YMCA of Metropolitan Denver

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Nurses Hidden Field
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Medication Administered Form YES
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Anaphylaxis Form YES
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Asthma Care Form YES
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How many children will you be registering?* This field is required.
Please Select
Please Select
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2
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5
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Please select the site location for your child/children:* This field is required.
Achieve - Before/After School Care
Achieve - Summer Day Camp
Arvada - Sports Camp
Arvada - Specialty Camp
Arvada - Summer Day Camp
Aurora - Adventure Camp
Aurora - Community College
Aurora - Sports Camp
Aurora - Specialty Camp
AXL - Before/After School Care
Christ the King Church - Summer Camp
Dennison - Before/After School Care
Dennison(Kindergarten Only) - Before/After School Care
Dennison - Summer Day Camp
Dora Moore - Summer Day Camp
Downtown - Summer Day Camp
Edison Elementary
Elkhart - Before/After School Care
Elkhart - Summer Day Camp
Explore - Specialty Camp
Excel Academy
Explore - Before/After School Care
Fairmount - Before/After School Care
Garden Place - Before/After School Care
Glendale - Before/After School Care
Glendale - Summer Day Camp
Holm - Before/After School Care
Iowa - Before/After School Care
Joe Shoemaker - Before/After School Care
Littleton - Sports Camp
Littleton - Specialty Camp
Meiklejohn - Before/After School Care
Montclair - Before/After School Care
Montessori - Del Mundo Before/After School Care
Palmer - Before/After School Care
Park Hill - Before/After School Care
Park Hill - Summer Day Camp
Peak Expeditionary - Before/After School Care
Peck - Before/After School Care
Reunion - Summer Day Camp
RMSEL - Before/After School Care
Samuels - Before/After School Care
Shelton - Before/After School Care
Shelton - Summer Day Camp
Shepard of the Hills - Specialty Camp
Sierra - Before/After School Care
Southwest - Sports Camp
Southwest - Summer Day Camp
Southwest YMCA - Before/After School Care
Swansea - Before/After School Care
Trailside - Before/After School Care
Trailside - Summer Day Camp
University Hills - Adventure Camp
University Hills - Summer Day Camp
University Hills - Specialty Camp
University Hills - Sport Camp
Vanderhoof - Before/After School Care
Weber - Before/After School Care
Welchester - Before/After School Care
Welchester - Summer Day Camp
Wyatt Academy - Before/After School Care
Yale - Before/After School Care
Yale - Summer Day Camp
Y Academy - Arvada
Y Academy - Southwest
Y Academy - University Hills
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Child 1 Information* This field is required.
Full Name
Date of Birth
Street Address, Apt #
Gender
City, State
Zipcode
School Name
Current School Grade
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Child 2 Information* This field is required.
Full Name
Date of Birth
Gender
School Name
Current School Grade
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Child 3 Information* This field is required.
Full Name
Date of Birth
Gender
School Name
Current School Grade
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Child 4 Information* This field is required.
Full Name
Date of Birth
Gender
School Name
Current School Grade
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Child 5 Information* This field is required.
Full Name
Date of Birth
Gender
School Name
Current School Grade
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Please attach a photograph of Child 1* This field is required.
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Select files to upload
Max. file size: 10.6MB
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Please attach a photograph of Child 2* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Please attach a photograph of Child 3* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Please attach a photograph of Child 4* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Please attach a photograph of Child 5* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Child 1 Name* This field is required.
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Child 1 Date of Birth
MM/DD/YYYY
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Child 1 Gender* This field is required.
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Child 1 School Name* This field is required.
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Child 1 Current grade in school* This field is required.
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Child 2 Name
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Child 2 Date of Birth
MM/DD/YYYY
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Child 2 Gender
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Child 2 School Name
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Child 2 Current grade in school
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Child 3 Name
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Child 4 Name
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Child 5 Name
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Child 3 Date of Birth
MM/DD/YYYY
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Child 4 Date of Birth
MM/DD/YYYY
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Child 5 Date of Birth
MM/DD/YYYY
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Child's Street Address* This field is required.
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Child City/State* This field is required.
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Child Zipcode* This field is required.
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Child 3 Gender
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Child 4 Gender
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Child 5 Gender
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Child 3 School Name
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Child 4 School Name
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Child 5 School Name
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Child 3 Current grade in school
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Child 4 Current grade in school
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Child 5 Current grade in school
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Primary Parent/Legal Guardian* This field is required.General Information
Full Name
Email
Street Address, apt. #
City, State
Zipcode
Relationship to Dependent
Siblings Attending Program
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Parent/Guardian Primary Phone Number* This field is required.
Please enter a valid phone number.
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Primary Phone Landline or Mobile?* This field is required.
Mobile
Landline
Please select phone type
