SPEND YOUR SUMMER AS A LEADER IN TRAINING LIT PROGRAM Covington Family YMCA

WHO: Responsible, caring 13, 14, and 15 year olds who are looking to gain valuable experience and skills in a safe and fun outdoor environment.

WHEN: May 26-July 30, 7am-6:30pm Monday-Friday

PRICE: $80 per week ($75 per week for facility members) $40 program membership fee if not a facility member $15 t-shirt fee (includes three t-shirts)

Capacity for this program is 12 LITs per week. Teens must apply for this program and get accepted before registering.

Teens in the LIT program will work with day campers throughout the day. They will assist counselors with crafts, activities, and games. LITs also help keep camp looking great (ex. clean

the camp building after lunch). LITs swim daily and participate in workshops and discussions. Attending weekly field trips is based on space availability. LITs get to lean leadership and re-

sponsibility in a hands-on, fun way!

LITs are role models for younger children. For this reason, inappropriate behavior of any kind is not tolerated and will result in dismissal from the program.

COVINGTON FAMILY YMCA

770.787.3908 (phone) 2140 Newton Drive ering@ymcaatlanta.org

770.787.3909 (fax) Covington, GA 30014 cvy.ymcaatlanta.org

NOW

ACCEPTING

APPLICATIONS!

LEADER IN TRAINING PROGRAM

SUMMER 2015

COVINGTON FAMILY YMCA

Registration for this program is done on an application basis only. Once your application and references have been reviewed, you may be called for an interview. You will receive a letter in the mail stating whether or not you have been accepted. Registration for this program

may only be completed after being accepted into the program by Covington Family YMCA Camp Staff.

To Complete Your Registration, the following documentation must be provided to the YMCA and must be stapled, paper clipped, or placed in a folder together.

______ Registration Form (to be completed by parent or legal guardian)

______ Application (to be completed by LIT applicant)

______ One Letter of Recommendation from a non-family member

______ Immunization Records (GA Form 3231)

POLICIES AND GUIDELINES

The LIT program is part of our Summer Day Camp. LIT program participants must follow all Summer Day Camp policies. Please initial each item below indicating that you understand and agree to follow all Day Camp Policies. Details of each item, along with other important policies, can be found in the Parent Handbook.

____ 1. I have received a copy of the Parent Policy Handbook for the Covington Family YMCA’s 2015 Summer Day Camp. I agree to review it with my child and together we agree to follow all policies and procedures outlined within the handbook. ____ 2. I understand that my child’s registration is not complete until I have signed the Parent/Athlete Concussion Information page and I have provided a copy of my child’s immunization records (GA Form 3231) to the Covington Family YMCA. ____ 3. I agree to provide each of the following for my child each day:

a. A sturdy water bottle with my child’s name written in permanent marker. Campers will be refilling water bottles throughout the day, so they must be sturdy.

b. A nutritious lunch. I understand that if I fail to provide a lunch for my child, one will be provided at an additional, non-negotiable cost of $5.

c. LIT T-Shirt: I understand that if my child comes to camp without his/her camp t-shirt, staff will provide my child with a shirt for the day at a cost of $3.

d. Closed-toed shoes. These are very important for my child’s safety at camp.

e. A swimsuit and towel. I understand that my child will not participate in any water-related activities if he/she does not have both of these items.

____ 4. I agree to ensure that my child does not bring the following items to camp:

Electronics (including cell phones): These items will be collected by staff and returned to parent/guardian at the end of the day. No exceptions. Please note that this rule is put in place for both the safety of your child’s electronic items and to ensure the quality of our camp programs.

Toys/personal items from home: These items can get lost or broken and cause disruptions in camp programs. Please make sure your children do not bring them!

Gum, candy, soda, energy drinks, coffee drinks: Gum is a choking hazard in camp. Sugary drinks can cause fatigue when children are playing outside in the warm weather. No food or drink in glass containers, please.

Jewelry: Hanging or loose jewelry can be a safety hazard when participating in active camp activities outside. It can also get lost or broken.

____ 5. Payments are due the Friday prior to the week of camp that your child will be attending. Each week of camp is filled on a first-come, first-served basis. Spaces are reserved by paying in full for the week of camp. Attending camp one week does not in any way guarantee a space for the next week of camp.

____ 6. A late pick-up charge of $1 per minute per child is assessed if your child is not picked

up by 6:30pm daily.

____ 7. I understand that this is an outdoor camp and that my child will be outside

for 6+ hours each day. I understand that the Y w ill follow NOAA guidelines for

extreme heat and in cases of bad weather.

Parent Signature: ___________________________________ Date: _____________

2015 Leader in Training Registration Form (must be completed by parent or legal guardian)

LIT INFORMATION

LIT’s Name: ______________________ Age: _____ Birth Date: ____________

Grade Entering Fall 2015: _________ School: _____________ Gender: ______

Home Address: _______________________________ City: ______________

State: _________ Zip: _________ Home Phone Number: _________________

LIT Lives With: ____________________ (parent(s), grandparents, legal guardians, etc.)

