CAMP WOW APPLICATION JUNE 21 - AUGUST 20, 2021 - Stamford YMCA
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CAMP WOW
APPLICATION
JUNE 21 – AUGUST 20, 2021
FOR MORE INFORMATION CONTACT
MELODY LAING (SCHOOL AGED CHILD CARE DIRECTOR)
(203) 357-7000 EXT. 9991
MELODY@STAMFORDYMCA.ORG
THE STAMFORD FAMILY YMCA | 10 BELL STREET, STAMFORD, CT 06901 | (203) 357-7000
WWW.STAMFORDYMCA.ORG
SUMMER CAMP MINI, CAMP WOW & TEEN ADVENTURE
PROTOCOLS, POLICIES & PROCEDURES
AS OF JANUARY 18, 2021
We are currently developing our full protocols drawing on resources from the Office of Early Childhood, the
American Camp Association, and the CDC. The following details are preliminary and subject to change. More
information will be available soon. As we continue to monitor all local, state and federal guidelines, as well as
best practices for camps, protocols will evolve and are subject to change
CAMP DATES/SESSIONS: JUNE 21, 2021 – AUGUST 20, 2021
• Session 1 June 21ST– July 2ND
• Session 2 July 6th – July 16th
• Session 3 July 19th – July 30th
• Session 4 August 2nd – August 13th
• Session 4 August 15th – August 20th
CAMP HOURS: 8 AM – 4 PM
There will be a staggered drop-off and pickup schedule with a designated window for each family. Parents
and others dropping off/picking up will need to stay in their vehicle.
AFTER CARE HOURS: 4 PM – 6 PM (Additional Fee)
ACCESS TO CAMP:
This summer our facility will be closed to parents during the camp day.
OUR PROGRAM:
This summer we will run a traditional Camp program only. There will be no afternoon electives or offsite trips.
SPECIALITY CAMPS:
Our Palace theatre classes are canceled for 2021 season. We do have a few special guests who will visit from
museums.
GROUP SIZE:
Campers will be in small groups (no more than 10) with two counselors. We are designing our spaces to
ensure that wherever possible we provide the traditional camp experience in a physically distant
environment.
ACTIVITIES:
Most camp activities will be indoors with limited outings to Mill River Park Nature Walk, all outdoor
activities will consist of only one group at any one activity at a time.
HEALTH SCREENING:
Everyone (campers and staff) will be screened for temperature and symptoms before being allowed into camp
on a daily basis. Any campers or staff members with a temperature over 100 degrees Fahrenheit will not be
permitted to attend camp. Parents and/or caregivers will be required to submit a daily attestation of their child
being healthy and symptom-freeILLNESS AT CAMP:
If anyone exhibits common symptoms of COVID-19 after arriving at camp for the day, they will be moved to our
designated sick-room (separate and apart from the camp health center) while they await a prompt pick-up from
their family. If someone is suspected of or becomes ill with COVID-19, we will immediately report to both state
and local health departments. Under the direction of the health officials, we will communicate with camp
families and staff immediately.
CAMP CLEANLINESS:
The camp will be continuity cleaned and disinfected during the day. The Stamford YMCA maintenance and all
staff will be cleaning bathrooms and other areas through camp constantly. Program areas and equipment will be
disinfected after each use.
HYGIENE:
There will be hand sanitizer throughout the camp. Counselors will assistant campers in cleaning their hands
regularly and will wear gloves if physical contact is needed.
SWIM:
Swim is the fun is part of the YMCA, but so is safety. Where there are YMCA day campers and pools, there are
YMCA lifeguards and counselors. Lifeguards are on the pool deck, and YMCA counselors are in the pools
swimming, splashing and playing games with the campers. Campers will swim twice a week, they must bring their
own towels and goggles. On swim days we suggest campers wear their bathing suit under clothes to facilitate
changing and allow more time in the pool. (The Y will not be providing towel service at this time.)
FOOD:
All Counselors and Campers must wash their hand before and after eating. Groups will be spread out in their
classroom for lunch and snacks. At this time all campers should bring in their own bagged lunches, until
further notice, no drop off will be permitted.
OUR STAFF:
All camp and staff (directors, counselors, specialists, directors) will wear masks at all times. Gloves will be used
when serving water, helping campers with their lunch, and when assisting in with activities.
STAYING FLEIXIBLE:
This is still an evolving situation and we will continue to modify and refine our plans leading up to and possibly
during camp. We pledge to proactively communicate with you as changes to our camp program are made.
CAMP CALENDARS:
The fun dress-up days and special events will continue! The updated Calendars will be available soon.
