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Camp Jorn YMCA
2020 Day Camp Parent Packet For more information regarding Day Camp Registration please call 715-543- 8808 or email Office Manager/Registrar Jenn Davis at [email protected] . Please note that all forms are due by May 6th, 2020. Registration will not be considered complete until all required forms are received.
DAY CAMP CHECK LIST
HEALTH HISTORY & EMERGENCY CARE PLAN
CHILD CARE ENROLLMENT FORM
DAY CARE IMMUNIZATION RECORD
TRANSPORTATION PERMISSION FORM IF TAKING AVW SHUTTLE
SUMMER 2020 TRANSPORTATION REGISTRATION FORM IF TAKING AVW SHUTTLE
AUTHORIZATION TO ADMINISTER MEDICATION – CHILD CARE CENTERS (ONLY IF YOUR CHILD WILL BE TAKING
MEDICATION WHILE AT CAMP)
SCHOLARSHIP APPLICATION IF APPLYING FOR FINANCIAL AID AND NON-REFUNDABLE $50 DEPOSIT PER CAMPER
Please mail complete forms to:
Camp Jorn YMCA
ATTN: JENN DAVIS
13591 Zenner Lane
Manitowish Waters, WI 54545
Fax complete forms to:
715-543-2390
Email complete forms to:
2020 Day Camp
Dates & Rates
Day Camp Sessions
Session 1 June 15– June19
Session 2: June 22– June 26
Session 3: June 29-July 3
Session 4: July 6– July10
Session 5: July 13– July17
Session 6: July 20–July 24
Session 7: July 27–August 31
Session 8: August 3-August 7
Session 9: August 10-August14
Session 10: August 12– August 21
Session 11: August 24-28 Registration 2020 Rate
Coming for 5 weeks or less?
$210 per week
Coming for more than 6 weeks?
$195 per week
Just coming for one or two days?
$60 Per day
Overnight (Thur on designated weeks)
$40
Bus @ AVW (Per child/ Per day)
$5
2020 Day Camp
Payment Options
Deposit Deposits are required to be paid via credit card at time of registra- tion. A $30 nonrefundable deposit per week is due upon registration to guarantee your child’s enrollment and will be credited towards your balance.
Pay As You Go
Feel free to pay at your leisure. We will automatically charge the card on file if an outstanding balance remains after 5 PM on June 1, 2020. Your camper will not be able to join us until your balance has been cleared. DO NOT CHOOSE THIS OPTION AFTER 6/1/20.
Installment Plan by Credit Card
I authorize my credit card to be automatically charged equal install- ments on the first Monday of each month between my date of en- rollment & the pay in full date of June 1, 2020. Installment amounts are based on date of enrollment.
Custom Payment Plan
Parents may request a custom payment plan for campers attending 6 or more weeks of day camp. Within 24 hrs after submitting your day campers application you must contact the Registrar/Office Manager Jenn Davis and request a payment plan form. Failure to do so will forfeit your payment plan request and your payment will be due in full on June 1st. If your camper will receive County Funding you should choose this option and contact our Registrar.
DEPARTMENT OF CHILDREN AND FAMILIES Division of Early Care and Education
CHILD CARE ENROLLMENT
http://dcf.wisconsin.gov
Use of form: Use of this form is mandatory for Family Child Care Centers to comply with DCF 250.04(6)(a)1. Failure to comply may result in issuance of a noncompliance statement. This form may also be used by Group Child Care Centers and Day Camps to comply with DCF 251.04(6)(a)1. and DCF 252.41(4)(a)1. respectively. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes].
Instructions: The parent / guardian shall fill out the form completely, sign it and submit it to the center prior to the child's first day of attendance. Information on this form shall be kept current. When enrolling a child under two years of age, a completed Intake for Child Under 2 Years form must also be on file prior to the child's first day of attendance.
CHILD INFORMATION Name (Last, First, MI) Birthdate (mm/dd/yyyy) First Day of Attendance
PARENT OR GUARDIAN – All parents / guardians are permitted to visit during center hours and are allowed to pick up the child unless access is prohibited or restricted by a court order. Attach court order, if any. If the child resides at multiple locations, the department recommends the provider obtain and attach a schedule. a. Name and Relationship to Child Email Address Where Reachable While Child is in Care
Home Address (Street, City, State, Zip) Home / Cell Phone No.
Does child reside at this location? Yes No
Place of Employment and Work Phone No.
b. Name and Relationship to Child Email Address Where Reachable While Child is in Care
Home Address (Street, City, State, Zip) Home / Cell Phone No.
Does child reside at this location? Yes No
Place of Employment and Work Phone No.
AUTHORIZED PERSONS – Persons other than parents / guardians who are authorized to pick up the child or accept the child if dropped off. If no one, write "None." a. Name and Relationship to Child Home / Cell Phone No.
Email Address Where Reachable While Child is in Care Place of Employment and Work Phone No.
b. Name and Relationship to Child Home / Cell Phone No.
Email Address Where Reachable While Child is in Care Place of Employment and Work Phone No.
EMERGENCY CONTACT – The person to be notified in an emergency when parents / guardians cannot be reached.
Yes No This person is authorized to pick up the child. Name and Relationship to Child Home / Cell Phone No.
Email Address Where Reachable While Child is in Care Place of Employment and Work Phone No.
DCF-F-CFS0062 (R. 12/2014)
Yes No I give permission for my child to participate in Transported Walking field trips and other activities during operating hours.
