RENAISSANCE POINTE TEEN PROGRAMS REGISTRATION PACKET
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ATTN:
Michael Roberson
Youth & Family Director
P: 260.755.4881
F: 260.447.0297
Michael_Roberson@fwymca.org
RENAISSANCE POINTE
TEEN PROGRAMS
REGISTRATION PACKET
2017-2018
NAME OF PARTICIPANT:_______________________________________________
PARTICIPANT IS REGISTERING FOR THE FOLLOWING PROGRAMS:
_____ 2017 CAMP P.L.U.G. _____ 2017-2018 S.O.S. Program ______ 2017-2018 TASS Program _____ 2017-2018 Leaders’ Club
DATE OF COMPLETION & SUBMISSION: ______________________________
DESIRED START DATE: ________________________
Note: Registration for paid programs is not complete without payment of the registration fee.
FOR OFFICE USE ONLY
Registration packet received on:
_____________________________
Received by:
________________________________________________________
Registration Packet Complete: YES NOREGISTRATION FORM
RENAISSANCE POINTE TEEN PROGRAMS 2017-2018
PARTICIPANT INFORMATION
LAST NAME: __________________________________________________________________ FIRST NAME: ___________________________________ ______________________________
GRADE (2017-18): __________________ AGE: ________________ GENDER: M F RACE: _________________ D.O.B: ______________
HOME ADDRESS: ________________________________________________________ CITY: ________________________________________ ZIP: ________________________
SCHOOL ATTENDING: ______________________________________________________ T-SHIRT SIZE:_______________________________________________________
PARENT/GUARDIAN INFORMATION (PRIMARY)
LAST NAME: _________________________________________________________________ FIRST NAME: ____________________________________ _____________________________
HOME ADDRESS: _____________________________________________________________ CITY: __________________________________________ ZIP: _______________________
HOME PHONE NUMBER: __________________________________________________ CELL/WORK: __________________________________________________________________
PARENT EMAIL: _____________________________________________________________ MARITIAL STATUS: SINGLE MARRIED DIVORCED
PARENT/GUARDIAN INFORMATION (SECONDARY)
LAST NAME: _________________________________________________________________ FIRST NAME: _________________________________________________________________
HOME ADDRESS: ____________________________________________________________ CITY: __________________________________________ ZIP: _______________________
HOME PHONE NUMBER: __________________________________________________ CELL/WORK: __________________________________________________________________
PARENT EMAIL: _______________________________________________________________________________________________________________ _______________________________________
EMERGENCY CONTACT INFORMATION
LAST NAME: _________________________________________________________________ FIRST NAME: ____________________________________ _____________________________
RELATION TO PARTICIPANT: _________________________________________________ BEST CONTACT NUMBER:___________________________________________________
REGISTRATION FORMS TO BE COMPLETED AND TURNED IN
*Registration is not complete until all forms are completed and first day or entire week’s payment is made.
_____ Registration Form _____ Participant Code of Conduct
_____ Parental Acknowledgement _____ Receipt of Registration Payment (if applicable)
_____ Parental Sign Out Consent Form _____ Permission & Health FormPARTICIPANT ACKNOWLEDGEMENT—BEHAVIORAL CODE OF CONDUCT (TO BE COMPLETED BY PARTICIPANT & PARENT) RENAISSANCE POINTE TEEN PROGRAMS 2017-2018 * Participant signature required The purpose of the Behavior Code of Conduct is to provide a safe, productive and fun environment that aligns with the mission and goals of the YMCA. I, _____________________________________________, as a participant in a teen program with the Renaissance Pointe YMCA, have carefully read the Parent & Participant Handbook and am fully aware of the Behavior Management Policy & Practices and understand the importance of taking responsibility for my actions. As a member of any program, I am committing myself to fully engaging in all the activities that will be offered. By signing this document, I am agreeing to abide by all policies and procedures of the Renaissance Pointe YMCA. Should I choose not to abide by these policies and procedures, I understand that I may be asked to work with the Staff, Director and Parents to correct behavior and/or be dismissed from the program. _____________________________________________________________________ _________________________________________ Participant Date _____________________________________________________________________ _________________________________________ Parent/Guardian Signature Date _____________________________________________________________________ _________________________________________ Director Signature Date
PARENT HANDBOOK ACKNOWLEDGEMENT RENAISSANCE POINTE TEEN PROGRAMS 2017-2018 I acknowledge that I have read the parent handbook and I am fully aware of the teen program philosophy, policies and procedures. I have read and understand the tuition and fee arrangements as well as all of the conditions detailed in this handbook. I have read that bus pick up availability for the After School Spot will be determined at least one week prior to school year start date once registrations determine demand for bus transportation and from which schools. _____________________________________________________________________ _________________________________________ Parent/Guardian Signature Date _____________________________________________________________________ _________________________________________ Director Signature Date PHYSICAL HEALTH PARENTAL ACKNOWLEDGEMENT This acknowledges that my child, __________________________________________________, who in Teen Programs with the Renaissance Pointe YMCA is in good health. Further, any health restrictions, allergies, medications taken by the child, or any other needs are in fact noted below and listed on the health information form. Immunization records or appropriate waivers are up to date and on file with my child’s school. Please use this space to provide any pertinent medical information for the Renaissance Pointe YMCA: _____________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _____________________________________________________________________ _________________________________________ Parent/Guardian Signature Date _____________________________________________________________________ _________________________________________ Director Signature Date
PARENTAL SIGN OUT CONSENT FORM RENAISSANCE POINTE TEEN PROGRAMS 2017-2018 PARTICIPANT PICK-UP All participants are expected to be picked up by the designated end time of the program. Exceptions in specific cases can apply (see PARTICIPANT SELF-SIGN OUT). If the parent or authorized pick up needs to pick up a participant before the end of a program, we ask that you enter the building to sign out your child. AFTER SCHOOL AND CAMP P.L.U.G. Parents or authorized pick-ups who pick up their child after the designated end time of the program will incur a late fee charge of $5 for the first 10 minutes, then an additional $1 for every minute after. To sign out a participant, the parent/guardian must supply a pick-up card with the participant’s first and last name on it. Pick-up Cards will be assigned on the first day the participant attends the program. Parent/guardians who do not show their pick-up card must present a valid form of photo identification to a staff member in order for the participant to be released. Only the people listed below have permission to sign out the participant with valid identification. Name #1: ______________________________________________________ Name #3:_________________________________________________________ Phone: _________________________________________________________ Phone: ____________________________________________________________ Name #2: ______________________________________________________ Name #4: ________________________________________________________ Phone: ___________________________________________________________ Phone: ____________________________________________________________ As the parent/guardian of the participant, I understand the pick-up policy of the Renaissance Pointe YMCA and will pick up my child in a timely manner, with risk of paying late fees due to being tardy for pick-up. ________________________________________________________________ ___________________________ Parent Signature Date PARTICIPANT SELF SIGN OUT Teens who are YMCA Members are eligible to sign themselves out after the program they have participated in has concluded, upon consent by the parent/guardian. Once a teen has signed his or herself out, they are expected to engage as a regular member inside the building until pick-up by the parent/guardian. As the parent/guardian of the participant, my teen has my permission to sign themselves out of the program they are participating in. I release the Renaissance Pointe YMCA from any responsibility related to my teen. I understand that when my teen signs his or herself out, I am taking full responsibility for their actions from that point on. I understand that disregarding the terms outlined herein may result in the dismissal of my teen from all teen programs at Renaissance Pointe. ________________________________________________________________ ___________________________ Parent Signature Date
PAYMENT AGREEMENT
RENAISSANCE POINTE TEEN PROGRAMS 2017-2018
AGREEMENT
A Registration fee for paid programs is due upon completion of registration to ensure your participant’s spot in that particular program. We also
require that arrangements for weekly, bi-weekly, or monthly drafts be made at the time of registration. Participants will not be allowed your child
enter the program until proof of payment has been provided.
1. I authorize the Renaissance Pointe YMCA to draw on the account listed below for my program payment(s).
2. I authorize the Renaissance Pointe YMCA to draft my account for any late pick-up charges which I may incur while participating in particular
programs.
3. Should any debit not be honored by my bank account or credit card company for any reason, I understand that I am still responsible for the
payment, plus a $15.00 service charge applied by the Renaissance Pointe YMCA. This is in addition to any service fee my bank/credit card company
may require.
PAYMENT
PLEASE SELECT ONE OF THE FOLLOWING METHODS OF PAYMENT TYPES:
CREDIT CARD DRAFT
Camp payment will be charged upon registration.
Credit Card Type (please circle one): VISA MASTERCARD DISCOVER AMERICAN EXPRESS
Name of Cardholder (as it appears on card): _________________________________________________________________________________ __________
Card Number: _______________ - ___________________ - _______________ - _______________ Exp. Date of Card: ____________________
I (we) hereby authorize the Renaissance Pointe YMCA to debit the above credit card on the date and for the amount indicated each
month for my child care services.
