S H A S T A F A M I L Y Y M C A • 1 1 5 5 N . C O U R T S T ,   R E D D I N G , C A 9 6 0 0 1 • 5 3 0 - 2 4 6 - 9 6 2 2 • W W W . S F Y M C A . O R G

SIGN UP TODAY! K-8TH GRADE

LIMITED SPACESAVAILABLE!

$50 DEPOSIT

We realize the price might be cost-prohibitive due to the

small group sizes required to adhere to social distancing

recommendations. Financial Aid is available to those who

qualify.

PRE-REGISTER TODAYEmail completed packet to:msweetwood@sfymca.org3day = $195 | 5day = $250

Youth wil l be organized in small groups (10 youth &1 staff) and activit ies are careful ly planned with aconsideration for social distancing.Frequent hand washing and use of hand sanitizersfor staff and youth.Limit unnecessary contact and potential exposure,by l imiting camp access to YMCA Camp Staff andcamp participants only.Parents/Guardians wil l be dropping off and pickingup at the entrance and not al lowed to access theprogram space.Ongoing cleaning wil l be scheduled during the day.

SUMMER CAMPAT THE Y

Moving forward

ADVENTURE AWAITS!

To Keep Your Children Safe

MONDAY-FRIDAY

7AM-6PM

With Support From:

The Ruffcorn & Miranda Group

QUESTIONS? CALL: 530-224-0952

SHASTA FAMILY YMCA • 1155 N. COURT ST, REDDING CA 96001 • P 530 246 9622 • F 530 246 9645 • WWW.SFYMCA.ORG

Shasta Family YMCA COVID-19 Screening Agreement:

The Shasta Family YMCA has been monitoring the Coronavirus (COVID-19) and ask that each camp participant and staff member honestly answer the questions below, as outlined by the CDC, before access will be given to the Shasta Family YMCA Emergency Day Camp.

A. Have you experienced the following symptoms within the last 4 days: • Fever• Shortness of breath• Cough

B. Have you been in close contact with a person known to have COVID-19? C. Have you traveled to an area with widespread or ongoing community spread of

COVID-19 in the last 14 days? D. Has anyone in your home or who you have been in close contact with

experienced the following symptoms within the last 4 days: • Fever• Shortness of breath• Cough

E. Has anyone in your home or who you have been in close contact with been in close contact with a person known to have COVID-19?

F. Has anyone in your home or who you have been in close contact with traveled to an area with widespread or ongoing community spread of COVID-19 in the last 14 days?

For the safety of others, if you, as a camp participant or staff member, answered yes to any of the questions above, access will not be given to the Shasta Family YMCA Summer Day Camp.

I HAVE READ THE ABOVE SCREENING AGREEMENT AND CAN TRUTHFULLY ANSWER “NO” TO ALL OF THE QUESTIONS ASKED.

Signature: ________________________________ Date: ______________________

Camper Employee Outside Vendor

SHASTA FAMILY YMCA • 1155 N. COURT ST, REDDING CA 96001 P 530 246 9622 • F 246 9645 • WWW.SFYMCA.ORG

SUMMER CAMP REGISTRATION

Participant Name (Last/First/Middle):_____________________________________________________________Child Date of Birth_________________________________

Grade Next Fall: __________________________ Age: ____________ Gender: M F Sibling in YMCA Camp Yes No

Parent/GuardianName(Last/First/Middle):_________________________________________________________________________________________________________________

Parent Date of Birth_______________________________________EmailAddress:___________________________________________________________________________________

Home Address:_________________________________________________________________ City:_______________ State:________Zip Code___________________________

Home phone:____________________________________________ Cell phone:______________________________________ Work phone____________________________________

Before registering please note, the YMCA requires a zero balance due on all childcare accounts prior to registering for summer camp. If there is a balance due on your account, the balance due plus your first session will be drafted on the date you indicated below. ________________ Initial

Please submit your registration 7 days prior to the first week of camp. Pre–scheduling is required at the time of registration for all weeks of summer camp. A 14-day written notice, on a Child Care Adjustment/Cancellation form, is required for any schedule changes. There is no refund of fees for non–attendance or cancellations. Withdrawal from all weeks of camp requires 14 days written notice on a Child Care Adjustment/Cancellation form. Without a written notice of withdrawal, you will be financially responsible for all pre-scheduled weeks. Credit Card automatic drafts are required. No payments will be accepted at camp.