DEPARTMENT OF CHILDREN AND FAMILIES 2 Division of Early Care and Education
PHYSICIAN OR MEDICAL FACILITY Name
AUTHORIZATIONS
Yes
No I have been informed of the number of pets in the center and their degree of contact with the enrolled children. Note: If pets are added after a child is enrolled, parents
shall be notified in writing prior to the pet's addition to the center. SIGNATURE – Parent or Guardian Date Signed
DCF-F-CFS0062 (R. 12/2014)
Address (Street, City, State, Zip Code) Telephone No.
Yes No I hereby give my consent for emergency medical care or treatment to be used only if I cannot be reached immediately.
Yes No I have had an opportunity to review the policies of this child care center and a summary of the Wisconsin Rules for Licensing Child Care Centers.
Camp Jorn YMCA Immunization Policy
Each year, the American Academy of Pediatrics and the Canadian Pediatric Society publishes a “Recommended Childhood and Adolescent Immunization Schedule.” Practicing pediatricians across North America recognize these schedules as the standard of care regarding childhood & adolescent vaccinations. Concurrently, the US Centers for Disease Control & Prevention (CDC) annually publish vaccine standards for adults.
Among our 3 pillars of the YMCA values is the imperative healthy living and social responsibility. We embrace this value specifically by taking preventive measures to protect the public health of our camp community as a whole. Therefore, Camp Jorn YMCA is requiring that all campers and staff attending camp be immunized as outlined below.
While parents may choose to defer the vaccination of their children, for Camp Jorn YMCA this is not an issue of individual rights and choice, but an issue of public health and policy. The routine vaccination of all campers and staff is an important public health matter especially in the confined environment of a residential summer camp with round-the-clock communal living where illnesses spread much more easily.
Policy: All those who are attending Camp Jorn YMCA programs are required to have age appropriate vaccines as recommended by the American Academy of Pediatrics (AAP), and the Center for Disease Control (CDC), with the exceptions noted.
• DTaP, DT, Td, or Tdap (Diphtheria,Tetanus and Pertussis)
• Tdap vaccine is now required for children over age 11, booster every 10 years
• IPV (Poliovirus)
• HIB (Haemophilus influenza type b bacteria)
• PCV 13 (Pneumococcal) vaccine
• Hepatitis B
• MMR (Measles, Mumps, Rubella) or serologic evidence of immunity. Adults born before 1957 are assumed to be immune to measles
• Varicella vaccine (Varivax – for Chicken Pox), or serologic or historical evidence of immunity
• Menactra (Meningococcal disease / Meningitis) – required for those age 11 and older
Policy Exceptions: We recognize that individuals who have had a documented allergy or severe adverse reaction to a particular vaccine may not be able to complete the immunization schedule outlined above. Additionally, individuals with medical conditions such as congenital immunodeficiency or HIV, cancer and who are receiving chemotherapy, transplant patients, and persons receiving immunosuppressive drugs and chronic steroids also may not be able to receive certain vaccines. In these extremely rare circumstances, current documentation from a Physician (MD or DO), or a Pediatric/Family Practice Advanced Practice Nurse (ARNP or PNP), describing the reason for exemption from immunization must be furnished to Camp Jorn YMCA. We are happy to discuss case by case management of the extremely rare circumstance of medical contraindication to partial or complete vaccination.
This policy will be enforced in accordance with all applicable local, state, and federal laws. In no way should this policy be interpreted to violate the laws of the State of Wisconsin or regulations affecting licensed Residential/Day Camps within the state.
IF THE CHILD MEETS ALL REQUIREMENTS (sign at STEP 5 and return this form to the day care center), OR IF THE CHILD DOES NOT MEET ALL REQUIREMENTS (check the appropriate box below, sign and return this form to day care center).
Although the child has not received all required doses of vaccine for his or her age group, at least the first dose of each vaccine has been received. I understand that it is my responsibility to obtain the remaining required doses of vaccines for this child WITHIN ONE YEAR and to notify the day care center in writing as each dose is received.
NOTE: Failure to stay on schedule or report immunizations to the day care center may result in court action against the parents and a fine of up to $25.00 per day of violation.
For health reasons this child should not receive the following immunizations (List in STEP 2 any immunizations already received)
Physician’s Signature Required For religious reasons this child should not be immunized. (List in STEP 2 any immunizations already received)
For personal conviction reasons this child should not be immunized. (List in STEP 2 any immunizations already received):
Date Signed
To the best of my knowledge this form is complete and accurate.
SIGNATURE - Parent, Guardian or Legal Custodian
DEPARTMENT OF HEALTH SERVICES Division of Public Health F-44192 (Rev. 09/08) DAY CARE IMMUNIZATION RECORD
STATE OF WISCONSIN ss. 252.04,Wis. Stats.
COMPLETE AND RETURN TO DAY CARE CENTER . State law requires all children in day care centers to present evidence of immunization against certain diseases within 30 school days (6 calendar weeks) of admission to the day care center. These requirements can be waived only if a properly signed health, religious, or personal conviction waiver is filed with the day care center. See “Waivers” below. If you have any questions on immunizations or how to complete this form, please contact your child’s day care provider or your local health department.
PERSONAL DATA PLEASE PRINT
STEP 1
STEP 2
STEP 3
STEP 4
IMMUNIZATION HISTORY List the MONTH, DAY AND YEAR the child received each of the following immunizations. DO NOT USE A (4) OR (X) except to indicate whether the child has had chickenpox. If you do not have an immunization record for this child, contact your doctor or local public health department to obtain the records.