________________________________________________________________________________________________________________________________
Authorizing Signature Date
BANK DRAFT
In order for a bank draft to be set up, a voided check must be provided upon registration.
Depository Name (bank): __________________________________________________
Account Number: ____________________________________________________________ Routing/Transit Number: _______________________________________________
Name(s) on Account (please print):
_____________________________________________________________________________________________________________________________ __
I (we) authorize the Renaissance Pointe YMCA to initiate debit entries to my/our account on the date and for the amount indicated
on each month for me child care services.
________________________________________________________________________________________ _______________________________________
Authorizing Signature DatePERMISSION & HEALTH FORM LAST NAME: ____________________________________
FIRST NAME: ___________________________________
RENAISSANCE PONTE TEEN PROGRAMS 2017-2018
DATE OF BIRTH: __________/__________/__________
SECTION 1: CONTACT INFORMATION
Primary Parent Guardian: _______________________________________________ Secondary Parent Guardian: ___________________________________________
Home Address: ____________________________________________________________ Home Address: ____________________________________________________________
Home Phone: ______________________________________________________________ Home Phone: ______________________________________________________________
Work/Cell: _________________________________________________________________ Work/Cell: _________________________________________________________________
Employer: _________________________________________________ Employer: _________________________________________________
Employer Address: _______________________________________________________ Employer Address: _______________________________________________________
Employer Phone: _________________________________________________________ Employer Phone: _________________________________________________________
Daily Work Times: _____________________________ Daily Work Times: _____________________________
Emergency Contact information:
Name: _______________________________________________________________________ Home Phone: ________________________ Work/Cell: ________________________
Relationship: ______________________________________________________________ Address: ______________________________________________________________________
SECTION 2: AUTHORIZATIONS (MUST BE COMPLETED TO PARTICIPATE)
Field Trip Permission: I give permission for my child to go on any field trips supervised by any of the Teen Program Offerings. I understand
that some trips consist of short walks to nearby locations as well as extended trips within Allen County. I understand further that I will be
notified in advance about any longer trips and that, if any vehicle is used to transport my child, each child will be required to wear a seat
belt or be placed in a car seat that I would provide.
Parent/Guardian Signature____________________________________________________________ Date_______________
Photography and Recording Permission: I hereby irrevocably release, consent and allow the Renaissance Pointe YMCA and its agents to use
and reproduce any and all photographs or video footage taken of me or my dependent(s) for Renaissance Pointe YMCA purposes. I
understand that I/my dependent(s) receive no reimbursement for allowing my photo to be taken or for the use of the photo or video.
Parent/Guardian Signature____________________________________________________________ Date_______________
Liability: I understand the physical activities which my child may participate in at the YMCA include, but may not be limited to: swimming,
mountain biking, and playing sports. I agree to assume all liability and release the YMCA from any liability for the risk of injury, illness or
death on account of my child’s presence in a YMCA facility or on account of my child’s involvement in any activity at a YMCA facility whether
caused by negligence of the YMCA or another person on the premises or at the sponsored activity.
Parent/Guardian Signature____________________________________________________________ Date_______________
Swimming: I give permission for my child to swim during planned trips to the pool. A lifeguard will always be present when my child swims
during a YMCA program.
Parent/Guardian Signature____________________________________________________________ Date_______________SECTION 3: MEDICATION (All medications must be sent in original containers)
The participant takes the following routine medications (including over-the-counter/non-prescription medications)
Strength Dosage Prescribing
Name of Medication (e.g. “100 mg”) (e.g. “12 pills”) Physician Reason for taking Other instructions
The participant takes the following medications AS NEEDED (includes inhalers, epi-pens, oral medications, topical medications or skin
medications)
Strength Dosage Prescribing
Name of Medication (e.g. “100 mg”) (e.g. “12 pills”) Physician Reason for taking Other instructions
SECTION 4: ALLERGIES/DIETARY RESTRICTIONS (To medicine, food, insect bites, etc.):
Allergy Reaction Management of Reaction
SECTION 5: PARTICIPANT’S HEALTH CARE PROVIDER
Name of preferred hospital in event of emergency:
_____________________________________________________________________________________
Primary Care Physician or Health Clinic: _________________________________________________________________________________________________
Address:____________________________________________________ Phone:_____________________________________________________________________
Health Insurance Carrier: ______________________________ Policy #: __________________________________________________________________
SECTION 6: PERMISSION TO TREAT (REQUIRED FOR PARTICIPATION)
I give permission to Teen Programs Staff to provide routine health care, dispense medications and secure
emergency medical and/or emergency surgical treatment to my child while in care.
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