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Home
Camp Registration
2023 Summer Camp Registration
Complete one registration per child.
Camper's Name
*
First
Middle
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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?
*
Returning Camper
ywcacm.org
Facebook/Twitter/Instagram
Parent Referral
Flyer/Postcard
Baystate Parent Magazine
Worcester Magazine
HulaFrog
Other
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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.3019 prior to June 13 or at 508-892-9814 after June 13, 2022.
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 1 or 2, you will be charged for June 19 (holiday) and July 4 (holiday).
Payment Options
*
A deposit of $30 PER SESSION is required upon registration. 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, 2023.
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 19-23 (closed June 19 for Juneteenth)
Session 2: June 26- June 30
Session 3: July 3-7 (closed July 4)
Session 4: July 10-14
Session 5: July 17-21
Session 6: July 24-28
Session 7: July 31-August 4
Session 8: August 7-11
Session 9: August 14-18
Session 10: August 21-25
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 19-23 (closed June 19 for Juneteenth)
Session 2: June 26- June 30
Session 3: July 3-7 (closed July 4)
Session 4: July 10-14
Session 5: July 17-21
Session 6: July 24-28
Session 8: August 7-11
Session 10: August 21-25
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 19-23 (closed June 19 for Juneteenth)
Session 2: June 26- June 30
Session 3: July 3-7 (closed July 4)
Session 5: July 17-21
Session 6: July 24-28
Session 10: August 21-25
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 19-23 (closed June 19 for Juneteenth)
Session 2: June 26- June 30
Session 3: July 3-7 (closed July 4)
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 19-23 (closed June 19 for Juneteenth)
Session 3: July 3-7 (closed July 4)
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 19-23 (closed June 19 for Juneteenth)
Session 2: June 26- June 30
Session 3: July 3-7 (closed July 4)
Session 4: July 10-14
Session 5: July 17-21
Session 6: July 24-28
Session 7: July 31-August 4
Session 8: August 7-11
Session 9: August 14-18
Session 10: August 21-25
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 19-23 (closed June 19 for Juneteenth)
Session 2: June 26- June 30
Session 3: July 3-7 (closed July 4)
Session 4: July 10-14
Session 5: July 17-21
Session 6: July 24-28
Session 8: August 7-11
Session 10: August 21-25
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 19-23 (closed June 19 for Juneteenth)
Session 2: June 26- June 30
Session 3: July 3-7 (closed July 4)
Session 5: July 17-21
Session 6: July 24-28
Session 10: August 21-25
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 19-23 (closed June 19 for Juneteenth)
Session 2: June 26- June 30
Session 3: July 3-7 (closed July 4)
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 19-23 (closed June 19 for Juneteenth)
Session 3: July 3-7 (closed July 4)
Deposit Fee
Quantity
(Deposit fee is required unless you pay in full)
Price:
$30.00
Quantity
Camp Fee (Pay in Full)
Quantity
Day Camper ($230 tuition per session) 6-13 yrs old
Price:
$230.00
Quantity
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
Quantity
Total
$0.00
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