MORE INFORMATION:
For more information contact Melody Laing, School Aged Child Care Director, melody@stamfordymca.org or
(203) 357-7000 ext. 9991
We hope that you will decide to send your child/ children to the Stamford YMCA Summer Camp. Not only does
the summer experience help children build self- confidence and independence, children also make new friends,
explore and learn new activities. And Although there will be new protocols and restrictions for social distancing
to keep our campers and staff healthy and safe, we feel children now, more than ever, need camp.
We look for seeing your child/ children this summer.
The Stamford Family YMCA | 10 Bell Street, Stamford, CT 06901 | (203) 357-7000For office use only Today’s Date: _____________________________
Group Name: Please print information on form.
______________________________
CAMP REGISTRATION FORM 2021
Child’s Information:
Last Name: _________________________________________________ First Name: ___________________________________________________MI: ___________________________
Nickname: __________________________________________________ Gender: Female Male Birth Date: _________________ Age: ____________
Address: __________________________________________ City: ________________________________________ State: __________________________ Zip: ____________________
Primary Phone #: ___________________________________________________________________________ Stamford YMCA Member: Yes No
List Previous Child Care Center/School: _______________________________________________ Member #: __________________________________________________
School Attending: _________________________ School Phone #: ________________________ Grade during the 2019-2020 Academic Year: _________
Parent(s)/Guardian(s) Information:
Parent/Guardian: __________________________________________________________ Birth Date: __________________________ Relationship: _______________________
Address: __________________________________________ City: _______________________________________ State: ____________________________ Zip: ___________________
Home Phone: ________________________________________ Work Phone: _____________________________________ Cell Phone: ___________________________________
Place of Employment: ______________________________________________________ Business Address: ________________________________________________________
Primary E-mail:
(To receive program updates)
Parent/Guardian: __________________________________________________________ Birth Date: __________________________ Relationship: _______________________
Address: __________________________________________ City: _______________________________________ State: ____________________________ Zip: ___________________
Home Phone: ________________________________________ Work Phone: _____________________________________ Cell Phone: ___________________________________
Place of Employment: ______________________________________________________ Business Address: ________________________________________________________
Primary E-mail:
(To receive program updates)
Person or agency having legal custody: ________________________________________________________________________________________________________________
Address if different from above: _________________________________________________________________________________________________________________________
EMERGENCY CONTACT INFORMATION: (Must list 2; local and other than Parent(s)/Guardian(s) listed above)
First Emergency Contact: _________________________________________________________________ Relationship: _______________________________________________
Home Phone: _______________________________________ Work Phone: ______________________________________ Company Name: _____________________________
Cell Phone: ______________________________________________________________ Alternate Phone: _______________________________________________________________
Address: __________________________________________________ City: __________________________________ State: ______________________________ Zip: ______________
Second Emergency Contact: _________________________________________________________________ Relationship: ___________________________________________
Home Phone: _______________________________________ Work Phone: ______________________________________ Company Name: _____________________________
Cell Phone: ______________________________________________________________ Alternate Phone: _______________________________________________________________
Address: __________________________________________________ City: __________________________________ State: ______________________________ Zip: ______________
Person(s) authorized to PICK-UP your child: _______________________________________________________ Relationship: _________________________________
Person(s) authorized to PICK-UP your child: _______________________________________________________ Relationship: _________________________________
Person(s) NOT authorized to PICK-UP your child: ________________________________________________ Relationship: _________________________________
Person(s) NOT authorized to PICK-UP your child: ________________________________________________ Relationship: _________________________________
Please note: Appropriate paperwork, such as custody papers, must be attached if the custodial parent requests not to release the child to the other parent.Medical Information:
Allergies or intolerance to food, medication, or any other substance:
If an allergic reaction occurs, please list steps to relieve reaction:
Chronic physical problems, pertinent developmental information, any special accommodations needed:
For special accommodations, or to share important information about your camper, please schedule a meeting with the Camp Director.
Does your child take medications or vitamins on doctor’s orders?
Please specify:
Registrants must submit a physical examination or a Youth Camp Exam Record Form completed by the camper’s physician by June 1,
2020.
