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2014 APPLICATION Rosie’s Girls Construction Trades Exploration Girls Ages 11-13 July 7- 25, 2014 Woodward Career and Technical High School Sponsored by the YWCA of Greater Cincinnati Contact: Rhonda L. Lindon-Hammon at 513-503-0056 or [email protected] This entire application must be completed with all documents signed and the $25.00 registration fee paid to be accepted. To ensure equal opportunity applications are accepted on an ongoing basis. Acceptance letters will be sent by June 15, 2014. If your child is not accepted into the program the registration fee will be returned. We will maintain a waiting list after June 15, 2014. If your child does attend July 7, 2014 the registration fee will not be returned. Copyright © 2007 by Vermont Works for Women, Inc. All Rights Reserved. No part of this Administrator’s Toolbox may be reproduced or distributed in any form or manner without prior written permission of Vermont Works for Women, Inc. PARTICIPANT APPLICATION 2014 $25 CASH REGISTRATION FEE DUE AT TIME OF APPLICATION Return Completed Application to: YWCA-Rosie’s Girls 898 Walnut Street Cincinnati, OH 45202 Camp Dates: July 17 – 25, 2014 ________________________________________ Camper name _____/_____/____ Date of birth _________________________________ CURRENT Grade (this year 2013-2014) ________________________________________________________ Mailing address _____________________________________ School Attending ________________________________________________________ City State Zip _____________________________________ Home phone OPTIONAL (for statistical reporting purposes only, not for use in application decisions) Race/ethnicity of camper (please check all that apply): ___ African American ___ Asian/Pacific American ___ Latina/Hispanic ___ Native American ___ White/Caucasian ___ Other (please specify) _________________________________________________________ Primary custodial guardian ________________________ Relationship to camper __________________________________________________________ Mailing address ______________________ Home phone _________________________ Work phone _________________________________________________________ Second custodial parent/guardian _________________________________ E-mail ________________________ Relationship to camper __________________________________________________________ Mailing address _______________________ Home phone _________________________ Work phone Additional emergency contacts: ______________________________ Name ______________________________ Name ______________________ Phone ______________________ Phone _________________________________ E-mail _____________________________________ Relationship to camper _____________________________________ Relationship to camper The following people, in addition to her parents/guardians named above, are approved to pick my child up from camp: 1)________________________________ 2) ____________________________________ How did you hear about Rosie’s Girls? ________________________________________________________________________ Camper t-shirt size: (Adult Sizes) S M L XL XXL Camper shoe size: _____ 898 Walnut Street Cincinnati, Ohio 45202 Phone- 513-241-7090 / Fax- 513-768-4381 / www.ywca.org/cincinnati -2- Copyright © 2007 by Vermont Works for Women, Inc. All Rights Reserved. No part of this Administrator’s Toolbox may be reproduced or distributed in any form or manner without prior written permission of Vermont Works for Women, Inc. The goal of the Rosie’s Girls summer program is to accept every camper (up to our total enrollment capacity) who can have a successful & safe experience at camp. We will review the ability of each camper to fully participate in camp & will discuss with parents any situations in which Rosie’s Girls activities would be an unsafe or inappropriate experience. Our experience shows that Rosie’s Girls is most beneficial to campers who ATTEND ALL THREE WEEKS. Please initial here to confirm that you plan for your camper to attend all three weeks of camp. ___________ ( Initial Here) In order to make this the best experience for your camper, we would appreciate your answers to the following (please attach another page if needed): 1) During Rosie’s Girls activities, campers work together as a group. Please describe any issues we should know about your camper’s ability to work with peers/adults in a group. ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ 2) Some activities at Rosie’s Girls (carpentry, welding, etc) require girls to follow set safety procedures & explicit directions & to use good judgment/common sense to ensure their own & other campers’ safety. Please describe any concerns you have about your camper’s ability to follow set procedures &/or to use good judgment. ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ 3) Rosie’s Girls staff members make every reasonable effort to accommodate the various needs of campers. Please describe any disabilities (learning challenges &/or physical) or other limitations or concerns about which Rosie’s Girls staff should be aware. Please note any special accommodations (including aides, equipment, or other assistance) your camper will need to have a successful experience at camp. Please include allergies &/or dietary restrictions. ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ 4) Is there anything else you believe would be important or useful for Rosie’s Girls staff to know about your camper? ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ 5) Can your daughter ride a bike? ________________________ 6) Has your daughter participated in Rosie’s Girls Camp before? If so what year?__________________________________ 898 Walnut Street Cincinnati, Ohio 45202 Phone- 513-241-7090 / Fax- 513-768-4381 / www.ywca.org/cincinnati -3- Copyright © 2007 by Vermont Works for Women, Inc. All Rights Reserved. No part of this Administrator’s Toolbox may be reproduced or distributed in any form or manner without prior written permission of Vermont Works for Women, Inc. PERMISSIONS & WAIVERS Waiver for Participant by Parent/Guardian I hereby grant my permission for ____________________ (camper’s name) to participate in all activities at Rosie’s Girls summer camp. Program Evaluation Information from Rosie’s Girls Summer Program participants is collected at the beginning & at the end of the program in order to evaluate the effectiveness of the program in meeting its stated goals. The information is gathered through surveys that the participants fill out on the first & last days of the program. The collection of data involves no risk to the participants & offers potential benefits to future participants in the program as well as girls in other programs, as the results will be used to refine the Rosie’s Girls programs & potentially to inform the development of other programs as part of “best practices.” The participant’s identities, & all identifying information, will be kept strictly confidential under all circumstances. I hereby grant permission for __________________________________ (camper’s name) to fill out surveys & participate in the program evaluation of the Rosie’s Girls Summer Program by YWCA & NAWIC as described above. Photo Release The undersigned hereby consents and authorizes the reproduction, publication and other use of my photographic or cinematic image, voice and/or property by the YWCA of Greater Cincinnati or any program of the YWCA, however designated. The undersigned further consents and authorizes the use of the above-mentioned cinematic image or photographic likeness in any motion picture, video, television broadcast, advertisement, publication or program at such time and in such places as the YWCA of Greater Cincinnati shall determine. The undersigned also consents and authorizes the irrevocable right to use his/her name, fictional name, written copy and/or photograph for the purposes outlined in the above paragraph. Field Trip Photo & Video Release I hereby give my permission for my camper to be photographed and/or videotaped by Administrators, faculty or staff of Rumpke Consolidated Companies, Inc. and its subsidiaries and affiliates and permission to use my likeness and/ or voice in a photograph or video in any and all of its publications or films including website entries, without payment or any other compensation. Pictures or videotapes which may include my camper’s name may also be published. _________ (Initial Here) Electronic Equipment Please be advised that we do not allow any type of electronic equipment to be used at camp. This includes I-pods, cell phones, CD players, & other devices. Campers must turn in cell phones each morning when they arrive at camp and it will be returned at the end of the day. We are not responsible for theft or loss. You will be able to reach your daughter via the camp staff telephone as necessary. Parent/Guardian Signature My signature below indicates my permission for my camper to participate in all camp activities, to attend field trips, to receive medical treatment, & to take part in photo or video sessions as indicated above. In consideration of your accepting my camper’s entry, I hereby, for myself, my child, my heirs, executors & administrators, waive & release any & all rights & claims for damages I or my child may have against Rosie’s Girls, YWCA, NAWIC or their sponsors & their representatives, successors & assigns for any & all injuries suffered by myself or my child in any activity sponsored by this group. ______________________________________________ Parent/guardian Signature _________________________________________________ Printed name Date 898 Walnut Street Cincinnati, Ohio 45202 Phone- 513-241-7090 / Fax- 513-768-4381 / www.ywca.org/cincinnati -4- Copyright © 2007 by Vermont Works for Women, Inc. All Rights Reserved. No part of this Administrator’s Toolbox may be reproduced or distributed in any form or manner without prior written permission of Vermont Works for Women, Inc. Education