TYPE OF VACCINE First Dose Month/Day/Year
Second Dose Month/Day/Year
Third Dose Month/Day/Year
Fourth Dose Month/Day/Year
Fifth Dose Month/Day/Year
Diphtheria-Tetanus-Pertussis (Specify DTP, DTaP, or DT)
Polio Hib (Haemophilus Influenzae Type B)
Pneumococcal Conjugate Vaccine (PCV)
Hepatitis B
Measles-Mumps-Rubella (MMR)
Varicella (chickenpox) vaccine Vaccine is required only if the child has not had chickenpox disease.
Has the child had Varicella (chickenpox) disease? Check the appropriate box and provide the year if known. Yes year (Vaccine is not required) No or Unsure (Vaccine is required)
REQUIREMENTS The following are the minimum required immunizations for the child’s age/grade at entry. All children within the range must meet these requirements at day care entrance. Children who reach a new age/grade level while attending this day care must have their records updated with dates of additional required doses.
AGE LEVELS NUMBER OF DOSES 5 months through 15 months 2 DTP/DTaP/DT 2 Polio 2 Hib 2 PCV 2 Hep B
16 months through 23 months 3 DTP/DTaP/DT 2 Polio 3 Hib1 3 PCV2 2 Hep B 1 MMR3
2 years through 4 years 4 DTP/DTaP/DT 3 Polio 3 Hib1 3 PCV2 3 Hep B 1 MMR3 1 Varicella At Kindergarten entrance 4 DTP/DTaP/DT 4 4 Polio 3 Hep B 2 MMR3 2 Varicella 1If the child began the Hib series at 12-14 months of age, only 2 doses are required. If the child received one dose of Hib at 15 months of age or after, no additional doses are required. Minimum of one dose must be received after 12 months of age (Note: a dose 4 days or less before the first birthday is also acceptable).
2If the child began the PCV series at 12-23 months of age, only 2 doses are required. If the child received the first dose of PCV at 24 months of age or after, no additional doses are required.
3MMR vaccine must have been received on or after the first birthday (Note: a dose 4 days or less before the 1st birthday is also acceptable). 4Children entering kindergarten must have received one dose after the 4th birthday (either the 3rd, 4th or 5th) to be compliant (Note: a dose 4 days or less before the 4th birthday is also acceptable).
COMPLIANCE DATA AND WAIVERS
STEP 5
SIGNATURE
Child’s Name(Last, First, Middle Initial) Date of Birth (Month/Day/Year) Area Code/Telephone Number
Name of Parent/Guardian/Legal Custodian (Last, First, Middle Initial) Address (Street, Apartment number, City, State, Zip)
DEPARTMENT OF CHILDREN AND FAMILIES Division of Early Care and Education DCF-F (CFS-2345) (R. 03/2009)
HEALTH HISTORY AND EMERGENCY CARE PLAN
STATE OF WISCONSIN Page 1 of 2
Use of form: This form is required for family and group child care centers and day camps to comply with DCF 250.04(6)(a)1. and 250.07(6)(L)5., DCF 251.04(6)(a)6. and 251.07(6)(k)5., and DCF 252.44(6)(g) of the Wisconsin Administrative Codes. Failure to comply may result in issuance of a noncompliance statement. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes].
Instructions: The parent / guardian should complete this form for placement in the child’s file prior to the child’s first day of attendance. Information contained on the form shall be shared with any person caring for the child. The department recommends that parents / guardians and center staff periodically review and update the information provided on this form.
CHILD INFORMATION Name (Last, First, MI) Address – Home (Street, City, State, Zip Code)
Telephone Number Birthdate (mm/dd/yyyy) Date – First Day of Attendance (mm/dd/yyyy)
PARENT / GUARDIAN INFORMATION Provide information where the parent(s) / guardian(s) may be reached while the child is in care. Name Telephone Number – Home Telephone Number – Work Telephone Number – Cellular
Name Telephone Number – Home Telephone Number – Work Telephone Number – Cellular
PHYSICIAN / MEDICAL FACILITY INFORMATION Name – Physician Address – Medical Facility Telephone Number
SUNSCREEN / INSECT REPELLENT AUTHORIZATION If provided by the parent, the sunscreen or insect repellent shall be labeled with the child’s name. Per DCF 251.07(6)(f)2., authorizations shall be reviewed every 6 months and updated as necessary. Per DCF 250.07(6)(f)2.a., Authorizations shall be reviewed periodically and updated as necessary.
Yes Yes
No No
I authorize the center to apply sunscreen to my child. I authorize the center to allow my child to self-apply sunscreen.
Brand Name Ingredient Strength
Yes Yes
No No
I authorize the center to apply repellent to my child. I authorize the center to allow my child to self-apply repellent.
Brand Name Ingredient Strength
HEALTH HISTORY AND EMERGENCY CARE PLAN If available, attach any health care plan information from the child’s physician, therapist, etc. 1. Check any special medical condition that your child may have.
No specific medical condition Asthma Diabetes Gastrointestinal or feeding concerns including special diet and supplements Cerebral palsy / motor disorder Epilepsy / seizure disorder Any disorder including Cognitively Disabled, LD, ADD, ADHD, or Autism Other condition(s) requiring special care – Specify.
Milk allergy. If a child is allergic to milk, attach a statement from the medical professional indicating the acceptable alternative. Food allergies – Specify food(s).
Non-food allergies – Specify.
SIGNATURE – Parent or Guardian Date Signed (mm/dd/yyyy)
DEPARTMENT OF CHILDREN AND FAMILIES Division of Early Care and Education DCF-F (CFS-2345) (R. 03/2009)
2. Triggers that may cause problems – Specify.
STATE OF WISCONSIN Page 2 of 2
3. Signs or symptoms to watch for – Specify.
4. Steps the child care provider should follow. If prescription or non-prescription medications are necessary, a copy of the form Authorization to Administer Medication should be attached to this form. Note: group child care centers and day camps may use their own form.