Physician Name: _________________________________________________________________________________ Physician’s Phone: _____________________________________________________
Emergency Medical Authorization:
I give The Stamford Family YMCA permission to provide my child cardiopulmonary resuscitation (CPR) and first aid treatment by a
certified staff member. I also give permission to transport my child by ambulance, staff vehicle, or YMCA vehicle to an emergency center
for treatment. I authorize the Stamford Family YMCA 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 my child or ward if an
emergency occurs and I cannot be located immediately. It is also understood that this agreement may only cover those situations which
are true emergencies. I understand that the provider will make 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:
Medical Insurance Provider: _________________________________________________________________________ Policy#: ____________________________________________
Parental Agreements:
I give permission for my child, ___________________________ , to attend The Stamford Family YMCA’s summer camp and to participate in all
activities and field trips. I authorize the camp program to use photographs and videos of my child (ren) for the purpose of telling the
program story and promoting the message of the program. I understand that the program is not responsible for the personal property
of the participant (s). In case of an emergency, I understand that every effort will be made to reach the parent (s) or guardian (s) of the
participant (s).
Cancellation Policy:
If fees have been paid and cancellation is made two weeks before the start of camp session, the balance camp session, the balance will be
returned less the deposit. If fees have been paid out but cancellation is made less than two weeks before the start of the camp session, no
refund will be issued.
Swimming Assessment: Non-Swimmer Beginner Intermediate Advanced
(unable to swim/no (some limited swim (average swimming (skilled swimmer)
swim instruction) instruction) ability)
All information on this form is true and complete to the best of my knowledge. I understand and agree to the
Emergency Medical Authorization, Parental Agreements, and Cancellation Policy outlined above.
Parent/Guardian Signature: __________________________________________________________________________________ Date: _______________________________________
STOP! If you are completing an online registration, please sign the participant waiver form, submit required additional forms & STOP HERE.
GO! If you are completing an in-person, mailed, e-mailed, or faxed registration, please CONTINUE TO THE NEXT PAGE as well as
submit required additional forms.Please fill out one form for each camper
Camper Name: __________________________________________________________ Date: _______________________________
2021 CAMP SELECTION & FEES
REGISTRATION SESSION 4
FULL SEASON SESSION 1 SESSION 2 SESSION 3 SESSION 5
FORM June 21 - Aug 20 June 21 - July 2 July 6- July 16 July 19 – July 30 Aug 2 – Aug 13 Aug 16 - Aug 20
Please check all that apply
CAMP MINI
(Kindergarten)
$1,980 $450 $405 $450 $450 $225
Member
Non-Member
$2,398 $490.50 $545 $545 $545 $272.50
CAMP WOW
(First Grade - Fifth Grade)
$1,980 $450 $405 $450 $450 $225
Member
Non-Member $2,398 $490.50 $545 $545 $545 $272.50
TEEN ADVENTURE CAMP
(Sixth Grade -
Eighth Grade)
Member $1,980 $450 $405 $450 $450 $225
Non-Member
$2,398 $490.50 $545 $545 $545 $272.50
CIT PROGRAM
(Ages 15 - 16)
Member
$462 $105 $94.50 $105 $105 $52.50
Non-Member
$682 $155 $139.50 $155 $155 $77.50
EXTENDED CARE OPTIONS
After Care 4:00 PM - 6:00 PM $352 $80 $72 $80 $80 $80
CAMP T-SHIRT INFORMATION TOTAL CAMP FEE:
Circle Size:
EXTENDED HOURS FEE:
Youth XS Youth S Youth M Youth L
Adult S Adult M Adult L Adult XL ADDITIONAL CAMP SHIRT(S):
Camp Shirts are required on every field trip and beach day!
GRAND TOTAL:
Each camper receives 1 camp shirt with registration
Additional camp shirts are $10 each. Would you like to TOTAL FEES PAID AT THIS TIME:
order camp shirts? Yes No
How Many? 1 2 3 4 REMAINING BALANCE DUE:CAMP PAYMENT OPTIONS
YMCA Financial Assistance participants must be authorized BEFORE REGISTERING. For more information call 203-357-
7000 x 1170 or email melody@stamfordymca.org BEFORE registering.
CAMP FEES: Camp fees must be paid in full prior to Monday June 7, 2021. Participant must be an active member to receive
member rates (M) or non-member (NM) rates will apply.
CANCELLATIONS: If fees have been paid and cancellation is made two weeks before the start of camp session, the balance will be
returned less the deposit. If fees have been paid out but cancellation is made less than two weeks before the start of the camp
session no refund will be issued.
ADDS: Additional camp sessions can be added after initial registration by submitting a new camper registration form. However, we
cannot guarantee availability.
PAYMENT OPTIONS: A $250.00 non-refundable deposit fee per camper is due upon registration. Camp fees may be paid in full
upon registration or remaining balance will be automatically drafted per fee schedule below. For drafted balances YOU MUST:
1) Pay the $250.00 non-refundable deposit fee
2) List the dates and amounts you want your remaining camp balance drafted
3) Provide an approved debit or credit card for scheduled balance payment;
4) Receive signed approval from ONLY the Camp Director.