By signing here, you agree to the terms listed above:

Signature of Applicant/Parent: ___________________________________________________________________________Date:_____________________________________

Weeks & Dates Days-Check 3 or 5 days

Total Weekly Charge

Date Payment is Drafted

Initial for Parent Payment Agreement

Week 1 6/01/20 M T W TH F $ 6/01/20

Week 2 6/8/20 M T W TH F $ 6/08/20

Week 3 6/15/20 M T W TH F $ 6/15/20

Week 4 6/22/20 M T W TH F $ 6/22/20

Week 5 6/29/20 M T W TH $ 6/29/20

Week 6 7/6/20 M T W TH F $ 7/06/20

Week 7 7/13/20 M T W TH F $ 7/13/20

Week 8 7/20/20 M T W TH F $ 7/20/20

Week 9 7/27/20 M T W TH F $ 7/27/20

Payment Agreement Form

Today’s Date: _________________________________ Camp Site: _____________________________________________________________________________Grade:_____________

Child’s Last Name: Child’s First Name: Child’s Date of Birth:

Parent’s Last Name: Parent’s First Name: Parent’s Date of Birth:

Home Address: __ City: State: Zip Code:

Home Phone: ____________Email:

Employer: _____________ Work/Cell Phone: _ _ _ _ _ _ _ _

Employer Address: __________________________________City: State: Zip Code: _________________

Payment Authorization Information THIS PERSON MUST SIGN THIS FORM BELOW

I authorize payment to be drafted from my account for $

Name on Account:

Payment Type: _____________ MasterCard _____________ Visa _____________ Discover _____________ Other

Account Number: Expiration Date: _______________ Security Code:___________

Payment Agreement - PLEASE INITIAL that you have read and agree to all of the Payment terms below:

Payments will be drafted upon registration.

Payments not honored by the bank for any reason, (NSF, closed account, invalid expiration date, referral) will incur a returned payment fee. This is in addition to any fees charged by the bank. Returned payments will automatically be redrafted, and will include a returned payment fee.

Two or more returned drafts may result in termination from the program.

There will be no refund of fees for non-attendance or cancellation.

YMCA will have the right to initiate legal action for collection of fees or outstanding balances, and the undersigned will be responsible for all costs of collection, including court expenses and reasonable attorneys fees.

I HAVE CAREFULLY READ THE ABOVE PAYMENT AUTHORIZATION AND AGREEMENTS, AND I AGREE TO ABIDE BY ALL OF ITS TERMS AND CONDITIONS AS OUTLINED ABOVE.

Signature: _____________________________________________________________________________________________________________ Date: _______________________________________

Please fill this out in person, not online. Thank you.

Enrollment Form

Today’s Date: ___________________________ Camp Site: _____________________________________________________________________________Grade:_____________

Participant’s Information

Child’s Last Name: __________________________________________________________________ First Name: ______________________________________________________ MI: _________________

Child’s D.O.B: _______________________________ Gender M / F Child Lives with Mother: Father: Other: __________

Home Address: ____________________________________________________________________ City: _________________________________________ State: ____________ Zip Code: ____________

Home Phone: ______________________________________________________________________ Parent’s Email: __________________________________________________________________________

Enrollment Information (Please check all that apply)

New to YMCA ProgramsCurrently enrolled in YMCA afterschool program Have two or more children in the YMCA program

Days your child will attend camp

Fees Holiday Program Fee: $

Less Sibling Discount (10%): $

Less YMCA Employee Benefit: $

Total: $

Enrollment Agreement – PLEASE INITIAL that you have read and agree to all of the Enrollment terms below: _________ I have received and understand the current rate sheet. _________ There will be no refund of fees for non-attendance or cancellation. _________ The YMCA can terminate this agreement if the parent or child becomes disruptive to the center; or if, in the opinion of the Site Director, the child does not progress well in our environment. _________ The center will close promptly at 6:00 p.m. There is a late pick-up fee of $1 for every 1 minute you are late

picking up your child. In the event we cannot reach you or an authorized person by 7:00p.m., the Shasta County Child Protection Agency will be called.

