Download participant application 2014

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
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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
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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
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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
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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
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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
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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
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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
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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
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