Summer Camp Registration

Camper's Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
I'm registering this camper as a:*
- Day Camper (6-13 years old)
Date of Birth*
Gender*
- Female
- Gender/Queer
- Intersex
- Male
- Transgender F-M
- Transgender M-F
- Transgender (Unspecified)
- Other
- Unspecified
- Unknown/Undisclosed
Race of Child*
- American Indian/Alaskan Native
- Asian
- Black
- Native Hawaiian/Pacific Islander
- Hispanic/Latino/a/x
- Multi Racial
- White
- Other Race
- Unknown/Undisclosed
Ethnicity of Child*
- African American
- Albanian
- American
- American Indian/Alaskan Native
- Asian Indian
- Brazilian
- Cambodian
- Cape Verdean
- Caribbean Islander
- Chinese
- Colombian
- Cuban
- Dominican
- European
- Filipino
- Ghanian
- Guatemalan
- Haitian
- Hispanic/ Latino/a/x
- Honduran
- Japanese
- Kenyan
- Korean
- Laotian
- Liberian
- Mexican
- Mexican American
- Chicano
- Middle Eastern
- Portuguese
- Puerto Rican
- Russian
- Salvadoran
- Vietnamese
- White (Non Hispanic)
- Unknown/Undisclosed
- Other
School Name*
Grade Entering in the Fall*
Type of School:*
- Worcester Public Schools
- Other Public School
- Private/Parochial School
- Homeschool
- Unknown/Undisclosed
Camper T-shirt Size*
(Included with registration)
- Youth Small
- Youth Medium
- Youth Large
- Adult Small
- Adult Medium
- Adult Large
How did you hear about YWCA Summer Camp?*
Parent/Guardian Name*
First Last
Email*
Phone*
Work Phone
Emergency Contact and Medical Info
Pickup List*
Anyone picking up a camper must provide a photo I.D. and be listed below. Click the "+" sign to add another parent/guardian.
Parent/Guardian Name Employer Phone Number
Emergency Contacts*
List up to 3 other people (other than parent/guardian) who are authorized to pick up the camper and should be contacted in case of a medical emergency or emergency pick-up if parent/guardian cannot be reached. To add a row, click the "+" sign.
Name Relationship Phone Number
Emergency Medical Release*
Please check box to agree
- In case of an emergency, I understand every effort will be made to contact me or the emergency contact persons listed above. In the event that we cannot be reached, I hereby give permission to the physician listed on the form to hospitalize, secure proper treatment and to order anesthesia or surgery for my child.
Physician Information*
Physician's Name Hospital Affiliation
Physician Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Physician Phone*
Medical Information*
Medical Insurance Provider Policy and/or Group Number
Medical Conditions:
The Permission to Administer Medication form must be completed and given to the Camp Director on the first day of each camp session. Medications must be accompanied by the original physician’s prescription with clearly written directions. If your child has other special needs (language, learning disability, speech, hearing, food allergies, etc) please contact the Camp Director at 508-767-2505, ext.125 prior to June 14 or at 508-892-9814 after June 17, 2024.
Please check all that apply
- ADD
- ADHD
- Anxiety
- Bipolar Disorder
- Depression
- Diabetes
- Food Allergies
- PTSD
- Seizure Disorder
Does your child need to take medication(s) during camp?*
- Yes
- No
If your child requires medication, please specify:
Disability*
- None
- Developmental/Intellectual/Acquired Brain Injury
- Other Cognitive Disability
- D/deaf or hard of Hearing
- Visual Mobility/Motor
- Mental Health/Psychiatric Substance Misuse
- Other Medical
- Other Disability
- Unknown/Undisclosed
If other disability, please specify:
Medical Release*
- I authorize the YWCA, as agent for the undersigned, to consent with respect to said minor, to an x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to rendered under general or special supervision of, any physician or surgeon licensed under the provisions of the MA Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of the physician or at the hospital. I understand that the YWCA is not responsible for costs incurred for medical care.
Demographic Information
Please choose the appropriate selection for your family:
Household Income*
- Under $17,000
- $17,000 - $49,999
- $50,000 - $99,999
- $100,00 and more
Source of Income:*
- Employment
- TAFDC
- SNAP
- EAEDC
- SSDI
- SSI/Pension/Other Retirement
- Partner/Spouse Support
- Child Support