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Parent/Guardian Secondary Phone Number* This field is required.
Please enter a valid phone number.
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Parent/Guardian Secondary Phone Landline or Mobile?* This field is required.
Mobile
Landline
Please select phone type
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Parent/Guardian #1 Name* This field is required.
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Parent/Guardian #1 - Relationship to Dependent* This field is required.
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Parent/Guardian #1 - Street Address* This field is required.
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Parent/Guardian #1 - City/State* This field is required.
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Parent/Guardian #1 - Zipcode* This field is required.
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Email - Parent #1* This field is required.
example@example.com
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Siblings also attending program
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Secondary Parent/Legal GuardianGeneral Information
Full Name
Email
Street Address, Apt #
City, State
Zipcode
Relationship to Dependent
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Second Parent/Guardian Phone Number
Please enter a valid phone number.
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Second Parent/Guardian Phone: Landline or Mobile?
Mobile
Landline
Please select phone type
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Parent/Guardian #2 Name
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Parent/Guardian #2 - Relationship to Dependent
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Parent/Guardian #2 - Street Address
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Parent/Guardian #2 - City/State
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Parent/Guardian #2 - Zipcode
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Email- Parent #2
example@example.com
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Primary Parent/Legal Guardian Cont.* This field is required.Please enter your work information
Employer
Occupation
Work Street Address
City, State
Zipcode
Times at Work
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Parent/Guardian Work Phone Number* This field is required.
Please enter a valid phone number.
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Parent/Guardian Work Phone: Landline or Mobile?* This field is required.
Mobile
Landline
Please select phone type
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Parent #1 -Employer* This field is required.
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Parent #1 -Occupation
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Parent #1 -Work Street Address
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Parent #1 -Work address- City/State
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Parent #1 -Work address- Zipcode
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Parent #1 -Work Hours
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Secondary Parent/Legal Guardian Cont.Please enter your work information
Employer
Occupation
Work Street Address
City, State
Zipcode
Times at Work
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Second Parent/Guardian Work Phone Number
Please enter a valid phone number.
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Second Parent/Guardian Work Phone: Landline or Mobile?
Mobile
Landline
Please select phone type
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Parent #2 -Employer
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Parent #2 -Occupation
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Parent #2 -Work Street Address
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Parent #2 -Work address- City/State
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Parent #2 -Work address- Zipcode
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Parent #2 -Work Hours
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Emergency Contact #1* This field is required.(Non-Guardian- DO NOT duplicate Emergency Contacts Please)
Name
Email
Primary phone number
Secondary phone number
Street Address
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Emergency Contact #1 - Name* This field is required.
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Emergency Contact #1 - Address* This field is required.
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Emergency Contact 1 - Primary Phone Number
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Emergency contact 1 - Secondary Phone
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Emergency Contact #1 - Email* This field is required.
example@example.com
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Emergency Contact #2* This field is required.(Non-Guardian- DO NOT duplicate Emergency Contacts Please)
Name
Email
Primary phone number
Secondary phone number
Street Address
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Emergency Contact #2 - Name* This field is required.
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Emergency Contact #2 - Address* This field is required.
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Emergency Contact 2 - Primary Phone
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Emergency Contact 2 - Secondary Phone
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Emergency Contact #2 - Email* This field is required.
example@example.com
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Emergency Contact #3* This field is required.(Non-Guardian- DO NOT duplicate Emergency Contacts Please)
Name
Email
Primary phone number
Secondary phone number
Street Address
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Emergency Contact #3 - Name* This field is required.
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Emergency Contact #3 - Address* This field is required.
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Emergency Contact 3 - Primary Phone
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Emergency Contact 3 - Secondary Phone
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Emergency Contact #3 - Email* This field is required.
example@example.com
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Authorized Pick-UpsPlease list any non-parent adults (up to 5) allowed to pick up your child from the program. (Emergency contacts are NOT considered authorized pickups - please add them again here if needed)
Full Name #1
Relationship to Member
Address
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Authorized Pick Up #1
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Authorized Pick Up #1 Primary Phone Number
Please enter a valid phone number.
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Authorized Pick Up #1 Secondary Phone Number
Please enter a valid phone number.
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Auth pick up #1 Address
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Auth Pick Up #1 Relationship to Member