Center Cincinnati Public Schools P.O. Box 5381 Cincinnati, Ohio 45201-5381 Phone: (513) 363-0075 Fax: (513) 363-0055 www.cps-k12.org Parent/Guardian Consent For Partner Access to Student Computerized Records The YWCA of Greater Cincinnati, a CPS partner, may access CPS's computerized records for my child. This consent allows the partner access my child's grades, disciplinary records, individual education plans, and other personally identifiable student data. The partner organization may use this data to identify and assign services to your child, but must otherwise maintain the confidentiality of the records. However, the partner organization is only permitted to access student records in their program and only to the extent necessary to perform his/her assigned duties. I have read the above and permit the partner to access my child’s personally identifiable information. ___________________________________ ___________________________________ Parent/Guardian Name (print) Student Name (print) __________________________________________ _____________________ Parent/Guardian Signature Phone Number Date __________________________________________ Parent/Guardian Email Address For Office Use Only Student ID #: _____________________________ 898 Walnut Street Cincinnati, Ohio 45202 Phone- 513-241-7090 / Fax- 513-768-4381 / www.ywca.org/cincinnati -5- Copyright © 2007 by Vermont Works for Women, Inc. All Rights Reserved. No part of this Administrator’s Toolbox may be reproduced or distributed in any form or manner without prior written permission of Vermont Works for Women, Inc. This MEDICAL FORM must be completed & signed by both parent/guardian & physician. This form must be received by the YWCA NO LATER THAN JUNE 5, 2014. Campers will not be allowed to attend without this completed form. CAMPER'S NAME: _______________________________________________________________________ Camper’s home address: ______________________________ City: ____________________ State: __________ ZIP: _________ Custodial parent/guardian: ____________________________ Second custodial parent/guardian: _________________________ Address: _________________________________________ Address: _____________________________________________ City: ______________________ State: ____ ZIP: ________ City: _____________________ State: ________ ZIP: __________ Home phone: _______________________ Home phone: __________________________ Work phone: ________________________ Work phone: ___________________________ Name of emergency contact other than parents/guardians listed above: _______________________________________________ Relationship to camper: _____________________________________ Home phone: _______________________________________ Work phone: ____________________________________ DATE OF BIRTH: HEIGHT IMMUNIZATIONS: SEX WEIGHT Please attach immunization history. The Rosie’s Girls program involves using hand-held power tools & welding equipment, as well as physical activities such as a ropes course, swimming, & outdoor games. Please describe any physical restrictions related to this kind of activity: __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Has the camper been treated for any medical problems in the following areas? Seizures Length of seizure Cardio Vascular Restrictions Orthopedic Observations Restrictions Pulmonary Restrictions Asthma Medications? Any limitations with sight or hearing? __ Inhaler? Does the camper wear glasses or contacts? Does the camper have any contagious or infectious diseases? If yes, explain 898 Walnut Street Cincinnati, Ohio 45202 Phone- 513-241-7090 / Fax- 513-768-4381 / www.ywca.org/cincinnati -6- Copyright © 2007 by Vermont Works for Women, Inc. All Rights Reserved. No part of this Administrator’s Toolbox may be reproduced or distributed in any form or manner without prior written permission of Vermont Works for Women, Inc. Has the camper been exposed to any contagious or infectious diseases in last 6 months? Be specific: ALLERGIES: Has the camper had any allergic reactions to the following (be specific) - If so, list in detail the reaction: Drugs: Reaction: Insect Bites: Reaction: Foods: Reaction: Other: Reaction: MEDICATION: Please list all medication patient is currently taking (or attach a current medication schedule for this person): MEDICATION DOSAGE SCHEDULE 1. 2. 3. 4. Please describe any other conditions about which Rosie’s Girls program staff should be aware. DATE OF MOST RECENT EXAM: (must be within last two years) PRACTITIONER’S NAME (please print): TITLE (circle one): MD PA NP Complete Address: Phone(s): PRACTITIONER’S SIGNATURE: DATE: __________________________________ Parental Signature _______________ Date 898 Walnut Street Cincinnati, Ohio 45202 Phone- 513-241-7090 / Fax- 513-768-4381 / www.ywca.org/cincinnati -7- Copyright © 2007 by Vermont Works for Women, Inc. All Rights Reserved. No part of this Administrator’s Toolbox may be reproduced or distributed in any form or manner without prior written permission of Vermont Works for Women, Inc. MEDICAL TREATMENT I give permission to the medical personnel selected by the YWCA of Greater Cincinnati staff to provide routine health care; to administer x-rays, routine tests & treatment; to release any records necessary for insurance or treatment purposes; & to provide or arrange necessary transportation for my child or ward. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the YWCA of Greater Cincinnati staff to secure & administer treatment, including hospitalization, for my child or ward. I hereby give permission to give my child/ward over the counter medications according to standard dose & written doctor’s order: Ibuprofen (e.g., Advil) __ YES __ NO Acetaminophen (e.g., Tylenol) __ YES __ NO Benadryl __ YES __ NO Medications, both over the counter and prescribed, must be in original bottles in order to be given at Camp by Staff. PLEASE FILL OUT COMPLETELY. Parent/guardian signature: __________________________________________________ Date: _________________ 898 Walnut Street Cincinnati, Ohio 45202 Phone- 513-241-7090 / Fax- 513-768-4381 / www.ywca.org/cincinnati -8- Copyright © 2007 by Vermont Works for Women, Inc. All Rights Reserved. No part of this Administrator’s Toolbox may be reproduced or distributed in any form or manner without prior written permission of Vermont Works for Women, Inc. FINANCIAL AID INFORMATION This form must be completed for your camper to qualify for full or partial scholarship to the Rosie’s Girls program. Name of camper: __________________________________________________________________ Name of Parent/Guardian:____________________________________________________________ Please be sure to answer all questions. If you have questions about this form, please call Rhonda L. Lindon-Hammon at (513) 503-0056. Thank you! 1. Does your child receive a free or reduced lunch at her school? Yes ___ No ___ 2 What is your monthly household income? $ ________________ 3. How many household members are dependent on this income? # _________________ 4. How many of these household members are under the age of 18? # _________________ 5. Please check all that apply: One or more family members have a disability or have been ill One or more adults is unemployed or under-employed Financial difficulty related to divorce or separation One or more adults is a college student or studying for a GED Debt payments that are difficult to meet Mortgage is more than 30% of income Unable to meet Credit card payments Student loan debt We cannot afford the tuition without help 6. Is there anything else you would like us to know in determining financial assistance? The Cost of camp is $500. Registration fee How much can you pay? Amount of assistance requested $25 required $__________ $__________ __________________________________________________ Parent/Guardian Signature ______________________________ Date All information on this form will be kept confidential. 898 Walnut Street Cincinnati, Ohio 45202 Phone- 513-241-7090 / Fax- 513-768-4381 / www.ywca.org/cincinnati -9- Copyright © 2007 by Vermont Works for Women, Inc. All Rights Reserved. No part of this Administrator’s Toolbox may be reproduced or distributed in any form or manner without prior written permission of Vermont Works for Women, Inc. Summer Program Behavior & Safety Contract We agree to follow the basic guidelines for Rosie’s Girls’ campers. We understand that if any camper does not follow these guidelines, the camp staff will take appropriate corrective action. In certain cases, a decision may be made to ask a camper not to return to the camp. Rosie’s Girls campers will: seek to participate fully in all Rosie’s Girls activities; follow directions given by Rosie’s Girls staff members, including, but not limited to, requests to protect a camper’s own safety or the safety of other campers and requests to maintain the camp’s facilities; Campers will turn in their cell phone and all electronic devices at the beginning of each day and it will be returned at the end of the day. follow the guidelines for safety, personal responsibility and behavior in the Parent Toolbox; not participate in the verbal or physical harassment of other campers or Rosie’s Girls staff members. This includes, but is not limited to, using offensive language, calling people names and causing physical harm to another individual. Campers: I understand and agree to the above Behavior and Safety Contract. _____________________________ Camper Signature Date Parents: I have received and read the Rosie’s Girls Parent Toolbox. I understand the camp policies and agree to terms stated in the Toolbox, including first aid and emergency procedures, medications requirements, and grounds for discipline or dismissal. I have read the above “Behavior & Safety Contract” with my camper and we understand and agree to the terms in the contract. _____________________________ Parent/Guardian Signature Date 898 Walnut Street Cincinnati, Ohio 45202 Phone- 513-241-7090 / Fax- 513-768-4381 / www.ywca.org/cincinnati - 10 -