarily assume the sole risk for any and all dangers, illnesses and personal injuries that may result from my or my minor child(ren)’s or ward(s)’ participation in any events/activities/programs/classes while at the YMCA and/or sponsored by the YMCA.

I also acknowledge that the YMCA often uses photographs, videotapes, television programs, motion pictures, tape recordings, or other similar media for promotional purposes. I hereby consent to the use of my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es) in such materials to be exhibited and used for advertising, trade purposes, solicitation of patronage, promotional purposes, or other similar purposes, even if my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es) are an integral part of such photograph, videotape, television program, motion picture, tape recording, or other similar media.Copy and paste the body of your waiver here.

RELEASE

In consideration of the YMCA allowing me and/or my minor child(ren) or ward(s) to attend and/or participate in any programs, events, classes, or other activities at the YMCA and/or sponsored by the YMCA, I hereby, for myself, my minor child(ren) or ward(s), heirs, and executors, waive, release and forever discharge the YMCA and its employees, agents, counselors, teachers, trainers, representatives, successors and assigns, from and against any and all rights and claims for any loss, damage, illness or injuries to person or property sustained as a result of my attendance and/or participation in any such programs, events, classes, and other activities, whether or not such loss, damage or injury results from the negligence of the YMCA and its employees, agents, or representatives or from some other cause. My agreement to release the YMCA does not include any loss, damage or injury that results from the YMCA's gross negligence or willful, wanton, or reckless misconduct.

 I further waive any and all rights to inspect or approve the photograph, videotape, television program, motion picture, tape recording or other use of my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es), including any written article, script, caption or other writing that may accompany such use of my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es). I hereby, for myself, my minor child(ren) or ward(s), heirs, and executors, waive, release and forever discharge the YMCA and its employees, agents, counselors, teachers, trainers, representatives, successors and assigns, from and against any and all liability, claims, losses, costs, expenses or damages for libel, slander, invasion of privacy, conversion, defamation, appropriation of likeness or any other claim based on the use of my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es) in any such materials.


INDEMNIFICATION

I hereby represent and warrant to the YMCA that I have the authority to execute this Participant Waiver Form on behalf of myself and/or on behalf of my minor child(ren) or ward(s) as parent, guardian and/or next friend, if applicable. In the event of any misrepresentation or breach of the foregoing warranty by me, or in the event that I, my minor child(ren) or ward(s), or any other person nevertheless asserts any claim against the YMCA arising out of my or my minor child(ren)’s or ward(s)’ participation in any program, event, class or other activity as set forth herein, I agree to indemnify, hold harmless and defend the YMCA from and against any and all liability, claims, losses, costs, expenses or damages resulting therefrom, including, but not limited to, claims of loss, damage, illness or injury to person or property whether or not such loss, damage, illness or injury results from the negligence of the YMCA or from some other cause.


ACCEPTANCE

I expressly acknowledge and agree to the terms and conditions set forth on this Participant Waiver Form.

November 21, 2024


PERMISSION FOR MEDICAL CARE AND PAYMENT

I give the YMCA of Metropolitan Washington permission for my child to be given cardiopulmonary resuscitation (CPR) and first aid treatment by a certified staff member of the YMCA of Metropolitan Washington. I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I authorize the YMCA of Metropolitan Washington to obtain immediate medical care and give consent to the hospitalization and performance of necessary diagnostic tests upon, the use of surgery on, and/or the administration of drugs to his/her child or ward if an emergency occurs when he/she cannot be located immediately. It is also understood that this agreement may only cover those situations which are true emergencies and only when he/she cannot be reached. I understand that the provider will take every effort to contact me and/or my designated emergency contacts. 

I/we will be responsible for payment of medical expenses. Medical treatment costs are covered by the medical insurance provider and policy I have listed on this form.

I Agree


PARENTAL AGREEMENT

  1. The YMCA agrees to notify the parent/guardian whenever the child becomes ill and the parent/guardian will arrange to have the child picked up as soon as possible if requested by the YMCA.
  2. The parent/guardian agrees to inform the YMCA within 24 hours or the next business day after his child or any members of the immediate household has developed a reportable communicable disease, as defined by the State Board of Health, except for life-threatening diseases which must be reported immediately. 
  3. My child has permission to be transported by a YMCA vehicle and to participate in all YMCA program activities and related field trips.
  4. My child has permission to participate in YMCA swimming activities.
  5. The parent / guardian authorizes the application of sunscreen and / or insect repellent for his/her child by YMCA staff. 
  6. I am aware that the parent handbook is available for review at https://www.ymcadc.org/summer-camp-registration-forms/ and understand that it is my responsibility to read and understand/be aware of ALL policies, and agree to all blanket permission forms and opt out requests, as outlined in the parent handbook. 