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Authorized Pick-Up #2
Full Name #2
Relationship to Member
Address
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Authorized Pick Up #2 Primary Phone Number
Please enter a valid phone number.
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Authorized Pick Up #2 Secondary Phone Number
Please enter a valid phone number.
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Authorized Pick Up #2
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Auth Pick Up #2 Address
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Auth Pick Up #2 Relationship to Member
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Authorized Pick-Up #3
Full Name #3
Relationship to Member
Address
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Authorized Pick-Up #3 Primary Phone Number
Please enter a valid phone number.
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Authorized Pick-Up #3 Secondary Phone Number
Please enter a valid phone number.
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Authorized Pick Up #3
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Auth Pick Up #3 Address
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Auth Pick Up #3 Relationship to Member
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Authorized Pick-Up #4
Full Name #4
Relationship to Member
Address
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Authorized Pick-Up #4 Primary Phone Number
Please enter a valid phone number.
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Authorized Pick-Up #4 Secondary Phone Number
Please enter a valid phone number.
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Authorized Pick Up #4
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Auth Pick Up #4 Address
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Auth Pick Up #4 Relationship to Member
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Authorized Pick-Up #5
Full Name #5
Relationship to Member
Address
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Authorized Pick-Up #5 Primary Phone Number
Please enter a valid phone number.
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Authorized Pick-Up #5 Secondary Phone Number
Please enter a valid phone number.
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Authorized Pick Up #5
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Auth Pick Up #5 Address
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Auth Pick Up #5 Relationship to Member
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Who should NOT pick up your child(ren)?
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Medical Info* This field is required.Hospital details
Hospital of Choice
Hospital Phone Number
Hospital Address
Is the member covered by medical insurance? Y/N
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Hospital Phone Number* This field is required.
Please enter a valid phone number.
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Hospital* This field is required.
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Hospital Address* This field is required.
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Covered by insurance?
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Insurance Provider Information* This field is required.
Insurance Company
Insurance Subscriber Name
Insurance Policy Number
Additional Details
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Insurance Company Phone Number* This field is required.
Please enter a valid phone number.
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Insurance Company
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Insurance Subscriber Name
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Insurance Policy Number
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Additional Details
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Doctor/Clinic Information* This field is required.
Doctor or Clinic Name
Doctor Type
Address:
Additional Details
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Doctor/Clinic Phone Number* This field is required.
Please enter a valid phone number.
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Doctor or Clinic Name* This field is required.
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Doctor Type* This field is required.
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Doctor Address* This field is required.
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Additional Details
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Dentist Information* This field is required.
Dentist Name
Dentist Address
Additional Details
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Dentist Phone Number* This field is required.
Please enter a valid phone number.
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Dentist Name* This field is required.
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Dentist Address* This field is required.
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Additional Details
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Does Child 1 have any known allergies?* This field is required.
Yes
No
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Child 1: If yes, please specify the following:
Environmental
Food
Medication
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Please provide details including allergen name, reaction when exposed, severity of reaction, preferred actions if exposed, and additional information.
Huge
Large
Normal
Small
Ok
Ok
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Does Child 1 need medication administered during program hours?* This field is required.
Yes
No
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Child 1 - MEDICATION AND TREATMENTS: Please list all medications (including non-prescriptions) that are taken routinely. It must be kept in its original packaging and have the physician's name, the medication's name, dosage and administration instructions (if applicable).Medication #1
Medication Name:
Treatment For:
Dose & Frequency:
Administered when and by who:
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Child 1 - Medications and Treatments ContinuedMedication #2
Medication Name:
Treatment For:
Dose & Frequency:
Administered when and by who:
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Child 1 - Medications and Treatments ContinuedMedication #3
Medication Name:
Treatment For:
Dose & Frequency:
Administered when and by who:
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Child 1 - Please list any possible side or adverse affects, or special instructions:
Huge
Large
Normal
Small
Ok
Ok
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Does Child 2 have any known allergies?
Yes
No
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Child 2: If yes, please specify the following:
Environmental
Food
Medication
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Child 2: Please provide details including allergen name, reaction when exposed, severity of reaction, preferred actions if exposed, and additional information.