_________ While participating in YMCA Child Care, the YMCA has my permission to photograph myself and/or my children for publicity purposes.

__________ The Department of Licensing Agency shall have the authority to interview children, staff, and to inspect and audit child or facility records without prior consent. The Licensee shall make provisions for private interviews with

any children or staff members, and for the examination of all records relating to the operation of the childcare center. The Department of Licensing Agency has the authority to observe the physical condition of the children, including conditions that could indicate abuse, neglect or inappropriate behavior.

I HAVE READ THE ABOVE AGREEMENT AND AGREE TO ABIDE BY ALL OF ITS TERMS.

Signature:_____________________________________________________________________________________ Date:_______________________________

Monday Tuesday Wednesday FridayThursday

Payment Due Now: Registration Fee: $

Less Discount/Benefit: $

Total Due Now: $

Department of Social Services

520 Cohasset Road, Suite 6

Chico 95926 530-895-5033

Shasta Family YMCA 1155 North Court St., Redding, CA 96001

Shasta Family YMCA

State of California – Health and Human Services Agency California Department of Social Services

IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE

CENTERS/FAMILY CHILD CARE HOMES

LIC 700 (10/19) (CONFIDENTIAL) Page 1 of 2

To Be Completed by Parent or Authorized Representative

CHILD’S NAME LAST MIDDLE FIRST SEX TELEPHONE

( )

ADDRESS NUMBER STREET CITY STATE ZIP BIRTHDATE

PARENT /

AUTHORIZED

REPRESENTATIVE

NAME

LAST MIDDLE FIRST BUSINESS

TELEPHONE

( )

HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME

TELEPHONE

( )

PARENT /

AUTHORIZED

REPRESENTATIVE

NAME

LAST MIDDLE FIRST BUSINESS

TELEPHONE

( )

HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME

TELEPHONE

( )

PERSON

RESPONSIBLE

FOR CHILD

LAST MIDDLE FIRST HOME

TELEPHONE

( )

BUSINESS

TELEPHONE

( )

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY

NAME ADDRESS TELEPHONE RELATIONSHIP

PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY

PHYSICIAN ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE

( )

DENTIST ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE

( )

IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?

CALL EMERGENCY HOSPITAL OTHER EXPLAIN: ________________________________

State of California – Health and Human Services Agency California Department of Social Services

LIC 700 (10/19) (CONFIDENTIAL) Page 2 of 2

NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY

(CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN

AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE)

NAME RELATIONSHIP

TIME CHILD WILL BE PICKED UP

SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE DATE

TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY

CHILD CARE HOMES LICENSEE

DATE OF ADMISSION LAST DATE OF ENROLLMENT

Department of Social Services

520 Cohasset Road, Suite 6, Chico, CA 95926

530-895-5033

Shasta Family YMCA

SHASTA FAMILY YMCA (A) 1155 N. COURT ST, REDDING CA 96001 ( P) 530 246 9622 (F) 246 9645 (W) WWW.SFYMCA.ORG

WELCOME TO A LLShasta Family YMCA Financial Assistance EVERYONE IS WELCOME The Shasta Family YMCA is committed to ensuring that everyone has the opportunity to learn, grow, and thrive. To that end, the Y provides financial assistance for those who may not be able to afford the full cost of membership and programs. The Y’s Financial Assistance Program is supported by contributions to our Annual Campaign.

COMMITTED TO OUR COMMUNITY By offering financial assistance to eligible individuals, YMCA programs become accessible to individuals and families of all income levels. Financial assistance only reduces the cost of membership and programs, with intent that all individuals contribute towards the fees to some extent. Y participants can feel confident knowing they are part of an organization that cares greatly for the well-being of the community.