5. Identify any child care staff to whom you have given specialized training / instructions to help treat symptoms. a.
b.
c.
6. When to call parents regarding symptoms or failure to respond to treatment.
7. When to consider that the condition requires emergency medical care or reassessment.
8. Additional information that may be helpful to the child care provider.
Review dates:
Transportation Permission – Child Care Centers Use of form: Use of this form is voluntary. However, completion of this form will help ensure compliance with portions of DCF 250.08, DCF 251.08 and DCF 252.09 of the Wisconsin Administrative Codes regarding regularly scheduled, center-provided / center-contracted transportation of children in care to and from the center. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes]. Instructions: The parent / guardian should complete this form for placement in the child's file at the center and update the information as needed. The center shall maintain the completed form in the child's file for the duration of the child's enrollment. Note: A copy of this form shall be carried in the vehicle when transporting the child. If the child has special health care needs, also include a copy of CFS-2345, Health History – Child Care Centers.
A. CHILD INFORMATION Name Address – Home (Street, City, State, Zip Code)
Yes No Does the child have any special health care needs? If "Yes", attach the department form, “Health History – Child Care Centers.” B. PARENT / GUARDIAN INFORMATION Provide information where the parent / guardian may be reached while the child is in care. 1. Name Telephone Number – Home Telephone Number – Work Telephone Number – Cellular
Address (Street, City, State, Zip Code)
2. Name Telephone Number – Home Telephone Number – Work Telephone Number – Cellular
Address (Street, City, State, Zip Code)
C. EMERGENCY CONTACT INFORMATION Provide information on the person to contact if the parent / guardian cannot be reached. Name Address (Street, City, State, Zip) Telephone Number
D. AUTHORIZED DESTINATIONS / PERSONS INFORMATION Address Child Transported From (Street, City) Address Child Transported To (Street, City) Person Authorized to Receive Child
1.
2.
3.
4. Procedure to follow when parent / guardian or authorized adult is not at destination to receive child – Specify.
E. CHILD’S HEALTH CARE PROVIDER INFORMATION Name – Physician Address (Street, City, State, Zip Code) Telephone Number
F. AUTHORIZATION 1. Yes No I hereby give my consent for emergency medical care or treatment to be used only if I cannot be reached immediately. 2. Yes No I hereby give permission for my school-aged child to enter a building unescorted. SIGNATURE – Parent / Guardian Date Signed
Camp Jorn YMCA Day Camp
Summer 2020 Transportation Registration Form
All campers utilizing the shuttle must be pre-registered for the bus. The “State of Wisconsin Transpor-
tation Permission-Child Care Centers” form must also be filled out and signed by a parent/guardian.
Shuttle Bus Service Bus service is available from Arbor Vitae-Woodruff Elementary School (AV-W).
Please see the Day Camp Parent Packet for additional information.
Please indicate each day your camper requires transportation below with an ”X”
DAY CAMP SESSION Monday Tuesday Wednes- day
Thursday Friday Weekly total
Session 1: June 15-19 $___________
Session 2: June 22-26 $___________
Session 3: June 29-July 3 $___________
Session 4: July 6-10 $___________
Session 5: July 13-17 $___________
Session 6: July 20-24 $___________
Session 7: July 27– 31 $___________
Session 8: August 3- 7 $___________
Session 9: August 10-14 $___________
Session 10: August 12– 21
$___________
Session 11: August 24-28 $___________
Please check the box if applicable: I would like transportation to/from Camp Jorn from the AVW School Shuttle
Bus fee
$5 per day/per camper
BUS TOTAL:
$___________
DEPARTMENT OF CHILDREN AND FAMILIES dcf.wisconsin.gov Division of Early Care and Education
AUTHORIZATION TO ADMINISTER MEDICATION – CHILD CARE CENTERS INSTRUCTIONS FOR USE
Use of form: This form is mandatory for family child care centers to comply with DCF 250.07(6)(f)1.a. Failure to comply may result in issuance of a noncompliance statement. This form is voluntary for group child care centers, day camps and certified providers; however, completion of this form meets the requirements of DCF 251.07(6)(f)1.a., DCF 252.44(6)(e)1.a. and DCF 202.08(4)(f) and 202.09(5)(c)., Wis. Admin. Codes. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes].
Instructions: When a parent is requesting that the provider administer prescription or non-prescription medication to a child in care, this form shall be completed and signed by the parent or guardian before any medication is administered. A separate form shall be used for each medication. Place the form in child's file when medication is no longer required / authorized. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes].
CERTIFIED CHILD CARE CENTERS: This form is voluntary for certified providers; however, completion of Page 1 Medication Information and Authorization and Page 2 Documentation of Medication Administration – Certified Child Care Providers meets the requirements of DCF 202.08(4)(f) and 202.09(5)(c)., Wis. Admin. Codes.
Have the child’s parent or guardian complete and sign Page 1 Medication Information and Authorization. Record administration of the authorized medication in the spaces provided on Page 2 Documentation of Medication Administration – Certified Child Care Providers. Lines should not be skipped.
LICENSED FAMILY CHILD CARE CENTERS: Page 1 Medication Information and Authorization is mandatory for family child care centers to comply with DCF 250.07(6)(f)1.a. Failure to comply may result in issuance of a noncompliance statement.
Have the child’s parent or guardian complete and sign Page 1 Medication Information and Authorization.