Huge
Large
Normal
Small
Ok
Ok
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Does Child 2 need medication administered during program hours?* This field is required.
Yes
No
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Child 2 - MEDICATION AND TREATMENTS: Please list all medications (including non-prescriptions) that are taken routinely. It must be kept in its original packaging and have the physician's name, the medication's name, dosage and administration instructions (if applicable).Medication #1
Medication Name:
Treatment For:
Dose & Frequency:
Administered when and by who:
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Child 2- Medications and Treatments ContinuedMedication #2
Medication Name:
Treatment For:
Dose & Frequency:
Administered when and by who:
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Child 2 - Medications and Treatments ContinuedMedication #3
Medication Name:
Treatment For:
Dose & Frequency:
Administered when and by who:
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Child 2 - Please list any possible side or adverse affects, or special instructions:
Huge
Large
Normal
Small
Ok
Ok
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Does Child 3 have any known allergies?
Yes
No
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If yes, please specify the following:
Environmental
Food
Medication
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Child 3: Please provide details including allergen name, reaction when exposed, severity of reaction, preferred actions if exposed, and additional information.
Huge
Large
Normal
Small
Ok
Ok
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Does Child 3 need medication administered during program hours?* This field is required.
Yes
No
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Child 3 - MEDICATION AND TREATMENTS: Please list all medications (including non-prescriptions) that are taken routinely. It must be kept in its original packaging and have the physician's name, the medication's name, dosage and administration instructions (if applicable).Medication #1
Medication Name:
Treatment For:
Dose & Frequency:
Administered when and by who:
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Child 3- Medications and Treatments ContinuedMedication #2
Medication Name:
Treatment For:
Dose & Frequency:
Administered when and by who:
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Child 3- Medications and Treatments ContinuedMedication #3
Medication Name:
Treatment For:
Dose & Frequency:
Administered when and by who:
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Child 3 - Please list any possible side or adverse affects, or special instructions:
Huge
Large
Normal
Small
Ok
Ok
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Does Child 4 have any known allergies?
Yes
No
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If yes, please specify the following:
Environmental
Food
Medication
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Child 4: Please provide details including allergen name, reaction when exposed, severity of reaction, preferred actions if exposed, and additional information.
Huge
Large
Normal
Small
Ok
Ok
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Does Child 4 need medication administered during program hours?* This field is required.
Yes
No
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Child 4- MEDICATION AND TREATMENTS: Please list all medications (including non-prescriptions) that are taken routinely. It must be kept in its original packaging and have the physician's name, the medication's name, dosage and administration instructions (if applicable).Medication #1
Medication Name:
Treatment For:
Dose & Frequency:
Administered when and by who:
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Child 4- Medications and Treatments ContinuedMedication #2
Medication Name:
Treatment For:
Dose & Frequency:
Administered when and by who:
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Child 4- Medications and Treatments ContinuedMedication #3
Medication Name:
Treatment For:
Dose & Frequency:
Administered when and by who:
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Child 4- Please list any possible side or adverse affects, or special instructions:
Huge
Large
Normal
Small
Ok
Ok
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Does Child 5 have any known allergies?
Yes
No
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If yes, please specify the following:
Environmental
Food
Medication
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Child 5: Please provide details including allergen name, reaction when exposed, severity of reaction, preferred actions if exposed, and additional information.
Huge
Large
Normal
Small
Ok
Ok
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Does Child 5 need medication administered during program hours?* This field is required.
Yes
No
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Child 5- MEDICATION AND TREATMENTS: Please list all medications (including non-prescriptions) that are taken routinely. It must be kept in its original packaging and have the physician's name, the medication's name, dosage and administration instructions (if applicable).Medication #1
Medication Name:
Treatment For:
Dose & Frequency:
Administered when and by who:
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Child 5- Medications and Treatments ContinuedMedication #2
Medication Name:
Treatment For:
Dose & Frequency:
Administered when and by who:
195
Child 5- Medications and Treatments ContinuedMedication #3
Medication Name:
Treatment For:
Dose & Frequency:
Administered when and by who:
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Child 5- Please list any possible side or adverse affects, or special instructions:
Huge
Large
Normal
Small
Ok
Ok
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Child 1 Medication 1 Name
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Child 1 Medication 2 Name
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Child 1 Medication 3 Name
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Child 1 Medication 1 Treatment For
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Child 1 Medication 2 Treatment For
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Child 1 Medication 3 Treatment For
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Child 1 Med 1 - Dose and Frequency
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Child 1 Med 2 - Dose and Frequency
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Child 1 Med 3 - Dose and Frequency
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Child 1 Med 1 - Administered when and by who
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Child 1 Med 2 - Administered when and by who
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Child 1 Med 3 - Administered when and by who
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Child 2 Medication 1 Name
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Child 2 Medication 2 Name