I Agree

CANCELLATION POLICY

I understand and agree that

  • A non-refundable deposit of $75 will be collected at time of enrollment. Families can pay for camp fees in full at time of enrollment; however, the $75 deposit is non-refundable should a family cancel.
  • Cancellations within 6 weeks before camp date, families forfeit 25% of camp fees in addition to camp deposit.
  • Cancellations within 4 weeks before camp date, families forfeit 50% of camp fees in addition to camp deposit.
  • Cancellations within 3 weeks before start of camp week or after, families forfeit all camp fees.
  • Families can request for a 100% credit to be applied on their YMCA Metropolitan Washington account for future enrollment at any YMCA Metropolitan Washington branch, including Youth Services or Membership (credits are valid for one year from date of cancellation and are non-refundable once issued as a credit to the family YMCA Membership account).

I Agree


YMCA MEMBERSHIP REQUIREMENT

I understand that campers are required to have an active YMCA membership (or be part of an active YMCA family membership) and that there are different membership types available. Membership status must be active throughout camp on either the qualifying annual or month-to-month membership option. Financial assistance is available for families/campers in need.

I Agree

All information on this form is true and complete to the best of my knowledge. I understand and agree to the Emergency Medical Authorization and the six (6) Parental Agreements, and cancellation policy outlined above.  

November 21, 2024

First Participant's Name

First Name*

Middle Name

Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Parent / Guardian's Contact Information

Full Name of Parent / Guardian #1 *

Cell/Phone number of Parent / Guardian #1 *

Home Address of Parent / Guardian #1 *

Place of Employment for Parent / Guardian #1 (if not applicable, type N/A) *

Work Phone Number for Parent / Guardian #1 (If not applicable, type N/A) *

Full Name of Parent / Guardian #2 *

Cell/Phone number of Parent / Guardian #2

Home Address of Parent / Guardian #2 *

Place of Employment for Parent / Guardian #2 (if not applicable, type N/A)

Work Phone Number for Parent / Guardian #2 (If not applicable, type N/A) *
PICK-UP / DROP-OFF PERMISSIONS

Full name of person(s) authorized to pick-up your child *

Relationship *

Phone Number of Individual Authorized for Child Pick-Up. *

Full name of an additional person authorized to pick-up your child. *

Relationship *

Phone Number of Individual Authorized for Child Pick-Up. *

Full name of any person NOT AUTHORIZED to pick-up your child. If this is not applicable, please list "n/a". If this is applicable, please list the full name and provide documentation. *

Relationship (enter "n/a" if not applicable). *

Full name of any additional person NOT AUTHORIZED to pick-up your child. If this is not applicable, please list "n/a". If this is applicable, please list the full name and provide documentation. *

Relationship (enter "n/a" if not applicable). *
MEDICAL INFORMATION

Your child's care and safety are critical to the YMCA. Please carefully complete the following information to the best of your knowledge. For any question that is required but not applicable to your child, please enter "n/a".

If the YMCA camp is to administer medications during the day, either emergency or routine, please complete the medication authorization section of this form. You are required to complete separate forms to authorize the YMCA to administer specific medications to your child, including use of epi-pen and/or inhalers. The link to these forms will be included in your summer camp registration confirmation email and also accessible at https://www.ymcadc.org/summer-camp-registration-forms/.  

if there are any special accommodations that need to be made for your child, please complete the inclusion section of this form. 


Please list any allergies or intolerance to food, medication or any other substance here. *

If an allergic reaction occurs, please enter details / list steps to relieve reaction.

Please enter any chronic physical, behavioral or psychological problems, pertinent developmental information, and any special accommodations needed here. If this is applicable to your child, please note that you are required to complete the inclusion section of this form.

Please list any medications or vitamins your child takes on doctor’s orders here.
For campers residing in the United States (or US territory or DC); is the child exempt from any immunizations?*

If YES, please specify.

Child’s Physician and Office Name: *

Physician’s Phone: *

PLEASE NOTE: MD CAMPERS: Who reside outside of the US, a US Territory or DC, must attach Department form DHMH-896 (vaccination record or immunity).  VA CAMPERS: Who are exempt from immunizations, must submit either a “Certification of Religious Exemption” or a MCH213B or MCH213C form that states one or more of the required immunizations may be detrimental to the child’s health.  ALL OTHERS attending camp in DC or VA must submit a physical and immunization record as outlined above. 

SUNSCREEN / INSECT REPELLANT
Do you request YMCA staff to help your child apply the sunscreen and insect repellent that you provide, as needed? If you answer YES below, you thereby also agree to release, indemnify, and hold harmless the YMCA and any of their staff members, or directors from lawsuits, claims, expenses, demands, or actions against them for helping your child to apply or use the sunscreen and insect repellent that you have provided.*
Yes
No

Please list the brand of sunscreen to be administered here.

Please list the brand of insect repellant to be administered here.
SWIM ASSESSMENT

Some YMCA camps includes swimming or a water day activity. Please indicate your child's swim ability below if this is applicable to the camp experience you have selected for your child. If this is not applicable to the camp experience you have selected, please list "n/a".  