Connecticut Care 4 Kids: If you receive Connecticut Care 4 Kids you MUST pay half of your total camp balance prior to June 14, 2021.
$ _______________________Total Camp Fees $ _________________________ Total Fees Paid At This Time $ _______________________ Balance Due
Payment Method
I have enclosed a check for $ _______________________ Check# _______________________________________________ OR Credit/Debit (check one) VISA MC AMEX DISC
Name on Card: __________________________________________________________________________________________________ Card# _____________________________________________________________________________
Exp. ____________________________________ VCODE _____________________ Signature ______________________________________________________________________ Date ______________________________________
Fee Schedule: By providing my signature below, I authorize the Stamford Family YMCA to charge my credit card on the following dates:
Payment 1: $_____________________________ on _________________________________ Payment 5: $_____________________________ on _________________________________
Payment 2: $_____________________________ on _________________________________ Payment 6: $_____________________________ on _________________________________
Payment 3: $_____________________________ on _________________________________ Payment 7: $_____________________________ on _________________________________
Payment 4: $_____________________________ on _________________________________ Payment 8: $_____________________________ on _________________________________
Total balance remaining balance of $__________________________________________________ paid in full on ______________________________________________________
I/We understand and agree to the above payment terms. I/We understand that completion of all required summer camp forms is a required condition of
participation in summer camp programs.
PARENT/LEGAL GUARDIAN Print Name: __________________________________________________________ Signature: __________________________________________ Date: ___________________________
CAMP DIRECTOR APPROVAL Print Name: ________________________________________________________ Signature: __________________________________________ Date: ____________________________
Summer Camp Registration Checklist:
___ Completed and signed camp registration form
___ Signed payment plan form (if applicable)
___ $250 non-refundable deposit made upon registration
___ A physical examination or a Youth Camp Exam Record Form completed by campers physician
___ Administration of Medication Form or Self Administration Form (must be signed by parent and physician) or you will not be
able to leave medicine at the YMCA
All summer camps fees must be paid by Monday, June 8, 2021. If your child receives Connecticut Care 4 Kids,
you pay your total family fees by Friday, June 18, 2021.
FOR OFFICE USE ONLY:
Accepted By: _________________________________________ Date: _________________ Processed By: ___________________________________ Date: ________________
Group Placement: __________________________________________________________________________________________________________________________________________State of Connecticut Department of Education
Health Assessment Record
To Parent or Guardian: cian assistant, licensed pursuant to chapter 370, a school medical advisor, or
In order to provide the best educational experience, school personnel a legally qualified practitioner of medicine, an advanced practice registered
must understand your child’s health needs. This form requests information nurse or a physician assistant stationed at any military base prior to school
from you (Part I) which will also be helpful to the health care provider when entrance in Connecticut (C.G.S. Secs. 10-204a and 10-206). An immunization
he or she completes the medical evaluation (Part II). update and additional health assessments are required in the 6th or 7th grade
State law requires complete primary immunizations and a health assess- and in the 9th or 10th grade. Specific grade level will be determined by the
ment by a legally qualified practitioner of medicine, an advanced practice local board of education. This form may also be used for health assessments
registered nurse or registered nurse, licensed pursuant to chapter 378, a physi- required every year for students participating on sports teams.
Please print
Student Name (Last, First, Middle) Birth Date ❑ Male ❑ Female
Address (Street, Town and ZIP code)
Parent/Guardian Name (Last, First, Middle) Home Phone Cell Phone
School/Grade Race/Ethnicity ❑ Black, not of Hispanic origin
❑A merican Indian/ ❑ White, not of Hispanic origin
Primary Care Provider Alaskan Native ❑ Asian/Pacific Islander
❑ Hispanic/Latino ❑ Other
Health Insurance Company/Number* or Medicaid/Number*
Does your child have health insurance? Y N If your child does not have health insurance, call 1-877-CT-HUSKY
Does your child have dental insurance? Y N
* If applicable
Part I — To be completed by parent/guardian.
Please answer these health history questions about your child before the physical examination.
Please circle Y if “yes” or N if “no.” Explain all “yes” answers in the space provided below.