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Child 2 Medication 3 Name
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Child 2 Medication 1 Treatment For
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Child 2 Medication 2 Treatment For
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Child 2 Medication 3 Treatment For
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Child 2 Med 1 - Dose and Frequency
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Child 2 Med 2 - Dose and Frequency
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Child 2 Med 3 - Dose and Frequency
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Child 2 Med 1 - Administered when and by who
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Child 2 Med 2 - Administered when and by who
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Child 2 Med 3 - Administered when and by who
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Child 3 Medication 1 Name
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Child 3 Medication 2 Name
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Child 3 Medication 3 Name
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Child 3 Medication 1 Treatment For
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Child 3 Medication 2 Treatment For
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Child 3 Medication 3 Treatment For
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Child 3 Med 1 - Dose and Frequency
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Child 3 Med 2 - Dose and Frequency
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Child 3 Med 3 - Dose and Frequency
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Child 3 Med 1 - Administered when and by who
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Child 3 Med 2 - Administered when and by who
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Child 3 Med 3 - Administered when and by who
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Child 4 Medication 1 Name
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Child 4 Medication 2 Name
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Child 4 Medication 3 Name
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Child 4 Medication 1 Treatment For
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Child 4 Medication 2 Treatment For
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Child 4 Medication 3 Treatment For
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Child 4 Med 1 - Dose and Frequency
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Child 4 Med 2 - Dose and Frequency
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Child 4 Med 3 - Dose and Frequency
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Child 4 Med 1 - Administered when and by who
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Child 4 Med 2 - Administered when and by who
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Child 4 Med 3 - Administered when and by who
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Child 5 Medication 1 Name
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Child 5 Medication 2 Name
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Child 5 Medication 3 Name
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Child 5 Medication 1 Treatment For
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Child 5 Medication 2 Treatment For
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Child 5 Medication 3 Treatment For
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Child 5 Med 1 - Dose and Frequency
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Child 5 Med 2 - Dose and Frequency
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Child 5 Med 3 - Dose and Frequency
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Child 5 Med 1 - Administered when and by who
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Child 5 Med 2 - Administered when and by who
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Child 5 Med 3 - Administered when and by who
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Please let us know what Child 1 identifies as:* This field is required.
Asian
Black/African
Caucasian
Hispanic/Latino
Native American
Pacific Islander
Prefer not to anser
Other
258
If "other" is selected please list Child 1 identifiers here:
259
Any behavior or special considerations for Child 1:* This field is required.
Yes
No
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If yes, please explain for Child 1:
Huge
Large
Normal
Small
Ok
Ok
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Please describe redirection techniques used at home for Child 1:
Huge
Large
Normal
Small
Ok
Ok
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What are you hoping your child will accomplish in the YMCA Program for Child 1?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
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Is there any other info that would be important to share with our staff about Child 1?
Huge
Large
Normal
Small
Ok
Ok
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Child 1: The person described herein has my permission to participate and engage in all child care activities (which may include swimming, gymnastics, roller or ice skating, field trips-walking/riding, transportation and other activities which may involve certain risks) except as otherwise noted:* This field is required.
Yes
No
265
If yes, please include any exclusions from authorizations for Child 1:
266
I hereby give my permission for the YMCA staff to apply sunscreen to Child 1 before going outdoors on an as needed basis. I understand that it is my responsibility to supply the sunscreen for my child. I am also aware that the YMCA cannot provide sunscreen due to the Department of Human Services rules and regulations.* This field is required.
Yes
No
267
Additional Sunscreen Questions for Child 1:
Please list any special application instructions:
Will additional sun protection be required/provided? (e.g. shirts, hats, etc.)?
268
Child 1 Sunscreen application instructions
269
Child 1 Additional sun protection required/provided
270
Please list any medical or mental conditions we should know about for Child 1:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
271
Are there any specific communications methods or needs we need to be aware of for Child 1?* This field is required.
Yes
No
272
If yes, please specify for Child 1:
Huge
Large
Normal
Small
Ok
Ok
273
Please let us know what Child 2 identifies as:* This field is required.
Asian
Black/African
Caucasian
Hispanic/Latino
Native American
Pacific Islander
Prefer not to anser
Other
274
If "other" is selected please list Child 2 identifiers here:
275
Any behavior or special considerations for Child 2:* This field is required.
Yes
No
276
If yes, please explain for Child 2:
Huge
Large
Normal
Small
Ok
Ok
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Please describe redirection techniques used at home for Child 2:
Huge