Please select the description that best matches your child's ability to swim.*
BEFORE / AFTER CAMP CARE
Does your child require care before the start of day camp each day? *
Does your child require care after 4pm? As some YMCA camps run to 4pm and others run to 5pm each day, please select "YES" if this applies to your child. *
INCLUSION

The YMCA of Metropolitan Washington is committed to living out our value of inclusiveness, which guarantees non-discrimination and equal access for all in our programs, services, and activities, and will provide reasonable accommodations upon request. This form must be completed by parents / guardians of children enrolled in camp with any chronic physical, behavioral or psychological problems to provide the YMCA with pertinent developmental information and to request any special accommodations needed. If this is applicable to your child, please note that you are required to complete the information requested in this section of the camp registration form.  If this is not applicable to your child, please skip this section. If you need to complete an inclusion form for multiple children, please email member.service@ymcadc.org.

Inclusion information for children with special needs must be provided at the time registration and directly to the child’s Camp Director on the first day of each camp. All parents / guardians of children with special needs or developmental disabilities must consult with camp staff prior to camp before registration can be considered complete.  The YMCA will make accommodations to the fullest extent possible based on available resources. One-on-one assistance is not guaranteed. If applicable, parents / guardians must submit Medication Authorization Forms for any medications (including OTC medications, Epi-pens, insulin or foods that treat medical conditions) that parents / guardians authorize the Y to administer. 



Name of child

Age of child

Describe the characteristics of your child's special needs

What type of support do you feel your child needs?

Does your child have any "triggers" the YMCA staff should be aware of?

Are there any special concerns that YMCA staff should be aware of?

Do you have any tips or suggestions to share with the YMCA to address special concerns?

Does the child have any favorite books, toys, or "security" items that would be appropriate to send to camp (must be approved by the camp director)?

Does the child exhibit severe emotional or physical reactions?

When should YMCA staff call the parent/guardian? Please note that parents/legal guardians will always be called if the child requires medical attention.
Does the child require medications?

Please list other pertinent information or concerns.
MEDICATION AUTHORIZATION

Please indicate your authorization for the YMCA to administer the following medications to your child, if needed. For any medication question below that you answer "YES", you must complete a separate authorization form that can be found at https://www.ymcadc.org/summer-camp-registration-forms/.  

I authorize the YMCA to administer specific medications to my child during camp and will complete the required Medication Authorization Form.*
Yes
No
I authorize the YMCA to administer an epi-pen to my child, if needed, and will complete the required Epi-Pen Authorization Form. *
Yes
No
I authorize the YMCA to administer an inhaler to my child, if needed, and will complete the required Inhaler Authorization Form.*
Yes
No
Additional Emergency Contact

Please note that TWO emergency contacts that are not a parent/guardian are required.


#1 Emergency Contact Name (not a parent/guardian) *

#1 Emergency Contact Address *

#1 Emergency Contact Cell/Phone Number *

#2 Emergency Contact Name (not a parent/guardian) *

#2 Emergency Contact Address *

#2 Emergency Contact Cell/Phone Number *
Insurance

Insurance Carrier*

Insurance Policy Number*
How did you hear about YMCA summer camp?

We'd like to know how you learned about this summer camp opportunity for your child at the YMCA. Thanks for sharing.

How did you hear about us? Please select all that apply. *
Returning camper / we have participated before
A friend recommended the Y camp to us
We received information in the mail
We picked up information at the Y
We visited the YMCA website
We saw an ad online (social media or other)
We saw the Y's camp signs in the area
Other
SUMMER CAMP REGISTRATION

As a reminder to all parents/guardians, to complete the process of reserving your child's summer camp experience at the YMCA, the following steps must be completed

(1) Purchase the camp experience online or at the YMCA branch / Program Center location. To purchase online, visit https://www.ymcadc.org/programs/camps/day-camp/and select Day Camp or Resident Camp. Select your camp location and desired camp experience. You will then be brought to the EZ to Enroll platform where you can complete the purchase. A receipt will be delivered to you via email when the purchase is complete.

(2) Complete and submit your YMCA Summer Camp Registration Form. When you have provided all of the required information on this form and click submit, you will have successfully completed and submitted the YMCA Summer Camp Registration form. You will then receive an email that contains a link to a copy of this completed form that you can download for your records (must complete within 36-hours of submitting the form).

(3) Complete any additional forms listed for your jurisdiction, as applicable. A complete list of all required and optional forms for camps in DC, MD and VA can be found at  https://www.ymcadc.org/summer-camp-registration-forms/

Have you purchased your child’s camp experience online (EZ to Enroll) or at the branch/program center? If your answer is NO, please know that your child's summer camp registration is not complete until you have made this purchase. To purchase online, visit https://www.ymcadc.org/programs/camps/day-camp/ and select Day Camp or Resident Camp. Select your camp location and desired camp experience. You will then be brought to the EZ to Enroll platform where you can complete the purchase. A receipt will be delivered to you via email when the purchase is complete. Please email member.service@ymcadc.org for assistance.*
Yes
No
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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