Any health concerns Y N Hospitalization or Emergency Room visit Y N Concussion Y N
Allergies to food or bee stings Y N Any broken bones or dislocations Y N Fainting or blacking out Y N
Allergies to medication Y N Any muscle or joint injuries Y N Chest pain Y N
Any other allergies Y N Any neck or back injuries Y N Heart problems Y N
Any daily medications Y N Problems running Y N High blood pressure Y N
Any problems with vision Y N “Mono” (past 1 year) Y N Bleeding more than expected Y N
Uses contacts or glasses Y N Has only 1 kidney or testicle Y N Problems breathing or coughing Y N
Any problems hearing Y N Excessive weight gain/loss Y N Any smoking Y N
Any problems with speech Y N Dental braces, caps, or bridges Y N Asthma treatment (past 3 years) Y N
Family History Seizure treatment (past 2 years) Y N
Any relative ever have a sudden unexplained death (less than 50 years old) Y N Diabetes Y N
Any immediate family members have high cholesterol Y N ADHD/ADD Y N
Please explain all “yes” answers here. For illnesses/injuries/etc., include the year and/or your child’s age at the time.
Is there anything you want to discuss with the school nurse? Y N If yes, explain:
Please list any medications your
child will need to take in school:
All medications taken in school require a separate Medication Authorization Form signed by a health care provider and parent/guardian.
I give permission for release and exchange of information on this form
between the school nurse and health care provider for confidential
use in meeting my child’s health and educational needs in school. Signature of Parent/Guardian Date
HAR-3 REV. 4/2017 To be maintained in the student’s Cumulative School Health RecordPart II — Medical Evaluation HAR-3 REV. 4/2017
Health Care Provider must complete and sign the medical evaluation and physical examination
Student Name Birth Date Date of Exam
❑ I have reviewed the health history information provided in Part I of this form
Physical Exam
Note: *Mandated Screening/Test to be completed by provider under Connecticut State Law
*Height _____ in. / _____% *Weight _____ lbs. / _____% BMI _____ / _____% Pulse _____ *Blood Pressure _____ / _____
Normal Describe Abnormal Ortho Normal Describe Abnormal
Neurologic Neck
HEENT Shoulders
*Gross Dental Arms/Hands
Lymphatic Hips
Heart Knees
Lungs Feet/Ankles
Abdomen *Postural ❑ No spinal ❑ Spine abnormality:
Genitalia/ hernia abnormality ❑ Mild ❑ Moderate
Skin ❑ Marked ❑ Referral made
Screenings
*Vision Screening *Auditory Screening Date
History of Lead level
Type: Right Left Type: Right Left ≥ 5µg/dL ❑ No ❑ Yes
With glasses 20/ 20/ ❑ Pass ❑ Pass *HCT/HGB:
❑ Fail ❑ Fail
Without glasses 20/ 20/ *Speech (school entry only)
❑ Referral made ❑ Referral made Other:
TB: High-risk group? ❑ No ❑ Yes PPD date read: Results: Treatment:
*IMMUNIZATIONS
❑ Up to Date or ❑ Catch-up Schedule: MUST HAVE IMMUNIZATION RECORD ATTACHED
*Chronic Disease Assessment:
Asthma ❑ No ❑ Yes: ❑ Intermittent ❑ Mild Persistent ❑ Moderate Persistent ❑ Severe Persistent ❑ Exercise induced
If yes, please provide a copy of the Asthma Action Plan to School
Anaphylaxis ❑ No ❑ Yes: ❑ Food ❑ Insects ❑ Latex ❑ Unknown source
Allergies If yes, please provide a copy of the Emergency Allergy Plan to School
History of Anaphylaxis ❑ No ❑ Yes Epi Pen required ❑ No ❑ Yes
Diabetes ❑ No ❑ Yes: ❑ Type I ❑ Type II Other Chronic Disease:
Seizures ❑ No ❑ Yes, type:
❑ This student has a developmental, emotional, behavioral or psychiatric condition that may affect his or her educational experience.
Explain: ____________________________________________________________________________________________________
Daily Medications (specify): ____________________________________________________________________________________
This student may: ❑ participate fully in the school program
❑ participate in the school program with the following restriction/adaptation: _____________________________
___________________________________________________________________________________________________________
This student may: ❑ participate fully in athletic activities and competitive sports
❑ participate in athletic activities and competitive sports with the following restriction/adaptation: ____________
___________________________________________________________________________________________________________
❑ Yes ❑ No Based on this comprehensive health history and physical examination, this student has maintained his/her level of wellness.
Is this the student’s medical home? ❑ Yes ❑ No ❑ I would like to discuss information in this report with the school nurse.
Signature of health care provider MD / DO / APRN / PA Date Signed Printed/Stamped Provider Name and Phone NumberStudent Name: ______________________________________ Birth Date: ___________________ HAR-3 REV. 4/2017
Immunization Record
To the Health Care Provider: Please complete and initial below.