Large
Normal
Small
Ok
Ok
278
What are you hoping your child will accomplish in the YMCA Program for Child 2?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
279
Is there any other info that would be important to share with our staff about Child 2?
Huge
Large
Normal
Small
Ok
Ok
280
Child 2: The person described herein has my permission to participate and engage in all child care activities (which may include swimming, gymnastics, roller or ice skating, field trips-walking/riding, transportation and other activities which may involve certain risks) except as otherwise noted:* This field is required.
Yes
No
281
If yes, please include any exclusions from authorizations for Child 2:
282
I hereby give my permission for the YMCA staff to apply sunscreen to Child 2 before going outdoors on an as needed basis. I understand that it is my responsibility to supply the sunscreen for my child. I am also aware that the YMCA cannot provide sunscreen due to the Department of Human Services rules and regulations.* This field is required.
Yes
No
283
Additional Sunscreen Questions for Child 2:
Please list any special application instructions:
Will additional sun protection be required/provided? (e.g. shirts, hats, etc.)?
284
Child 2 Sunscreen application instructions
285
Child 2 Additional sun protection required/provided
286
Please list any medical or mental conditions we should know about for Child 2:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
287
Are there any specific communications methods or needs we need to be aware of for Child 2?* This field is required.
Yes
No
288
If yes, please specify for Child 2:
Huge
Large
Normal
Small
Ok
Ok
289
Please let us know what Child 3 identifies as:* This field is required.
Asian
Black/African
Caucasian
Hispanic/Latino
Native American
Pacific Islander
Prefer not to anser
Other
290
If "other" is selected please list Child 3 identifiers here:
291
Any behavior or special considerations for Child 3:* This field is required.
Yes
No
292
If yes, please explain for Child 3:
Huge
Large
Normal
Small
Ok
Ok
293
Please describe redirection techniques used at home for Child 3:
Huge
Large
Normal
Small
Ok
Ok
294
What are you hoping your child will accomplish in the YMCA Program for Child 3?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
295
Is there any other info that would be important to share with our staff about Child 3?
Huge
Large
Normal
Small
Ok
Ok
296
Child 3: The person described herein has my permission to participate and engage in all child care activities (which may include swimming, gymnastics, roller or ice skating, field trips-walking/riding, transportation and other activities which may involve certain risks) except as otherwise noted:* This field is required.
Yes
No
297
If yes, please include any exclusions from authorizations for Child 3:
298
I hereby give my permission for the YMCA staff to apply sunscreen to Child 3 before going outdoors on an as needed basis. I understand that it is my responsibility to supply the sunscreen for my child. I am also aware that the YMCA cannot provide sunscreen due to the Department of Human Services rules and regulations.* This field is required.
Yes
No
299
Additional Sunscreen Questions for Child 3:
Please list any special application instructions:
Will additional sun protection be required/provided? (e.g. shirts, hats, etc.)?
300
Child 3 Sunscreen application instructions
301
Child 3 Additional sun protection required/provided
302
Please list any medical or mental conditions we should know about for Child 3:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
303
Are there any specific communications methods or needs we need to be aware of for Child 3?* This field is required.
Yes
No
304
If yes, please specify for Child 3:
Huge
Large
Normal
Small
Ok
Ok
305
Please let us know what Child 4 identifies as:* This field is required.
Asian
Black/African
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If "other" is selected please list Child 4 identifiers here:
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Any behavior or special considerations for Child 4:* This field is required.
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If yes, please explain for Child 4:
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Please describe redirection techniques used at home for Child 4:
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What are you hoping your child will accomplish in the YMCA Program for Child 4?* This field is required.
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Is there any other info that would be important to share with our staff about Child 4?
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Child 4: The person described herein has my permission to participate and engage in all child care activities (which may include swimming, gymnastics, roller or ice skating, field trips-walking/riding, transportation and other activities which may involve certain risks) except as otherwise noted:* This field is required.
Yes
No
313
If yes, please include any exclusions from authorizations for Child 4:
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I hereby give my permission for the YMCA staff to apply sunscreen to Child 4 before going outdoors on an as needed basis. I understand that it is my responsibility to supply the sunscreen for my child. I am also aware that the YMCA cannot provide sunscreen due to the Department of Human Services rules and regulations.* This field is required.
Yes
No
Other
315
Additional Sunscreen Questions for Child 4:
Please list any special application instructions:
Will additional sun protection be required/provided? (e.g. shirts, hats, etc.)?
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Child 4 Sunscreen application instructions
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Child 4 Additional sun protection required/provided
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Please list any medical or mental conditions we should know about for Child 4:* This field is required.
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Are there any specific communications methods or needs we need to be aware of for Child 4?* This field is required.
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If yes, please specify for Child 4:
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Please let us know what Child 5 identifies as:* This field is required.
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Black/African
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Other
322
If "other" is selected please list Child 5 identifiers here:
323
Any behavior or special considerations for Child 5:* This field is required.
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No
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If yes, please explain for Child 5:
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Please describe redirection techniques used at home for Child 5:
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What are you hoping your child will accomplish in the YMCA Program for Child 5?* This field is required.
