2013 - CDJ - prescolaire

CHOOSE YOUR YMCA AND YOUR AGE GROUP
Notre-Dâme-de-Grace YMCA :	*	2 to 5
West-Island YMCA :	*	2 ½ to 5
Westmount YMCA :	*	2 ½ to 3

FAMILY INFORMATION
Child
Family Name	*
First Name	*
Date of Birth (JJ/MM/AAAA)	*
Age	*
Sex	*	M F
Grade completed on June 30 2013	*
Languages spoken	*	English French Other
If other language, specify :
Address	*
City	*
Province	*
Postal Code	*
Has your child taken swimming lessons?	*	Yes No
What was the last level passed?
Where did your child take them?
Please submit a picture of your child

PARENT #1
Last Name	*
First Name	*
Tel. Home	*
Tel. Work
Cell
E-Mail	*

PARENT #2
Last Name	*
First Name	*
Tel. Home	*
Tel. Work
Cell
E-Mail	*

EMERGENCY CONTACTS OTHER THAN PARENTS
Name #1	*
Relation to the child	*
Tel. Home	*
Tel. Work
Cell
Name #2	*
Relation to the child	*
Tel. Home	*
Tel. Work
Cell

INCOME TAX RECEIPT Indicate the name of the person paying. He/she will receive the income tax receipt.
Name (Enter NA if it does not apply to you)	*
S.I.N. (Enter NA if it does not apply to you)	*

MEDICAL INFORMATION
Medicare number (Enter NA if it does not apply to you)	*
Expiry date (Enter NA if it does not apply to you)	*
Does your child have any of the following * Epilepsy Haemophilia Hearing problems Diabetes Hyperactivity Attention deficit Vision troubles Incontinence Asthma Speech impediment Allergies None
Allergies or Other, specify :
Is your child presently taking medication?	*	Yes No
If yes, please name
Does your child need to carry an EpiPen (medication)?	*	Yes No
Are there any other physical or emotional factors concerning your child that you would like us to be aware of
IN CASE OF AN EMERGENCY, I HEREBY AUTHORIZE THOSE RESPONSIBLE FOR MY CHILD’S CARE TO TAKE THE NECESSARY MEASURES TO ENSURE MY CHILD’S HEALTH. * Yes No

PEOPLE AUTHORIZED TO PICK-UP YOUR CHILD
PEOPLE AUTHORIZED TO PICK-UP YOUR CHILD	*	MOTHER FATHER OTHER
If Other:
Name #1
Relation to the child
Tel. Home
Tel. Work
Cell
Name #2
Relation to the child
Tel. Home
Tel. Work
Cell
NON-AUTHORIZED (If the non-authorized person is the other parent, we will ask you to submit a court document.)
Name
Relation to the child

AUTHORIZATION FOR PHOTOGRAPHS AND VIDEOS
I am aware that The YMCAs of Québec day camps produce promotional materials (video, photographs) which may include my child. * Yes, I accept No, I do not accept

AUTHORIZATION FOR OUTINGS
I hereby authorize the YMCAs of Québec day camp to allow the afore-mentioned child to participate in all outings and all related activities * Yes No

DAY CAMP PARENT INFORMATION GUIDE
I understand that I am responsible for reading the Parent Guide, which I can obtain from the customer service counter in my YMCA centre or by consulting this Guide online http://www.ymcaquebec.org/data/pdf/camp/ParentGuide_en_2013.pdf * Yes No

HOW DID YOU FIND OUT ABOUT OUR DAY CAMP? * Friend Returning camper Poster Banner Camp fair School Advertisement Internet Other
If Internet or Other, please specify :

ACCESS FOR ALL POLICY Access for All, a YMCA for everyone! At the YMCA, everyone matters. With this in mind, we offer financial assistance to promote equal access to our programs. Eligibility requirements available upon request.

EARLY BIRD DISCOUNT 5 % discount on the weekly rate if you register your child before March 31^st 2013. Does not apply to the Pointe-Saint-Charles camps.

DISCOUNT POLICY 10% discount applied to the 2nd, 3rd and 4thchild from the same family (applied to the lower-priced camp). 15% discount for Family membership holders.
- These two discounts cannot be combined (but each may be combined with the Early Bird discount).

CAMP WEEKS – $111/week
Registration deadline for each camp week is the Wednesday prior to the week you are registering for. After this deadline, please contact the manager of the day camp. You may switch weeks at any point after registration providing there is space available. A $10 fee will apply to any switch after June 1^st.
Choose your dates : * June 24^th - June 28^th (Date of postdated payments - June 12^th) July 1^st - July 5^th (Date of postdated payments - June 19^th) July 8^th - July 12^th (Date of postdated payments - June 26^th) July 15^th - July 19^th (Date of postdated payments - July 3^rd) July 22^nd - July 26^th (Date of postdated payments - July 10^th) July 29^th - August 2^nd (Date of postdated payments - July 17^th) August 5^th - August 9^th (Date of postdated payments - July 24^th) August 12^th - August 16^th (Date of postdated payments - July 31^st) August 19^th - August 23^rd (Date of postdated payments - August 7^th)

PAYMENT A $15 reservation fee per week registered is required at the time of registration. This amount will be deducted from the total amount owed. Please note that in the event of a cancellation, the reservation fee will not be reimbursed. The balance of the amount owed must be post-dated 12 days prior (on the Wednesday) to the first day of each camp week registered. These post-dated payments must be submitted at the time of registration. If paying by cheque, please make them payable to the centre you are registering with. A $15 fee will be charged for any declined payments. A $10 fee will be charged for any switch of weeks after June 1^st.

REIMBURSEMENT / CANCELLATIONS Full reimbursement, minus the $15 reservation fee, can be granted if a written request is received before 12:00 p.m. on the Monday (1 week prior) preceding the start of a camp week for which your child is registered. A reimbursement will not be granted without the written request. No cancellations or changes will be accepted over the telephone. Absence from day camp does not constitute a withdrawal from the program. A reimbursement will not be granted for those days.

CONFIRMATION	*	I hereby declare that all the above information is true, and that I have read and understand the payment, reimbursement/cancellation sections.
FIRST & LAST NAME (Person filling out form)	*
DATE (JJ/MM/AAAA)	*