Page 2 Documentation of Medication Administration – Certified Child Care Providers, is only for use by certified child care providers. It is not used by Family Child Care Centers because medication administration must be documented in the center medical log book on the day that the medication is administered.
Log the dates and times medication was administered in the center medical log book. Blanket authorizations that exceed the length of time specified on the label are prohibited; no medication intended for use by a child in the care of the center may be kept at the center without a current medication administration authorization from the parent. For more information, see the document Directions for Use of Center Medication & Injury Log or Logs available from the Child Care Information Center website as part of the Appendix J Resource List.
LICENSED GROUP CHILD CARE AND DAY CAMPS: Page 1 Medication Information and Authorization is voluntary for group child care centers and day camps; however, completion of this form meets the requirements of DCF 251.07(6)(f)1.a. and DCF 252.44(6)(e)1.a., Wis. Admin. Codes.
Have the child’s parent or guardian complete and sign Page 1 Medication Information and Authorization.
Page 2 Documentation of Medication Administration – Certified Child Care Providers, is only for use by certified child care providers. It is not used by Group Child Care Centers because medication administration must be documented in the center medical log book on the day that the medication is administered.
Log the dates and times medication was administered in the center medical log book. Blanket authorizations that exceed the length of time specified on the label are prohibited; no medication intended for use by a child in the care of the center may be kept at the center without a current medication administration authorization from the parent. For more information, see the document Directions for Use of Center Medication & Injury Log or Logs available from the Child Care Information Center website as part of the Appendix J Resource List.
DCF-F-CFS0059-E (R. 08/2010) i
Name – Child Birthdate (mm/dd/yyyy)
SIGNATURE – Parent or Guardian Date Signed
DEPARTMENT OF CHILDREN AND FAMILIES dcf.wisconsin.gov Division of Early Care and Education
AUTHORIZATION TO ADMINISTER MEDICATION – CHILD CARE CENTERS MEDICATION INFORMATION AND AUTHORIZATION
A. FACILITY AND CHILD INFORMATION
Name – Child Care Center
B. MEDICATION INFORMATION: Medication shall be in the original container and labeled with the child’s name. The label shall include dosage and directions for administration.
Name – Medication Dosage Time(s) of Day to be Administered
How to be Administered
Dates – Medication Time Period From To
AM PM
AM PM
AM PM
AM PM
Yes No Does the over-the-counter (OTC) medication label indicate the child’s physician should be consulted? If “Yes” I have consulted with my child’s physician, and I am authorizing a dosage consistent with the physician’s recommendation.
Name – OTC Medication
Parent Initials
Additional information / special instructions / contraindications – Specify.
C. AUTHORIZATION
I hereby authorize administration of the above medication to my child by staff of the child care center listed above.
DCF-F-CFS0059-E (R. 08/2010) 1
DEPARTMENT OF CHILDREN AND FAMILIES dcf.wisconsin.gov Division of Early Care and Education
AUTHORIZATION TO ADMINISTER MEDICATION – CHILD CARE CENTERS DOCUMENTATION OF MEDICATION ADMINISTRATION – CERTIFIED CHILD CARE PROVIDERS
Instructions: This section is to be completed only by certified child care providers to document the actual administration of the medication. Lines should not be skipped.
Date Administered Time Administered Dosage Signature / Initials of Person Who Administered the Medication 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
DCF-F-CFS0059-E (R. 08/2010) 2
A LETTER FROM OUR CEO
Dear Camp Jorn Family and Friends,
Thank you for considering a Camp Jorn experience! Together at Camp Jorn YMCA, we make a positive difference for our community through our child care, day camp and resident camp programs. We are committed to making each one of these program accessible to all who would like to participate.
Camp Jorn counts on the generosity of our alumni, fellow community members and volunteers to raise funds to help us keep our fees affordable! We know sometimes, families do need extra help, and we plan for that as well.
Our Y provides quality, affordable child care to more than 25 children, giving them a safe and enriching start to learning while mom and dad are at work. We provide a safe environment for children to learn, grow and develop social-emotional, cognitive and physical skills, so that parents can go to work knowing your kids are with trained professionals who care about their development and well-being.
Through our summer day and resident camps, we also provide a fun and safe community for children and teens to explore new environments, build confidence through accomplishments, make lasting friends and memories, so they can grow as individuals and leaders.
We hope that you join us and if needed, please use the funds that we have raised, to help to make these life changing experiences affordable. We are committed to making sure each person and family feels welcome and supported!
Warmly, Dennis Lipp : CEO
CAMP JORN YMCA SCHOLARSHIP GUIDELINES AND APPLICATION Camper scholarships are available to assist families who need financial help. A scholarship provides
funding for camp fees for campers with a proven need.
Camp Jorn YMCA is committed to making our camping experience available and affordable to all children and families without regard to sex, ethnic origin, religious affiliation or socio-economic level. Scholarship dollars are received through many sources. We are grateful for the generosity of all our sponsors.
GUIDELINES:
e For Res camp, scholarships range between 20% & 75% of the base rate of one session only. For Day camp, scholarships are assessed for the duration of care, as long as funds are available
• Extra programs like Busing, Horsemanship and Water-ski may be covered by scholarship funds.
e For Child Care, scholarships are assessed for the duration of care, as long as funds are available. 0
Please submit this application with a registration form, along with the non refundable $50 deposit.
• Please make sure to complete all sections.
• Confidentiality will be maintained at all times. • Upon receipt of both forms, your application will be reviewed and you will be notified of your
allocation via phone or email. • It is the responsibility of the parent/guardian to pay all costs in excess of the benefits available
from the scholarship before the session starts.