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Is there any other info that would be important to share with our staff about Child 5?
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Child 5: The person described herein has my permission to participate and engage in all child care activities (which may include swimming, gymnastics, roller or ice skating, field trips-walking/riding, transportation and other activities which may involve certain risks) except as otherwise noted:* This field is required.
Yes
No
329
If yes, please include any exclusions from authorizations for Child 5:
330
I hereby give my permission for the YMCA staff to apply sunscreen to Child 5 before going outdoors on an as needed basis. I understand that it is my responsibility to supply the sunscreen for my child. I am also aware that the YMCA cannot provide sunscreen due to the Department of Human Services rules and regulations.* This field is required.
Yes
No
331
Additional Sunscreen Questions for Child 5:
Please list any special application instructions:
Will additional sun protection be required/provided? (e.g. shirts, hats, etc.)?
332
Child 5 Sunscreen application instructions
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Child 5 Additional sun protection required/provided
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Please list any medical or mental conditions we should know about for Child 5:* This field is required.
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Ok
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Are there any specific communications methods or needs we need to be aware of for Child 5?* This field is required.
Yes
No
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If yes, please specify for Child 5:
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Immunization Records for all Children* This field is required.Colorado Law requires the CERTIFICATE OF IMMUNIZATION form to be completed for each participant attending Colorado programs.
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Medical Health Appraisals for all Children (*Childcare Only)Please upload your child’s most recent Medical Health Appraisal. Please remember to fill out and sign the top box of the form. This form needs to be completed and uploaded at every well child visit.
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Medication Administration for all ChildrenIf your child will be taking medication during program hours, kindly attach a copy or include a completed “Medication Administration Permission for School and Child Care” form.
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Allergy and Anaphylaxis PlanIf your child has any severe allergies, kindly attach a completed “Colorado Allergy and Anaphylaxis Emergency Care Plan and Medication Orders” form.
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Asthma Care PlanIf your child has asthma, kindly attach a completed “Colorado School Asthma Care Plan” form.
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Max. file size: 10.6MB
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Legal Court Documentation Colorado State Law prevents the Y programs from withholding a child from their Legal Parent or Guardian without proper and Legal Court Documentation. If you are requesting the Y program to not release your child(ren) to a Legal Parent or Guardian, please attach current Court documentation supporting the request to deny Parent or Legal Guardian pick up.
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Special Medical Needs
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Behavior Plan
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Other(If there is something else you feel we should have on file)
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Have you added your work information?* This field is required.It is required that you add your work information, including the employers address. if you haven't added them, please go back and add your work information.
Yes
No
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I authorize my child to sign themselves in/out of program and walk home.* This field is required.
Yes
No
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I will provide a Health Care Plan signed by my child's health care provider. I understand that I may have to provide/administer medications until the center staff is delegated by the nurse consultant.* This field is required.
Yes
No
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I understand that the nurse consultant will review the health care plan and is available to assist in this process.* This field is required.
Yes
No
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My child doesn't have any special health needs at this time.* This field is required.
Yes (True)
No (False)
351
The aforementioned health history is correct, and I understand that no medication will be administered unless the "Parent/Guardian Request for Giving Medicine and Release Agreement" is completed and signed by the Parent/Guardian.* This field is required.
Initials
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I have received and agree to follow the rules, guidelines, procedures and policies described in the parent information materials. I understand the handbook is provided on the website and I am responsible for the material in the handbook.* This field is required.
Initials
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I understand that the YMCA has supervisory control over YMCA staff only during YMCA sanctioned programs and/or events. Any arrangement outside these sanctioned programs and/or events is the sole responsibility of the parent/guardian.* This field is required.
Initials
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I understand the fee structure for YMCA programs, and will pay according to the prescribed payment plan unless prior written agreement has been made in writing by an authorized staff member.* This field is required.
Initials
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In the event I cannot be reached in an EMERGENCY, I hereby give permission, to the physician selected by the YMCA to secure treatment, hospitalize and order injection, anesthesia or surgery for my child at my expense.* This field is required.
Initials
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I give my permission to the YMCA, without obligation to me, to use any photographs, film footage, tape recordings which may include my child's image or voice for purposes of promoting or interpreting YMCA programs.* This field is required.
Initials
357
The terms herein shall serve as the parent/guardian authorization release, and assumption or risks for claims arising from incidents surrounding child care programs for my child, myself, my spouse, my heirs, executor, administration, assigness, and for all other members of my family.* This field is required.
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Dear Parents/Guardians,

