2021 Camp Required forms

1
Camper name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
3
Age* This field is required.
4
How many years has this child attended Camp Wakonda?* This field is required.If first year, enter zero.
Years in Camp
5
Gender* This field is required.
Male
Female
6
Grade Fall 2021* This field is required.
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
7
Cabin mate request* This field is required.List none if no cabin mate requested
One, please
8
Dates of Attendance
June 6-11
June 13-18
June 20-25
July 4-9
July 11-16
July 18-23
July 25-30
August 1-6
9
Does this camper have any known allergies?* This field is required.
YESNO
10
List of allergies* This field is required.
Please list all food allergies
Please list all medication allergies
Please list all environmental allergies (insect stings, hay fever, etc.)
Please list all other allergies
11
Camper Diet* This field is required.
This camper eats a regular diet
This camper eats a vegetarian diet
This camper has special food needs
12
Please describe your camper's dietary needs* This field is required.
13
After reviewing the program and activities of Camp Wakonda, do you feel your camper can participate without restrictions?* This field is required.
YESNO
14
What restrictions or adaptations would you like to put in place?* This field is required.
15
Insurance
Yes
No
Is this camper covered by medical insurance?
Insurance company
Policy number
Subscriber
Insurance company phone number
16
Are this camper's immunizations up to date?* This field is required.
YESNO
17
Please check all that apply to your camper* This field is required.About your camper's general health
Has been hospitalized
Has been treated for attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)
Had surgery
Has been treated for emotional or behavioral difficulties or an eating disorder
Had recurrent/chronic illness
Has seen a professional to address mental or emotional health concerns during the last 12 months
Had a recent infectious disease
Has had a significant life event that continues to affect his or her life
Has had a recent injury
Has asthma/wheezing/shortness of breath
Has diabetes
Has seizures
Has headaches
Wears glasses, contacts or protective eyewear
Has experienced fainting or dizziness
Has passed out or had chest pain during exercise
Has had mononucleosis during the last 12 months
Has had problems with menstruation
Has had problems with falling asleep or sleepwalking
Has had back or joint problems
Has a history of bedwetting
Has had problems with diarrhea or constipation
Has any skin problems
None of the Above
18
Please explain your camper's health history for each checked box on previous page* This field is required.
Huge
Large
Normal
Small
Ok
Ok
19
Has your camper traveled outside the US in the past 9 months?* This field is required.
YESNO
20
Which countries?* This field is required.Please provide dates if you can
21
Help your counselor get to know you betterPlease fill this section out with your camper if you can. It's great to hear these answers in their own words.
Nickname or preferred name
Yes
No
Has this camper ever spent the night away from home before?
My favorite camp activities are
I really like to play
I'm really good at
I'd like to get better at
Some of my hobbies and interests are
One last thing we should know about you
22
Will your camper take any daily medications while attending camp?* This field is required.Medication is any substance a person takes to maintain and/or improve their health.
YESNO
23
Please describe all medication* This field is required.Remember to provide enough medication to last the entire week. All medication must be in its original packaging that identifies the prescribing physician (if a prescription drug),name of patient (must be prescribed to camper), name of medication, dosage and frequency of administration.
Name of medication
Reason for taking
When given
Dosage given
How given
Medication 1
Medication 2
Medication 3
Medication 4
Medication 1
Medication 2
Medication 3
Medication 4
Name of medication
Reason for taking
When given
Dosage given
How given
Name of medication
Reason for taking
When given
Dosage given
How given
Name of medication
Reason for taking
When given
Dosage given
How given
Name of medication
Reason for taking
When given
Dosage given
How given
1 of 4
24
Please check any medication your camper should NOT be given* This field is required.The following non-prescription medications may be stocked in the camp health center and are used on an as needed basis to manage illness and injury.
Acetaminophen (Tylenol)
Phenylephrine decongestant (Sudafed PE)
Antihistamine/allergy medicine
Diphenhydramine antihistamine/allergy medication (Benadryl)
Sore throat spray
Lice shampoo or cream (Nix or Elimite)
Calamine lotion
Laxatives for constipation (Ex Lax)
Ibuprofen (Advil or Motrin)
Pseudoephedrine decongestant (Sudafed)
Guaifenesin cough syrup (Robitussin)
Dextromethorphan cough syrup (Robitussin DM)
Generic cough drops
Antibiotic cream
Aloe
Bismuthsubsalicylate for diarrhea (Pepto Bismol)
All medications listed may be given to my child
25
Parent/Guardian* This field is required.
First Name
Last Name
26
Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
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
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
27
Email* This field is required.
the_y@orymca.org
28
Primary phone number* This field is required.
29
Secondary phone numberoptional
30
Second Parent/Guardian(optional)
First Name
Last Name
31
Second Parent/Guardian phone number(optional)
32
Second Parent/Guardian secondary phone number(optional)
33
Emergency contact* This field is required.Other than Parents/Guardians
First Name
Last Name
34
Relationship to camper* This field is required.
35
Emergency phone number* This field is required.
36
Are you applying for Financial Assistance?* This field is required.
Yes
No
37
Financial assistance is available for Sessions 3-8 for those who qualify. Unfortunatly, due to the already reduced rate, financial assistance is not available for Early Bird Sessions. To apply, please email the following to campwakonda@orymca.org. Please allow up to 2 weeks to process, keeping in mind payment due dates.