• Financial assistance reduces membership and program fees on apercentage basis; it does not eliminate them. Assistance may range up to 50% for membership and swim lessons; up to 20% for child care; and up to 20% for programs that cost $30 or more.

• All applications must be completed entirely before beingprocessed. Applications with all required information will be processed within five business days of being received.

• You will be notified once the application is processed. To acceptfinancial assistance, you must join in-person at the Y.

• Participants will be asked to reapply annually.

• Any falsification of application information and documentationwill result in removal from the Financial Assistance Program.

SHASTA FAMILY YMCA • 1155 N. COURT ST, REDDING CA 96001 P 530 246 9622 • F 246 9645 • WWW.SFYMCA.ORG

LIST INCOME FOR ALL ADULTS IN HOUSEHOLD

In order to verify information, you may be asked to provide proof of income

⃝ Gross wages, salaries, tips, etc. $____________________ ⃝ Child/spousal support $____________________

⃝ Unemployment compensation $____________________ ⃝ Social security: SSI, SSDI, SDI $____________________

⃝ Calfresh $____________________ ⃝ Passport To Services $____________________

⃝ Retirement/pension $____________________ ⃝ School financial assistance $____________________

⃝ HUD assistance $____________________ ⃝ Other $____________________

⃝ Are there circumstances that substantially impact your gross income and household finances? _______________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________

⃝ Taking into consideration our regular memberships rates, how much do you feel you can afford to pay per month for memberships? $ ____________/ month

FOR OFFICE USE ONLY:

Income total $__________________________ # in household_______________ ⃝ Qualifies for: _____________ ⃝ Does not qualify Awarding: ________ % membership _________ % program _________ % camp/child care _________ % swim lessons Comments ______________________________________________________________________________________________________ Processed by_______________ Date_______________

Print Name _______________________________________________________________________________________________________________________________________________________

Mailing Address ___________________________________________________________________________ City ______________________________________ Zip____________________

Primary Phone __________________________________________________________________ Other phone _______________________________________________________________

Email: ______________________________________________________________________________________________________________________________________________________________

I am applying for:⃝ Youth membership ⃝ Student membership

⃝ Adult membership ⃝ Adult Couple membership

⃝ Senior membership ⃝ Senior Couple membership

⃝ Family membership ⃝ Afterschool care: location: __________________________________________

⃝ Swim lessons ⃝ Summer/Holiday Day Camp: _________________________________________

⃝ Camp McCumber

Please complete information below for all individuals to be included on the membership or program:

Name____________________________________________________ DOB _______________________ Relation ___Self________________ ⃝ adult ⃝ child

Name____________________________________________________ DOB _______________________ Relation ________________________ ⃝ adult ⃝ child

Name____________________________________________________ DOB _______________________ Relation ________________________ ⃝ adult ⃝ child

Name____________________________________________________ DOB _______________________ Relation ________________________ ⃝ adult ⃝ child

Name____________________________________________________ DOB _______________________ Relation ________________________ ⃝ adult ⃝ child

Shasta Family YMCA Financial Assistance Application

YMCA Child Care Policies

1.) Parents are responsible for informing the Site Director and the Y office of any changes in their child’s attendance schedule, address, phone, work, or

emergency telephone numbers, etc. 2.) There is a 3-day minimum charge per week. Monthly fees apply regardless of absences, illness, vacation, etc. 3.) There will be no refund of fees for non-attendance. 4.) Fees are paid by an automatic draft from either a Credit Card or Debit Card. A second form of payment from either a bank account or credit card is

required. Payments not honored by the bank for any reason, (including NSF, closed accounts, invalid expiration date) will incur a returned payment fee. This is in addition to any fees charged by the bank. In the event a payment is returned we will automatically redraft, using the second form of

payment and will include a returned payment fee. 5.) For those using a Third Party Payer, I authorize the YMCA to charge my credit card on file for any balances left unpaid by the Third Party Payer

selected. I understand that my primary form of payment will automatically be charged on the 25th of each month for any balances left unpaid by the Third Party Payer.

6.) The YMCA has the right to initiate legal action for collection of fees or outstanding balances, and the undersigned will be responsible for all cost of collection, including court expenses and reasonable attorney’s fees.

7.) The YMCA may terminate this agreement if the parent or child becomes disruptive to the center; or if, in the opinion of the Site Director, the child

does not progress well in our environment. 8.) Year-end tax notices are available upon request. Our tax ID # is 94-1212141. 9.) The YMCA reserves the right to adjust fees at any time with a 30 day advance notice to program participants.

10.) Only authorized adults (must be18) with identification will be permitted to sign children in and out of camp. Parents must walk their children into the Y to sign them in and out. The center will close promptly at 7:00 p.m. There is a late pick-up fee of $1 for every 1 minute you are late picking up

your child. In the event we cannot reach you or an authorized person by 8:00 p.m., the Shasta County Child Protection Agency will be called. 11.) Medications can only be given with specific written instructions from a physician. Directions on the bottle must include dosages, times and dates

that medication is to be administered. Children cannot attend if they are ill. You must make alternate arrangements for child care. (See the Health Policy in your Parent Handbook).

12.) The YMCA staff will act according to his/her best judgment in any emergency requiring medical care. Parents will be notified immediately and are

responsible for the cost of all medical care. 13.) If deemed necessary for the safety of your child or others, the YMCA staff has permission to restrain and/or physically remove a child from an

unsafe situation. Parents will be notified if this circumstance occurred.

14.) Photographs or likeness or voice of your child may be used in promotional material such as brochures, newspaper, or radio releases without reimbursement for such photographs or promotions.

15.) The Department of Licensing Agency shall have the authority to interview children, or staff, and to inspect the audit child or facility records without prior Notice.

16.) I understand that failure to adhere to these conditions will jeopardize continued participation in the program.

WAIVER: I hereby agree for myself, my child(ren), my heirs, executors and administrators, to indemnify, defend and hold the Shasta Family YMCA and its officers, directors, board members, employees, volunteers, agents, independent contractors and other participants in the program, harmless from any and all liability and claims with respect to any bodily injury, personal injury or illness, including death, or property damage which may occur to my child(ren) or which may be aggravated by participating in a YMCA program. I take full responsibility for the welfare and safety of my minor children, during Shasta Family YMCA activities. I also agree to abide by the rules of the YMCA in regard to my child being in their program. The Y reserves the right to dismiss a child for continual behavioral problems. I understand the Shasta Family YMCA carries no medical insurance, and it is expected that I have health insurance to cover any injuries or losses. In case of accident or illness, the Shasta Family YMCA has my permission to secure the necessary medical attention if unable to contact me. I, individually, and on behalf of any minor children, hereby release the Shasta Family YMCA from any claim whatsoever which may arise as a result of any first aid treatment or assistance provided to my child(ren) in connection with any injury that arises from participating in a YMCA activity. I consent to be photographed and to allow the Shasta Family YMCA to use photos taken of me and/or my minor children for promotional purposes. The Shasta Family YMCA Child Care programs are a non-profit child care center. The operation of our program is overseen by the Shasta Family YMCA Board of Directors. For the names and addresses of current members, please contact the Sr. Director: Finance & Operations. I have received and understand the YMCA Parent’s Manual and the current school year rate sheet.

_______________________________________________________________________________________ Child’s Name

____________________________________________ _____________________________ Parent or Guardian Signature Date

____________________________________________ _____________________________ Staff Signature Date

YMCA Copy

YMCA Child Care Policies

1.) Parents are responsible for informing the Site Director and the Y office of any changes in their child’s attendance schedule, address, phone, work, or

emergency telephone numbers, etc. 2.) There is a 3-day minimum charge per week. Monthly fees apply regardless of absences, illness, vacation, etc. 3.) There will be no refund of fees for non-attendance. 4.) Fees are paid by an automatic draft from either a Credit Card or Debit Card. A second form of payment from either a bank account or credit card is

required. Payments not honored by the bank for any reason, (including NSF, closed accounts, invalid expiration date) will incur a returned payment fee. This is in addition to any fees charged by the bank. In the event a payment is returned we will automatically redraft, using the second form of

payment and will include a returned payment fee. 5.) For those using a Third Party Payer, I authorize the YMCA to charge my credit card on file for any balances left unpaid by the Third Party Payer

selected. I understand that my primary form of payment will automatically be charged on the 25th of each month for any balances left unpaid by the Third Party Payer.