Every child care center in Colorado is required by law to train specific staff to give medication at their center. This training is recognized and approved by:

- Colorado Department of Education

- Colorado Department of Public Health and Environment

- Colorado State Board of Nursing

- Colorado Department of Human Services- Division of Child Care

After the staff member successfully completes the medication training, your center's nurse consultant will delegate the administration of medication to selected staff members. This process has been developed to ensure safe and proper administration of medication. Non-compliance is considered a childcare licensing violation.

This letter describes the authorization forms required in order to administer medication in a child care center.

· Children needing any medication during program hours require completed Medication Authorization(s) that is signed by the child's guardian and health care provider.

Medication includes all prescription medication, over-the-counter medication, nebulizers and inhaled medication. No Exceptions.
Note: Program staff can only administer medication if the authorization is completed by your health care provider and with parent/guardian signature.

- Children with Severe Allergies requiring medication need a completed health care plan that is signed by your health care provider.

- Children with Asthma that regularly require asthma medication during program hours need a completed asthma health care plan that is signed by your health care provider.

- Children with Special Health Conditions need a completed health care plan signed by your health care provider. This plan will be individually designed for your child; in collaboration with the program's nurse consultant, program staff and the child's parent/guardian.

By initialing on the next screen I agree to the above statement.
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Parent/Guardian Initials* This field is required.
Initials
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I hereby certify that I have received and read a copy of the YMCA of Metropolitan Denver Parent Handbook (copies are available online at www.denverymca.org) I will abide by the policies set forth in the parent handbook. I have also discussed the policies and procedures with my child.* This field is required.Parent/Guardian Initials
Initials
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I understand that payments are due in full two weeks prior to the start of each week of camp. If full payment is not received by the Monday of the week attending, your child(ren) will not be able to return on Tuesday of that week, or until payment is made in full. I understand that my child will be considered unregistered for Day Camp at the YMCA and will not be able to attend until the payment is collected in full. Further, any cancellation must be submitted in writing two weeks prior to the start of each week. If this is not done, the parent is responsible for that weeks payment.* This field is required.
Initials
362
I hereby give my permission for my child to watch G movies at the YMCA. YMCA staff will determine the appropriateness of specific PG movies, and movie titles will be made available to parents prior to showing, a permission slip for viewing the PG movie will be made available for signing prior to the movie being viewed. Alternate activities will be provided for children not viewing the movie.* This field is required.
Initials
363
I authorize the YMCA to contact and obtain emergency medical care as needed for my child in the case that I cannot be reached or it is necessary to contact emergency personnel prior to myself.* This field is required.
Initials
364
I hereby give my child permission to attend and be transported to and from field trips and special excursions and to and from school in YMCA vehicles or in local school district busses that are contracted with the YMCA of Metropolitan Denver.* This field is required.
Initials
365
Screen time is limited to only approved field trip screen viewing as planned activity. The YMCA does not allow electronics/ cellular devices or wifi based tablets from home use during program hours, and is not responsible for any electronic items that your child(ren) may bring to the program. If your child(ren) do bring electronics and they are using them inappropriately, they will be confiscated and returned to the parent. If a case of inappropriate use occurs, the child will receive suspension or expulsion from the program depending on the instance.* This field is required.
Initials
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I understand that if my child does not wish to participate in the scheduled activity, there may not be an alternate activity, and I (parent) will be responsible for picking up my child prior to the activity start. I understand that if my child requires special medical care or attention that my child may not be able to participate in the full scope of the activity or program as to allow for necessary accommodations for my child’s safety and required medical care as prescribed by the signing physician.* This field is required.
Initials
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BEHAVIOR SUPPORT GUIDELINES
It is the YMCA of Metropolitan Denver’s goal to provide a healthy, safe, and secure environment for all participants. Youth who attend the program are expected to follow the behavior guidelines based on the YMCA’s four core values and to interact appropriately in a group setting.

BEHAVIOR GUIDELINES:

- We will CARE for ourselves and for those around us

- HONESTY will be the basis for all relationships and interactions

- People are RESPONSIBLE for their actions

- We RESPECT each other and the environment

WHEN A YOUTH DOES NOT FOLLOW THE BEHAVIOR GUIDELINES, WE WILL TAKE THE FOLLOWING STEPS:
1. Staff will redirect the youth to more appropriate behavior.

2. The youth will be reminded of the behavior guidelines and program rules, and a discussion will take place.

3. If the behavior persists, a parent or guardian will be notified of the behavior.

4. The staff will document the situation using a Behavior Support Alert. This written documentation will include what the behavior is, what provoked the behavior, and the corrective action taken. In addition a Behavior Goal Sheet may be necessary.

5. Staff will schedule a conference with the parent or guardian so they can determine the appropriate strategy for resolution.

6. Staff will schedule a progress check or a follow-up conference.

7. If the problem persists, staff will schedule a conference that includes the parent or guardian, youth, staff, and program director.

8. If a youth’s behavior at any time threatens the immediate safety of themselves, other participants, or staff, the parent or guardian will be notified and expected to pick up the youth immediately.

9. If a behavior persists and a youth continues to disrupt the program, the YMCA reserves the right to suspend the youth from the program. Expulsion from the program will be considered in each individual circumstance.

UNACCEPTABLE BEHAVIORS:
The following behaviors are never acceptable and will result in an immediate Behavior Support Alert, suspension of a youth for the remainder of the current day. Additional suspension up to expulsion will be considered dependent of behavior and circumstance.

• ENDANGERING THE HEALTH AND SAFETY OF YOUTH, STAFF, OR ANY OTHER PERSON

• STEALING OR DAMAGING YMCA OR LOCATION PROPERTY

• STEALING OR DAMAGING PERSONAL PROPERTY

• LEAVING THE PROGRAM WITHOUT PERMISSION

• CONTINUALLY DISRUPTING THE PROGRAM WITH BEHAVIORS THAT REQUIRE STAFF TO BE TAKEN OUT OF RATIO

• USING PROFANITY, VULGARITY, OR OBSCENITY OR ACTING IN A LEWD MANNER

• REFUSING TO FOLLOW THE BEHAVIOR GUIDELINES OR PROGRAM RULES

Immediate expulsion will occur if a youth is in possession of or using tobacco, alcohol, controlled substances, illegal drugs, firecrackers, weapons, firearms, or explosives.

By initialing on the following screen I confirm:

I have reviewed the Behavior Support Guidelines with my youth. I understand and agree to all of the terms presented in this document.
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By initialing below I agree to the Behavior Support Guidelines presented to me.
Initials
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By entering your name and signature, you are supplying a legally binding signature; it confirms that all information provided to the YMCA of Metropolitan Denver is correct to the best of your knowledge, and you confirm each of its waivers, consents, and other permissions. It is your responsibility to keep this information up to date.
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Primary Parent/Guardian Signature* This field is required.
Clear
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Additional Parent/Guardian Signature
Clear
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Additional Parent/Guardian Name (if needed)
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Parent/Guardian #3 Signature
Clear
374
Email
example@example.com
375
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