• Child(ren)’s Name

• Camp Session

• Number of adults in the household

• Number of Children in the household

• Most Recent Tax returns for all adults in the household

• 2-month benefit statements for all adults in the household for all other types of income, including but not limited to

1. Child support

2. Food stamps

3. Disability

4. Social Security

5. Retirement

6. TANIF

7. Pension

If approved, you can receive up to a 50% discount off the Tier A rate of camp. Please note that each child can only receive Financial assistance on one week of camp.
38
Is this a foster child?* This field is required.
Yes
No
39
Does this child receive SNAP benefits?* This field is required.
Yes
No
40
Please provide your SNAP case number
41
Does this child receive TANF benefits?* This field is required.
Yes
No
42
Please provide your TANF case number
43
Primary household adult income based on* This field is required.
Yearly
Monthly
Twice a month
Every two weeks
Weekly
44
Primary household adult income* This field is required.Place a "0" in boxes that do not apply
45
Do you have a Social Security number?* This field is required.
Yes
No
46
Last 4 digits of Social Security number* This field is required.
47
Additional household members* This field is required.Please list all household members, regardless of income
Full name
Gross wages
Welfare child support, alimony
Pensions, retirement, social security
Other
Household member 1
Household member 2
Household member 3
Household member 4
Household member 5
Household member 1
Household member 2
Household member 3
Household member 4
Household member 5
Full name
Gross wages
Welfare child support, alimony
Pensions, retirement, social security
Other
Full name
Gross wages
Welfare child support, alimony
Pensions, retirement, social security
Other
Full name
Gross wages
Welfare child support, alimony
Pensions, retirement, social security
Other
Full name
Gross wages
Welfare child support, alimony
Pensions, retirement, social security
Other
Full name
Gross wages
Welfare child support, alimony
Pensions, retirement, social security
Other
1 of 5
48
Email* This field is required.
example@example.com
49
* This field is required.
50
USDA Nondiscrimination Statement* This field is required.
51
Immunization acknowledgement* This field is required.
52
Authorization for health care* This field is required.
53
Terms of Program Participation* This field is required.
54
Signature* This field is required.By providing this signature I hereby certify that all information provided is correct and true to the best of my knowledge.
55
Are you ready to have fun this summer? We are! In order for you to have a fun, exciting and safe summer, everyone needs to follow the same guidelines. Below is a list of the basic rules that you will need to follow while you’re at camp. Keep in mind that more specific rules will be talked about when you get here (mealtimes, bedtime, activities, etc.). Please read over all of these guidelines and make sure that you understand them. You will be expected to follow these guidelines upon arrival at YMCA Camp Wakonda. This form MUST be completed along with all required forms for your child to participate at Camp Wakonda. All forms MUST be turned in two weeks prior to your child’s attendance at camp.

WHILE AT CAMP WAKONDA:

I will be honest and respectful (of my peers, my camp staff, and myself).

I will follow directions and rules at camp.

I will not act violently toward any camper or staff member.

I will not steal or destroy property belonging to Camp Wakonda, other campers, or staff members.

I will not use/practice inappropriate conduct and language.

I will stay within camp boundaries.

I will do my best to HAVE FUN!!!

Camp Behavior Policy:

Step 1: Inappropriate behavior is discussed with the camper by their counselor and/or program director, helping the camper to understand the rules and take responsibility for changing the behavior. The 4 core values of the YMCA, the ‘I’m Third’ motto, appropriate behavior as well as consequences are discussed.

Step 2: A call home is made by senior staff to discuss the behavior and gain insight. The camper will meet with the program director/camp director to discuss their actions, the negative impact these actions have, appropriate behavior and consequences should inappropriate behavior continue. Camper will call home.

Step 3: The camp director will inform parents that their camper cannot remain at camp. A parent or guardian will be asked to pick up the camper from Camp Wakonda as soon as possible. Parent or guardian is responsible for pick up/transportation of camper.

There are a few situations that will automatically result in a child being sent home. Those situations include, but are not limited to; causing physical injury to another camper, intentionally damaging another campers belongings or camp property, and violating other items on this Camper Conduct Policy.
56
Camper Agreement* This field is required.
57
Parent Agreement* This field is required.
Should be Empty: