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* Camper Name
* Camper Address
* City
* State
* Zip
* Date of Birth
Camper Email
* Gender (select) Female Male
* Camper Shirt Size (select) YSmall YMedium YLarge Adult Small Adult Medium
* Parent/Guardian Name
* Parent/Guardian Address
Home Phone
Work Phone
Cell Phone
* Parent/Guardian Email
For 6-12 year oldsPlease note that there are no partial weeks or sessions.Each week at Camp Wind-in-the-Pines cost $225.00. Each session is one-week long.
Please check the Camp Wind-in-the-Pines sessions you would like to register your camper for: Session 1: June 17 - 21 Session 2: June 24 - 28 Session 3: July 1 - 5* Session 6: July 22 - 26 Session 7: July 29 - August 2 Session 8: August 5 - 9 Session 11: August 26 - 30
Session 1 can be prorated based on the last day of school.*No camp July 4, 2013
For 13-15 year oldsPlease note that there are no partial weeks or sessions.Each week in the CIT program cost $110.00.
Please check the Camp Wind-in-the-Pines sessions you would like to register your camper for: Session 1: June 17 - 21 Session 2: June 24 - 28 Session 3: July 1 - 5* Session 7: July 29 - August 2 Session 8: August 5 - 9 Session 11: August 26 - 30
Worcester: 1 Salem Square Drop-off: 7:30 - 8:25 a.m. / Pick-up: 4:30 - 6:00 p.m.
Westborough: 15 Grove Street Drop-off: 7:30 - 8:10 a.m. / Pick-up: 4:45 - 6:00 p.m.
* Please choose one form of transportation: (select) I will pick-up and drop-off my child at Camp Wind-in-the-Pines. I want my child to take the bus from Worcester. I want my child to take the bus from Westborough.
Anyone picking up a camper must provide a photo ID and be listed below
* Parent 1
Employer
Telephone
Parent 2
List up to 3 other people (other than parent/guardian) that are authorized to pick-up the camper or should be contacted in case of a medical emergency or emergency pick-up:
* Name
Relationship
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's Name
Hospital Affliation
Address
Medical Insurance Provider
Policy/Group #
Allergies and Medication
Known Allergies
Does your child need to take medication during camp: Yes No
If your child requires medication, please specify:
The Permission to Administer Medication form must be filled out 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 17 or at 508-892-9814 after June 17.
Medical ReleaseI 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.
* Please enter your initials after reading above release.
SunscreenI give permission for sunscreen to be administered and/or applied to my camper as deemed necessary by the camp staff.
Backpack SearchI agree that any camp participant's belongings may be searched outside the participant's presence for drugs, alcohol, weapons or other forbidden objects.
Lost or Stolen ItemsCampers are asked to leave any valuables, electronics (mp3 players, digital cameras, etc.) at home. The YWCA and its employees are not responsible for lost or stolen items.
PhotographsI give permission for my child's photograph to be taken for use by the YWCA Central Massachusetts in program brochures, annual report, website, and other promotional materials and for release to local newspapers.
AgreementI have read, understand and agree to the terms of this application. * Please enter your FULL name after reading above release. Script by Dagon Design
* Please enter your FULL name after reading above release.
