Summer Camp Registration 2025 Summer Camp Registration Camper's Name* First Middle Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland 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 Camperywcacm.orgFacebook/Twitter/InstagramParent ReferralFlyer/PostcardBaystate Parent MagazineWorcester MagazineHulaFrogOtherParent/Guardian Name* First Last Email* Phone*Work PhoneEmergency Contact and Medical InfoPickup 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 NameEmployerPhone 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.NameRelationshipPhone 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 NameHospital AffiliationPhysician Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Physician Phone*Medical Information*Medical Insurance ProviderPolicy and/or Group NumberMedical 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 13 or at 508-892-9814 after June 16, 2025.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 InformationPlease 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, and participate in free swim. In order for campers to participate in free swim and boating activities, they must participate in swim lessons. Swimmers have access to personal floatation devices 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 at home. I understand the YWCA and its employees are not responsible for lost or stolen items. I understand the use of cellphones is strictly prohibited. If a camper is observed using their cellphone, it will be taken away and held in the Camp Office until dismissal time. Excessive cellphone use may lead to suspension/termination. Sessions and Payment OptionsPlease note that if you enroll in session 2, you will be charged for July 4 (holiday). Payment Options*A non-refundable deposit of $30.00 per camp session is due with application. The deposit is applied to your total balance. Balances for sessions 1-6 must be paid in full by June 1 of the respective year. Balances for sessions 7-10 must be paid in full by July 1 of respective year. I am paying a deposit of $30 per session today. I wish to pay my balance in full today. 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 23-27 Session 2: June 30 - July 4 (closed July 4th) Session 3: July 7-11 Session 4: July 14-18 Session 5: July 21-25 Session 6: July 28 - August 1 Session 7: August 4-8 Session 8: August 11-15 Session 9: August 18-22 Deposit Fee Quantity(Deposit fee is required unless you pay in full. Please enter how many sessions your child is attending.) Price: $30.00 Quantity Camp Fee (Pay in Full) QuantityDay Camper ($240 tuition per session) 6-13 yrs old. Please enter how many sessions your child is attending. Price: $240.00 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 TotalNOTE: Camp registrations submitted without payment are NOT guaranteed. To secure your camper’s spot, payment must be completed at the time of registration. When clicking "Submit," please proceed with payment via PayPal. You have the option to pay as a guest without creating a PayPal account. Failure to complete payment may result in the loss of your camper’s reservation. $0.00 Explore More