- Alimony
- Unemployment
- Other
- None
- Unknown/Undisclosed
Housing Status*
- Homeless
- Own
- Rent
- Shelter
- Other
- Unknown/Undisclosed
Total Number Living in Household:*
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8 or more
- Unknown/Undisclosed
What language do you primarily speak at home?
Chose one:
- English
- Spanish
- French
- Arabic
- Portugese
- Haitian Creole
- Cape Verdean Creole
- Khmer
- Chinese (any dialect)
- Korean
- Vietnamese
- Russian
- Somali
- Twi
- American Sign Language (ASL)
- Other language not listed
- Unknown/Undisclosed
Camp Participation Permissions*
- I understand that it is my responsibility to provide insect repellent, which has not expired and is labeled with my child’s name.
- I give the YWCA staff permission to assist in applying insect repellent to my child no more than once per day and only if it is recommended by public health authorities due to a high rate of insect-borne disease.
- I understand that it is my responsibility to provide sunscreen, which has not expired and is labeled with my child’s name.
- I give the YWCA staff permission to assist in applying sunscreen to my child.
- I give permission for photographs/video to be taken of my child for use by the YWCA in program brochures, annual report, website, Facebook, Twitter, and Instagram, and other promotional materials and for release to local media.
- I give permission for my child to: Use play equipment, participate in ALL activities, participate in free swim
- I understand that if my child doesn’t participate in swim lessons, they will be identified as non-swimmers and at-risk swimmers and have access to personal floatation device when engaged in swimming activities.
- I agree that any camp participant’s belongings may be searched outside the participant’s presence for drugs, alcohol, weapons, or other forbidden objects
- Campers are asked to leave any valuables and electronics (cellphones) at home. I understand the YWCA and its employees are not responsible for lost or stolen items.
Sessions and Payment Options
Please note that if you enroll in session 2, you will be charged for July 4 (holiday).
Payment Options*
A deposit of $30 PER SESSION is required upon registration (unless you pay in full). You are also welcome to pay your balance in full upon registration. In order to ensure your child's spot in the program, balances MUST be paid in full by June 1, 2024.
- I am paying a deposit of $30 per session today.
- I wish to pay my balance in full today.
Hidden
Please indicate which camp sessions you are registering for.*
(Please note there are no partial sessions. Check as many boxes as apply.)
- Session 1: June 24-28
- Session 2: July 1-5 (closed July 4)
- Session 3: July 8-12
- Session 4: July 15-19
- Session 5: July 22-26
- Session 6: July 29-Aug 2
- Session 7: August 5-9
- Session 8: August 12-16
- Session 9: August 19-23
Hidden
Please indicate which camp sessions you are registering for.
(Please note there are no partial sessions. Check as many boxes as apply.)
- Session 1: June 24-28
- Session 2: July 1-5 (closed July 4)
- Session 3: July 8-12
- Session 4: July 15-19
- Session 5: July 22-26
- Session 6: July 29-Aug 2
- Session 9: August 19-23
Hidden
Please indicate which camp sessions you are registering for.
(Please note there are no partial sessions. Check as many boxes as apply.)
- Session 1: June 24-28
- Session 2: July 1-5 (closed July 4)
- Session 5: July 22-26
Please indicate which camp sessions you are registering for.*
(Please note there are no partial sessions. Check as many boxes as apply.)
- Session 1: June 24-28
- Session 2: July 1-5 (closed July 4)
Deposit Fee Quantity
(Deposit fee is required unless you pay in full)
Price: $30.00
Camp Fee (Pay in Full) Quantity
Day Camper ($235 tuition per session) 6-13 yrs old
Price: $235.00
Worcester Drop Off and Pick Up Transportation Fee: Quantity
* NOTE: The actual cost of transportation is $90. The YWCA is able to reduce the cost thanks to private donations received.
Price: $60.00
Total
$0.00

YWCA Central Massachusetts

Summer Camp Registration

Emergency Contact and Medical Info

Medical Conditions:

Demographic Information

Sessions and Payment Options

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Parent/Guardian Name	Employer	Phone Number

Name	Relationship	Phone Number