• If you have any questions or concerns, please contact the camp office at 715-543-8808 or [email protected]
• We do require parents to assist their camper in writing a thank you letter to our sponsors upon return fom camp. A few lines of how they enjoyed camp, what activities they did and what it means to them will be greatly appreciated. The letters are forwarded to the sponsors.
Please note that your Scholarship Application will not be reviewed without first submitting a Day Camp Application and a $50 non refundable deposit per camper. You can
make this payment by calling our Registrar, Jenn Davis, with a credit card number at 715-543-8808 or by sending a check to camp:
CAMP JORN YMCA ATTN: JENN DAVIS 13591 ZENNER LANE
MANITOWISH WATERS WI 54545
Camper's Name: _
Camper Scholarship 2020 Application
Camp Jorn YMCA (Only one form per family is needed)
_
(Last Name) (First Name) (Date of Birth)
List additional siblings __________ List additional siblings: _ _
Put a • next to siblings planning to attend camp
How many children in the household_ _
_____
Parent/Guardian Applying ______________________________________ (Last Name) (First Name)
Email: _ _
Spouse or Partner's name _
1 am applying for: Child care_ Day Camp_ Resident Camp_
ESTIMATED 2020 FAMILY INCOME (Check One) (Include a/J unearned Income. Examples: SSDI, SSP, Food stamps Child support, student loans, WIC, Pensions, TANF, Soc. S, Unemployment)
FINANCIAL STATEMENT:
Last Year's Gross Family Income (before taxes):
What is your Family total monthly income?
What are your Family total monthly expenses?
$
$ _
$
Is participant in their school's Free or Reduced-fee Lunch Program? Yes □ No □ If YES, please attach copy of Lunch Letter.
$0-$14,999 $15,000 -$19,999 $20,000 · $29,999
$30,000 · $39,999 $40,000 • $49,999 $50,000 · $69,999 $70,000 +
PROOF OF YOUR CURRENT FINANCIAL SITUATION -Check all items that you are supplying. You must include copies in order for your application to be processed.
One item from the list below is needed to prove income:
__ Copy of2019 Federal Tax form Uust the first page) __ Copy of two recent paycheck stubs r
Copy of Illinois/WI Medicaid Card (copy of f ont and back side of card)
Copy of Free/Reduced Lunch Letter Other: Please describe:
ADDITIONAL INFORMATION:
A) Have you received a Camp Jorn YMCA camper scholarship previously? __ Yes No
If yes, what were the years? _
B) Ifyou would like to include a narrative as to your circumstances for requesting a scholarship, please do so below. Please include any special information relating to this application. (Use space below or attach a separate page)
ESTIMATE AMOUNT YOU CAN CONTRIBUTE:
I can contribute approximately$ towards my camper(s) total camp balance.
(Do not leave blank! We need to know how much you can contribute)
VERIFICATION STATEMENT: I certify that all information provided to Camp Jorn YMCA on this camper scholarship application is true. I understand that providing false information will make me ineligible for participation in Camp Jorn YMCA programs at a reduced fee. The YMCA reserves the right to refuse assistance to any applicant
Signature of Parent/Guardian Date:
2020 Day Camp
Parent and Camper Handbook
Hello Day Camp Families!
There is no place like Camp Jorn – a home away from home where kids laugh, learn, explore and grow in the outdoors, while creating memories and friendships that last a lifetime. Our mission is building character, confidence, and community through enriching outdoor experiences.
At Camp Jorn, caring and professional role models are committed to helping kids build confidence and character. Our highly trained staff helps campers realize that the Y is a place where they can be themselves while trying new things, building new skills and making new friends.
Parents look to the Camp Jorn YMCA for a safe and secure environment where children can learn practical social skills and develop positive values. To ensure the well-being of each child, we review our health and safety policies on an ongoing basis. Our staff-to-child ratio also allows our staff to give each camper the attention and guidance necessary to create a positive and safe environment.
We look forward to a summer that will create memories for your child that last a lifetime! Please do not
hesitate to contact us at any time!
Dennis Lipp
CEO
Camp Jorn YMCA
(P) 715-543-8808
Nina Rouse
Camp Director
Camp Jorn YMCA
(P) 715-543-8808
(C) 262-443-4512
Payment Options & Info.
Important Parent Information
Deposit Deposits are required to be paid via credit card at time of registration. A $30 nonrefundable deposit per week is due upon registration to guarantee your child’s enrollment and will be credited towards your balance.
Pay as You Go
Feel free to pay at your leisure. We will automatically charge the card on file if an outstanding balance remains after 5 PM on June 1, 2020. Your camper will not be able to join us until your balance has been cleared. DO NOT CHOOSE THIS OPTION AFTER 6/1/20.
Installment Plan by Credit Card
I authorize my credit card to be automatically charged equal installments on the first Monday of each month between my date of enrollment & the pay in full date of June 1, 2020. Installment amounts are based on date of enrollment.
Custom Payment Plan
Parents may request a custom payment plan for campers attending 6 or more weeks of day camp.Within 24 hrs after submitting your day camper’s application you
must contact the Registrar/Office Manager Jenn Davis and request a payment plan form. Failure to do so will forfeit your payment plan request and your payment will be due in full on June 1st. If your camper will receive County Funding you should choose the option and contact the Registrar.
We accept checks, money orders, Visa, MasterCard and Discover. Please make checks payable to Camp Jorn
YMCA. There is a $25 fee for all returned checks. Go to www.campjornymca.org to make your payments directly
online.