6.) The YMCA has the right to initiate legal action for collection of fees or outstanding balances, and the undersigned will be responsible for all cost of collection, including court expenses and reasonable attorney’s fees.

7.) The YMCA may terminate this agreement if the parent or child becomes disruptive to the center; or if, in the opinion of the Site Director, the child

does not progress well in our environment. 8.) Year-end tax notices are available upon request. Our tax ID # is 94-1212141. 9.) The YMCA reserves the right to adjust fees at any time with a 30 day advance notice to program participants.

10.) Only authorized adults (must be18) with identification will be permitted to sign children in and out of camp. Parents must walk their children into the Y to sign them in and out. The center will close promptly at 7:00 p.m. There is a late pick-up fee of $1 for every 1 minute you are late picking up

your child. In the event we cannot reach you or an authorized person by 8:00 p.m., the Shasta County Child Protection Agency will be called. 11.) Medications can only be given with specific written instructions from a physician. Directions on the bottle must include dosages, times and dates

that medication is to be administered. Children cannot attend if they are ill. You must make alternate arrangements for child care. (See the Health Policy in your Parent Handbook).

12.) The YMCA staff will act according to his/her best judgment in any emergency requiring medical care. Parents will be notified immediately and are

responsible for the cost of all medical care. 13.) If deemed necessary for the safety of your child or others, the YMCA staff has permission to restrain and/or physically remove a child from an

unsafe situation. Parents will be notified if this circumstance occurred.

14.) Photographs or likeness or voice of your child may be used in promotional material such as brochures, newspaper, or radio releases without reimbursement for such photographs or promotions.

15.) The Department of Licensing Agency shall have the authority to interview children, or staff, and to inspect the audit child or facility records without prior Notice.

16.) I understand that failure to adhere to these conditions will jeopardize continued participation in the program.

WAIVER: I hereby agree for myself, my child(ren), my heirs, executors and administrators, to indemnify, defend and hold the Shasta Family YMCA and its officers, directors, board members, employees, volunteers, agents, independent contractors and other participants in the program, harmless from any and all liability and claims with respect to any bodily injury, personal injury or illness, including death, or property damage which may occur to my child(ren) or which may be aggravated by participating in a YMCA program. I take full responsibility for the welfare and safety of my minor children, during Shasta Family YMCA activities. I also agree to abide by the rules of the YMCA in regard to my child being in their program. The Y reserves the right to dismiss a child for continual behavioral problems. I understand the Shasta Family YMCA carries no medical insurance, and it is expected that I have health insurance to cover any injuries or losses. In case of accident or illness, the Shasta Family YMCA has my permission to secure the necessary medical attention if unable to contact me. I, individually, and on behalf of any minor children, hereby release the Shasta Family YMCA from any claim whatsoever which may arise as a result of any first aid treatment or assistance provided to my child(ren) in connection with any injury that arises from participating in a YMCA activity. I consent to be photographed and to allow the Shasta Family YMCA to use photos taken of me and/or my minor children for promotional purposes. The Shasta Family YMCA Child Care programs are a non-profit child care center. The operation of our program is overseen by the Shasta Family YMCA Board of Directors. For the names and addresses of current members, please contact the Sr. Director: Finance & Operations. I have received and understand the YMCA Parent’s Manual and the current school year rate sheet.

_______________________________________________________________________________________ Child’s Name

____________________________________________ _____________________________ Parent or Guardian Signature Date

____________________________________________ _____________________________ Staff Signature Date

Parent Copy