Vaccine (Month/Day/Year) Note: *Minimum requirements prior to school enrollment. At subsequent exams, note booster shots only.
Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 Dose 6
DTP/DTaP * * * *
DT/Td
Tdap * Required 7th-12th grade
IPV/OPV * * *
MMR * * Required K-12th grade
Measles * * Required K-12th grade
Mumps * * Required K-12th grade
Rubella * * Required K-12th grade
HIB * PK and K (Students under age 5)
Hep A * * See below for specific grade requirement
Hep B * * * Required PK-12th grade
Varicella * * Required K-12th grade
PCV * PK and K (Students under age 5)
Meningococcal * Required 7th-12th grade
HPV
Flu * PK students 24-59 months old – given annually
Other
Disease Hx ________________________________ ________________________________ ________________________________
of above (Specify) (Date) (Confirmed by)
Exemption: Religious ____________ Medical: Permanent ____________ Temporary ____________ Date: ____________
Renew Date: _____________________ _____________________ _____________________ ____________________
Religious exemption documentation is required upon school enrollment and then renewed at 7th grade entry.
Medical exemptions that are temporary in nature must be renewed annually.
Immunization Requirements for Newly Enrolled Students at Connecticut Schools (as of 8/1/17)
KINDERGARTEN THROUGH GRADE 6 GRADES 7 THROUGH 12 HEPATITIS A VACCINE 2 DOSE
REQUIREMENT PHASE-IN DATES
• DTaP: At least 4 doses, with the final dose on • Tdap/Td: 1 dose of Tdap required for students
or after the 4th birthday; students who start the who completed their primary DTaP series; for • August 1, 2017: Pre-K through 5th grade
series at age 7 or older only need a total of 3 students who start the series at age 7 or older a • August 1, 2018: Pre-K through 6th grade
doses of tetanus-diphtheria containing vaccine. total of 3 doses of tetanus-diphtheria contain- • August 1, 2019: Pre-K through 7th grade
• Polio: At least 3 doses, with the final dose on ing vaccines are required, one of which must • August 1, 2020: Pre-K through 8th grade
or after the 4th birthday. be Tdap. • August 1, 2021: Pre-K through 9th grade
• MMR: 2 doses at least 28 days apart, with the • Polio: At least 3 doses, with the final dose on • August 1, 2022: Pre-K through 10th grade
1st dose on or after the 1st birthday. or after the 4th birthday. • August 1, 2023: Pre-K through 11th grade
• Hib: 1 dose on or after the1st birthday • MMR: 2 doses at least 28 days apart, with the • August 1, 2024: Pre-K through 12th grade
(children 5 years and older do not need proof 1st dose on or after the 1st birthday.
of vaccination). • Meningococcal: 1 dose
** Verification of disease: Confirmation in
• Pneumococcal: 1 dose on or after the 1st • Hep B: 3 doses, with the final dose on or after
writing by an MD, PA, or APRN that the
birthday (children 5 years and older do not 24 weeks of age.
child has a previous history of disease, based
need proof of vaccination). • Varicella: 2 doses, with the 1st dose on or after
on family or medical history.
• Hep A: 2 doses given six months apart, with the 1st birthday or verification of disease.**
the 1st dose on or after the 1st birthday. • Hep A: 2 doses given six months apart, with Note: The Commissioner of Public Health
See “HEPATITIS A VACCINE 2 DOSE the 1st dose on or after the 1st birthday. may issue a temporary waiver to the schedule
REQUIREMENT PHASE-IN DATES” See “HEPATITIS A VACCINE 2 DOSE for active immunization for any vaccine if
column at the right for more specific REQUIREMENT PHASE-IN DATES” the National Centers for Disease Control and
information on grade level and year required. column at the right for more specific Prevention recognizes a nationwide shortage
• Hep B: 3 doses, with the final dose on or after information on grade level and year required. of supply for such vaccine.
24 weeks of age.
• Varicella: 2 doses, with the 1st dose on or after
the1st birthday or verification of disease.**
Initial/Signature of health care provider MD / DO / APRN / PA Date Signed Printed/Stamped Provider Name and Phone NumberYOUTH CAMP HEALTH EXAM/RECORD
FOR CAMPERS AND STAFF
Physical Exams Are Valid For 3 Years
From Date of Last Examination
Camper Please Return Completed Form to the Camp
Staff
Name_____________________________________________ Date of Birth Phone
Guardian Address
Emergency Contact Telephone
Date of Arrival at Camp: _________________________________ Departure Date: ______________________________________________
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
TO BE COMPLETED BY THE HEALTH CARE PROVIDER
Date of Exam ____/____/____
May participate in all camp activities YES NO
May participate except for: ____________________________________________________________________________________
Does the individual have any known medical or emotional illness or disorder that poses a risk to other children or which affects the
individual’s functional ability to participate safely in a youth camp? YES NO
If yes, please explain _________________________________________________________________________________________
___________________________________________________________________________________________________________
Are there any prescription or over the counter medication(s) this individual needs to take while at camp? YES NO
If yes, indicate names of medication(s):___________________________________________________________________________
NOTE: A written authorization and parent permission for the administration of medication at camp are required.
Does the individual have any disabilities or special health care needs such as allergies, special dietary needs? YES NO
If yes, please explain _________________________________________________________________________________________
___________________________________________________________________________________________________________
NOTE: If the camper has a special health care need or disability that requires special care be taken or provided during the time the individual is at camp, an
individual plan of care shall be developed with the parent and health care provider and updated as necessary. The plan shall include appropriate care of the
camper in the event of a medical or other emergency and signed by the parent and staff responsible for the care of the camper.
If camper/staff is school aged or younger, have they been immunized in accordance with the schedule adopted by the Commissioner of
Public Health pursuant to section 19a-7f of the Connecticut General Statutes? YES NO
Additional Comments:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Printed Name of Health Care Provider: ___________________________________________________________________________
Address: ________________________________________________________________ Phone: ____________________________
Signature of Physician, PA, APRN or RN ______________________________________ Date Form Signed: __________________THE STAMFORD FAMILY YMCA
RELEASE AND WAIVER OF LIABILITY AND INDEMNITY
and PHOTO/TALENT RELEASE AGREEMENT
In consideration for being permitted to utilize the facilities, services, and programs of the YMCA for any purpose,
including but not limited to observation or use of facilities or equipment, or participation in any program affiliated
with the YMCA, without respect to location, the undersigned, for himself or herself and any personal representatives,
heirs, and next of kin, hereby acknowledges, 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 or participation in
such affiliated program constitutes an acknowledgement that such premises and all facilities and equipment thereon
and such affiliated programs 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.
The YMCA conducts regular sex offender screenings on all members, participants, and guests. If a sex offender match
occurs, the YMCA reserves the right to cancel membership, end program participation, and remove visitation access.
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 PROGRAM AFFILIATED
WITH THE YMCA, WITHOUT RESPECT TO LOCATION, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING ON
HIS OR HER BEHALF AND/OR BEHALF OF HIS/HER CHILDREN OR GUESTS (herein referred to as “the undersigned”):
1. MEMBER CONDUCT The undersigned agrees to abide by all rules and regulations of the Stamford Family
YMCA (hereafter “YMCA”), and I understand that failure to act in accordance with the rules may result in
expulsion from the YMCA and cancellation of membership.
2. PROPERTY LOSS The undersigned understands that the YMCA is not responsible for personal property lost,
damaged or stolen while using YMCA facilities or participating in YMCA programs.
3. PHOTO/TALENT RELEASE The undersigned irrevocably releases, consent and allow the YMCA and its agents
to use my photograph, likeness, voice, as it pertains to my participation with the YMCA, in any manner for
promotional efforts without expectation of any reimbursement for its use. (My initials here revoke
photo/talent release__________).
4. INSURANCE The undersigned understands that the YMCA does not provide any accident or health insurance
for its members or participants and it is my responsibility to provide such coverage.
5. MEDICAL RELEASE The undersigned authorizes the YMCA, as my agent, to give consent to medical treatment
by a licensed physician or hospital when such treatment is deemed necessary by the physician, and I am
unable to give such consent. I authorize a qualified YMCA staff member to administer CPR or first aid if
necessary. I understand that it may be necessary for me to provide a release form from my physician regarding
my current health status.
6. 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, his or hers, and next of kin for any loss or damage, and any
claim or demands therefor 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.
7. 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 or
participating in any program affiliated with the YMCA whether caused by the negligence of the releasees or
otherwise.
8. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH, OR
PROPERTY DAMAGE due to negligence of 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 Connecticut 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
INDEMNITYAGREEMENT, and further agrees that no oral representations, statements, or inducement apart from the
foregoing written agreement have been made.
I HAVE READ THIS RELEASE I HAVE READ THIS RELEASE
____/____/____ _______________________________________________ ____/____/____ _______________________________________________
date participant’s signature date parent’s or guardian’s signature
(if participant is legally a minor)MINOR PARTICIPANT WAIVER, RELEASE, INDEMNIFICATION OF
ALL CLAIMS & COVENANT NOT TO SUE
NOTICE: THIS IS A LEGALLY BINDING AGREEMENT. Read this document carefully and in entirety. By
signing this agreement, you give up your right and the named minor’s right to bring a court action to
recover compensation or obtain any other remedy for any personal injury or property damage
however caused arising out of the named minor’s participation in the Stamford Family YMCA
Programs, now or any time in the future.