Or mail payments to:
Camp Jorn YMCA
13591 Zenner Lane
Manitowish Waters, WI 54545
Attn: Camp Registrar
***Please indicate in the memo
section your campers name &
session of attendance
Refunds/Cancellation/Changes Policy
We understand that things change in your life. Any changes that need to be made to your camp schedule need to be made in writing to our camp office. We will try to accommodate these changes based on availability. The $30 deposit is non-refundable. The balance is refundable if cancelled at least 2 weeks before your camper’s session start date. Exceptions may be made for medical reasons. Feel free to contact us with questions at any time. Campers are not eligible for refunds or credits for partial or single day absences and or illnesses.
Scholarships Available for All Families Camp Jorn YMCA believes that every child deserves the chance to experience the wonder of camp and the
opportunity to benefit from the camp experience. We are committed to providing this opportunity to
children of all ages, backgrounds, abilities, and incomes. The scholarship form can be downloaded from our
website.
How to Find Us Camp Jorn YMCA is located at: 13591 Zenner Lane, Manitowish Waters, WI 54545.
Camp is situated on a 70+ acre peninsula of mature pine forest in Wisconsin’s Northern Highland State
Forest. Located on the shores of Rest Lake, part of the Manitowish Chain of Lakes
Sample Daily Schedule 7:45 – 8:30 am
8:30 – 9:00 am
9:00 – 9:15 am 9:15– 10:15 am
10:15 – 10:45 am 11:00 – 11:30 am
11:45 am – 12:30 pm
12:30 – 1:30 pm 1:30 – 2:30 pm
2:45 – 3:00 pm
3:00 – 4:00 pm 4:00 – 4:15 pm
4:30 – 5:30 pm
Child Arrival and Choice Activities
Opening Ceremony
Healthy Snack Play 60 Time!
Activity 1 (by age group)
Activity 2 (by age group) Lunch
R&R (Reading and Relaxation) Hour
Swimming & Tubing Healthy Snack
Activity 3 (Choice Activity)
Closing Activity Choice Activities and Child Pick-Up
Activities Here at Camp Jorn we believe every camper should have the opportunity to experience every activity! Below are some of the activities your camper will be able to participate in weekly:
Tubing – One of the campers’ favorite activities! All groups have the opportunity to go tubing at least
one time during the week.
Swimming- Swimming is one of the most favored activities of the day! On their first day here, campers
will have the opportunity to participate in a swim assessment to determine their swimming ability. Based
on their swimming ability campers are allowed into the shallow, middle or deep sections. Shallow
swimmers are allowed to go down our slide in the middle section if they wear a PFD.
Archery/Air Riflery/Slingshots- At each range, campers will have the opportunity to practice shooting
targets with their group. Campers must be 7 years old and up to be able to experience target sports.
Overnights- Children participating in the overnights must be 8 years old or older. Campers must be
registered for both Thursday and Friday to attend an overnight session. There is an extra fee of $40
for the overnight program. Parents can sign up at the time of registration or by calling our camp office.
During the overnight campers have a chance to experience more camp activities such as a large group
game, gnome hunts, arts and crafts, reading at rest hour, fishing, boating and pontoon rides.
Shuttle Bus Service Bus service is available from Arbor Vitae-Woodruff Elementary School (AV-W). Please use the
transportation form during the registration process to select this option for your camper. There is a fee
of $5 per day per camper. Campers will be supervised by camp staff during their travel to and from camp.
Pick up/drop off location: Back parking lot at AV-W, 11065 Old 51 N, Woodruff, WI 54568
• The shuttle starts loading at 7:10am and leaves AV-W at 7:30 am • Shuttle leaves Camp Jorn at 4:45 pm and arrives back at AV-W at 5:15 pm.
Check in and check out will be done at the bus stop with Camp Jorn staff. Buses will always have staff on board to supervise campers. Supervisors go through orientation during staff training regarding bus transportation and assisting parents and campers at stops. Bus staff will assist campers during the bus ride (getting seated, roll call, answer questions, help with any needs, etc.) Let your camper know staff is there to help!
We request that all children be picked up from the shuttle drop off by 5:30 pm. If there should be changes that would affect a campers’ pick-up or drop off time (emergencies, weather, etc.) camp will email all parents, and use Facebook to notify parents.
If a child is not picked up by 5:30 PM, and no contact can be made with authorized persons, the camper will return to Camp Jorn with their counselor and can be picked up there.
All campers utilizing the shuttle must be pre-registered for the bus. A permission form must also be filled out and signed by a parent/guardian.
Please go over with your camper on their first Day:
Camper Expectations and Safety Guidelines on the Bus 1. Have fun on the bus while staying safe 2. Always listen closely to staff/driver instructions
3. Stay seated
4. Respect the driver at all times
5. Respect those around you
6. Speak with an inside voice
7. Take care of your own belongings and garbage
8. You may bring a book or notebook to draw or color in
9. Think of the great times you’re going to have/just had at camp!!
Drop off & Pick Up When you are dropping off or picking up your camper parents/guardians must sign their camper in and out. Please have a photo ID ready at pick up as our counselors need to verify everyone as an authorized person. We will not release campers to any unauthorized person. All authorized persons should be listed on the Enrollment Form. If your authorized persons change, please notify us in writing to either the Office Manager or Program Director.
• Drop off time at camp: 7:30-8:30am • Pick up time at camp: 4:30-5:30pm • Parents/guardians arriving after 5:30pm will be charged $1.00 per minute for every minute past
What to Bring We suggest that you put first and last name on all items that your camper brings.