Acknowledgment of Risk
I, in my legal capacity as the parent/guardian of the minor named below, do hereby acknowledge and
agree that participation in Summer Camp Mini, Camp Wow and/or Teen Adventure activities comes
with inherent risks. I have full knowledge and understanding of the inherent risks associated with
Summer Camp Mini, Camp Wow and/or Teen Adventure participation, including but in no way limited
to: (1) slips, trips, and falls, (2) aquatic injuries, (3) athletic injuries, and (4) illness, including exposure
to and infection with viruses or bacteria. I further acknowledge that the preceding list is not inclusive
of all possible risks associated with Summer Camp Mini, Camp Wow and/or Teen Adventure
participation and that said list in no way limits the operation of this Agreement.
Coronavirus / COVID-19 Warning & Disclaimer
Coronavirus, COVID-19 is an extremely contagious virus that spreads easily through person-to-
person contact. Federal and state authorities recommend social distancing as a mean to prevent the
spread of the virus. COVID-19 can lead to severe illness, personal injury, permanent disability, and
death. Participating in the Stamford Family YMCA programs or accessing the Stamford Family YMCA
Initial facilities could increase the risk of contracting COVID-19. The Stamford Family YMCA in no way
warrants that COVID-19 infection will not occur through participation in the Stamford Family YMCA
programs of accessing Stamford Family YMCA facilities.
Waiver, Release, Indemnification & Covenant Not to Sue
In consideration of ____________________’s participation in the Stamford Family YMCA’s Summer Camp Mini,
Camp Wow and/or Teen Adventure, I, ____________________, the parent/guardian of the minor named above,
agree to release and on behalf of myself and the minor named above, my heirs, representatives,
executors, administrators, and assigns, HEREBY DO RELEASE the Stamford Family YMCA, its officers,
directors, employees, volunteers, agents, representatives and insurers (“Releasees”) from any causes
of action, claims, or demands of any nature whatsoever including, but in no way limited to, claims of
negligence, which I, the named minor, my heirs, representatives, executors, administrators and
assigns may have, now or in the future, against the Stamford Family YMCA on account of personal
injury, property damage, death or accident of any kind, arising out of or in any way related to the
use of the Stamford Family YMCA facilities/equipment or participation in the Stamford
Family YMCA programs whether that participation is supervised or unsupervised,
Initial
Page 1 of 2however the injury or damage occurs, including, but not limited to the negligence of Releasees.
In consideration of the named minor’s participation in Summer Camp Mini, Camp Wow and/or Teen
Adventure, I, the undersigned parent/guardian of the named minor, agree to INDEMNIFY AND HOLD
HARMLESS Releasees from any and all causes of action, claims, demands, losses, or costs of any
nature whatsoever arising out of or in any way related to the named minor’s Summer Camp Mini,
Camp Wow and/or Teen Adventure participation.
I hereby certify on behalf of myself and the named minor that I have full knowledge of the nature and
extent of the risks inherent in Summer Camp Mini, Camp Wow and/or Teen Adventure participation
and that I, on behalf of myself and the named minor, am voluntarily assuming said risks. I understand
that I and the named minor will be solely responsible for any loss or damage, including personal
injury, property damage, or death, the named minor sustains while participating in Summer Camp
Mini, Camp Wow and/or Teen Adventure and that by signing this agreement I, on behalf of myself
and the named minor, HEREBY RELEASE Releasees of all liability for such loss, damage, or death. I
further certify that the named minor is in good health and has no conditions or impairments which
would preclude his/her safe participation in Summer Camp Mini, Camp Wow and/or Teen Adventure.
I further certify that my date of birth is _____________ (MM/DD/YYYY), that my present age is ______, that
I am therefore of lawful age (18 years or older) and otherwise legally competent to sign this
agreement, and that I have legal capacity to act as the parent/guardian of the named minor. I further
understand that the terms of this agreement are legally binding and certify that I am signing this
agreement, after having carefully read it, of my own free will.
________________________________________________________ ________________________________________________________
Participant Name (Print Clearly) Date
________________________________________________________ ________________________________________________________
Parent/Guardian Signature Parent/Guardian Name (Print Clearly)
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The Stamford Family YMCA | 10 Bell Street, Stamford, CT 06901 | (203) 357-7000 | www.stamfordymca.orgYou can also read