• Backpack to hold personal items • Water bottle with name on it • Closed toed shoes • Long pants when cool • Extra clothing • Swimsuit & towel (each day) • Sunscreen • Insect repellent • Raincoat • Sweater, Sweatshirt, or Light Jacket when cool
Items to NOT bring: (Camp Jorn is not responsible for lost or stolen property) If your campers brings these to camp, we will keep them in the office for the day.
• Electronics: tablets, phones, music devices, etc. • Valuables • Camping knives • Candy/Soft Drinks/food • Nut-products of any kind
Snacks & Meals Camp Jorn will provide a light morning snack (9:00 am), lunch (12:00 pm) and a light afternoon snack (4:00
pm), as well as milk and water for meal and snack times. If your camper is participating in an overnight,
dinner and breakfast will be provided as well. In the case of any dietary restrictions please make sure to
provide all information on the Health Form.
Sunscreen/Insect Repellent Please send sunscreen and insect repellent to camp with your camper. Sunscreen will be provided by the
center if you wish to use that option. Please instruct your camper on how to apply and to periodically
reapply throughout the day. Our camp staff cannot apply sunscreen for your camper in body areas covered
by a bathing suit, but will remind your camper to reapply periodically, especially before and after swimming.
Weather Camp is held rain or shine. Campers should dress appropriately for any weather; we suggest packing a spare set of dry clothing and raincoat for rainy days. In the event of severe weather such as extreme heat or rain, campers will be moved inside the YMCA to a safe area where their camp activities willcontinue.
Medications Should your camper need to receive any medication while at camp, the parent/guardian must complete, sign and return the “Authorization to Administer Medication” form available on our website at campjornymca.org. Prescription medication must be in the original bottle supplied by the doctor or pharmacist with the camper’s name, date, dosage, directions for administering and physician’s name printed on it. Non-prescription medication is to be labeled with the camper’s name and the form signed by the parent/guardian including the dosage and directions for administration.
Medical/Emergency Procedures If a minor injury occurs at camp, the camp staff follows standard first aid procedures. Any injury that may result in a scar, an injury to the head, face, or mouth, camp staff will call parents as soon as possible. In the event of a serious injury or illness, the camp staff will notify the parents/guardians immediately to secure permission for appropriate medical attention or need to pick up the child. If the injury requires immediate medical treatment, the camp staff will call 911 and then notify the parents/guardians. The designated hospital for treatment of any serious injury is Howard Young Medical Center – Emergency Room, Woodruff, 715-356-8005.
Health Concerns Any health concerns listed on your camper’s health form (non-food allergies, ADHD, etc.) will be addressed by the Health Officer. Staff working directly with your camper will be aware of any additional needs your camper may have while in our care.
Ill child procedure When a child with an illness or condition, such as vomiting or diarrhea, having the potential to affect the health of other persons is observed at camp, the child shall be isolated in the Health Center Room. Our isolation rooms have a bed and are monitored by our health care staff. Isolation shall be used until the child can be picked up from camp. The child’s parent, or emergency contact will be contacted as soon as possible after the illness is discovered and your camper will need to be picked up as soon as possible.
Trading Post During their time at camp, your camper will be able to visit Trading Post, our camp store. Trading post has many items such as t-shirts, sweatshirts, water bottles, stickers, hats, mugs, and flashlights. A store deposit of $10-20 is recommended your camper. Refunds are issued to campers with $8.00 or more remaining in their account and are made in the fall.
Lost and Found Please mark all personal items clearly with camper’s full name. If your camper loses a personal item at camp, please contact our camp office as soon as you notice. If the item has been found, we will work with you to get it returned to you.
Unclaimed personal items are stored until September 15th and them we donate them to a local charity.
Camper Conduct and Behavior Camp staff is trained in behavior management techniques, including positive guidance, redirection, and the setting of clear limits and expectations. Our intent is for your camper to have a very positive experience at camp. With your support, we will ensure that everyone has a great summer. Attempts to correct behavior through action plans, behavior contracts, and parent/guardian meetings are all part of our behavior management plan. Behavior that disrupts programming, endangers self or others, disrespects property or individuals, or requires repeated one-to-one attention may result in the camper being suspended and/or expelled from Camp Jorn. Any disciplinary action taken will relate directly to the child’s action, not personality and will be handled in a timely manner. No physical punishment, humiliation, scare tactics, or controlling measures will be used by our staff. Methods using food or sleep deprivation, or extended isolation time will not be permitted.
Behavior Management Guidelines: Problem behavior addressed by on site staff. Parents notified based on seriousness and if behavior persists. Action plans with set time line created and put into place for camper’s continuation in programs. Follow up meetings are set. Outcome-decision made regarding continuation or removal from program.
Camp Staff Our counselors are selected on the basis of their proven abilities in working with children. Each staff member goes through an extensive hiring process including a criminal history background check, reference checks and an interview. All counselors receive 40 hours of training prior to the start of camp, including training in camp program areas, relating to children, licensing policies, health and safety skills and are certified in CPR and Standard First Aid and many will be certified life guards. Counselor to Camper ratio is:
5 & 6-year-old campers: 2 staff: 12 campers 7 years old and over: 2 staff: 18 campers
Questions and Who to Contact Please do not hesitate to contact us at any time!
If you child won’t be attending camp on a day they are scheduled to please contact us no later than 7 am. You can text Nina at 262-443-4512 or call our office at 715-543-8808 and leave us a message.
For any questions about our day camp program please call, Nina Rouse, Camp Director at 715-543-8808 ext. 209 .
For registration or payment questions, please contact Jenn Davis, Office Manager/Registrar at 715-543- 8808.