FAMILY INFORMATION

Mother/Guardian’s Name: _____________________ Birth Date: _____________

Home Address (if different from child’s): __________________________________

Work Phone: ___________________ Cell Phone: _________________________

Employer/Company: ___________________ Email Address: _________________

Father/Guardian’s Name: _____________________ Birth Date: _____________

Home Address (if different from LIT’s): ___________________________________

Work Phone: ___________________ Cell Phone: _________________________

Employer/Company: ___________________ Email Address: _________________

EMERGENCY CONTACT - To be reached if parents/guardians cannot be reached

Name: ___________________________ Home Phone: ____________________

Work Phone: ______________________ Cell Phone: ______________________

LIT CHECK-OUT/RELEASE

Persons Authorized to Pick LIT Up – ID must be presented at time of pick-up

1. ______________________________ 2. _____________________________

3. ______________________________ 4. _____________________________

Persons NOT Authorized to Pick LIT Up

If a non-custodial parent is on the “NOT Authorized” list, an appropriate court order must be provided to the YMCA in order to enforce this request.

Name: ___________________________ Relation to LIT: __________________

Name: ___________________________ Relation to LIT: __________________

T-SHIRT SIZE Each LIT will receive three shirts for $15. Purchase of new shirts is required. 2014 shirts may not be worn in 2015. Registration must be completed by May 4th to guarantee shirt size.

____ Youth L ____ Adult S _____ Adult M ______ Adult L ______ Adult XL

HEALTH INFORMATION

Information on this form is not part of a camper acceptance process, but gathered to assist in identifying appropriate care for every camper. Parents enrolling a camper with special needs are encouraged to meet with the camper direc-tor prior to program registration to ensure the best camp experience for that child.

Camper’s Physician: _________________________ Phone Number: _________________

Health Insurance Company: ___________________ Policy Number: _________________

Name of Policy Holder: _______________________ Group Number: _________________

Please describe any current physical, mental, or physiological conditions requiring medication, treatment, special re-

strictions, or considerations while at camp. __________________________________________

____________________________________________________________________________________

Has child been hospitalized or had operations, serious injuries, fractures, etc. in the past five years? □ No □ Yes

Does he/she have any disability, special needs, chronic or recurring illness or conditions? □ No □ Yes

Are there any activities from which your child should be exempted for health reasons? □ No □ Yes

If answered “yes” to any of the above questions, please explain: ____________________________________________

_____________________________________________________________________________________________________

Name current medications (prescribed or over the counter) and give instructions:________________________________

______________________________________________________________________________________________________

List all allergies and diet restrictions: ___________________________________________________________________

YMCA OF METRO ATLANTA WAIVER AND MEDICAL AUTHORIZATION FORM

Parent/Guardian Authorization:

I certify that, in advance of participation in YMCA programs, I have received any and all information which I deem necessary or important in making an informed choice regarding my child/ward’s participation in such activity or program. I acknowledge the risks inherent in my child’s participation in activities. In consideration for the Metro Atlanta YMCA, allowing my child/ward to participate in such activity or program, I here-by voluntarily agree to assume all risks of his/her participation in such activity or program. I understand that the YMCA day camp program is not licensed and is not required to be licensed by the State. The YMCA has been granted an exemption from licensing by the Department of Early Care and Learning.

IN EXCHANGE FOR ALLOWING MY CHILD/WARD TO PARTICIPATE IN YMCA PROGRAMS AND SERVICES, I HEREBY AGREE TO RE-LEASE AND HOLD HARMLESS the YMCA, its employees, officers, directors and volunteers, from any loss, liability, claim of bodily injury or death or property damage, or costs which may arise due to my use of the YMCA’s facilities and equipment and my participation in YMCA pro-grams, including claims arising out of negligence of the YMCA and its employees and volunteers. The use of all YMCA facilities shall be under-taken at the undersigned’s own risk. This agreement shall be governed by the laws of Georgia. I give permission for my child/ward to partici-pate on supervised field trips away from the site. The health information about my child that I have provided to the YMCA (including my child’s immunization records) is complete and correct so far as I know. My child has permission to engage in all prescribed activities except as noted in his/her registration materials.

Authorization of Treatment:

I hereby give my permission to the medical personnel selected by the director to secure emergency medical treatment including but not limited to, first aid, CPR, admission to any hospital, tests, surgery or general anesthesia, so long as care is provided by persons or facilities licensed in the state in which such treatment is rendered. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the director to secure and administer treatment, including hospitalization, for the child named above. The completed forms may be photocopied for field trips. I further acknowledge that any medical treatment ordered is my financial responsibility and not that of Metro Atlanta YMCA, or any of its agents, volunteers or employees.

Hospital Consent:

Hospital has permission to treat my child (specify name of hospital): ____________________________________________

Acknowledgement of Policies & Guidelines

Step 1: Is your membership current? □ No – Proceed to Step 2 □ Yes – Skip to Step 3

To participate in any Y programs you must have a membership:

Program memberships are $40 per year per family (valid for one year after purchase date.)

Facility Members have full access to the workout facility and pool and receive discounts on programs. Family Facility Memberships are $60 per month (plus $99 joining fee.)

Step 2: Purchase membership

□ $40 Family Program Membership

□ Checked box for $40 Program Membership on my other child’s camp

registration form (only need one membership per family)

□ Purchasing a Family Facility Membership (additional paperwork required)

Membership

Fee Total:

$_______

Step 3: T-Shirt fees

□ $15 T-Shirt Fee (includes three shirts)

This fee is required as all participants must wear LIT shirt daily.

□ $10 for two extra shirts (optional)

T-Shirt Fee

Total:

$_______

Step 3: Payments made in full for camp weeks

□ $80 per week. First week is required at registration.

Dates of first week child will be attending the program (ex 5/26-5/29):________

□ $80 for each additional week. These fees can be paid today or weekly

throughout the summer. The weeks my child will be attending are (check all

that apply):

□ Week 1 (May 26-29) □ Week 6 (June 29-July 3)

□ Week 2 (June 1-5) □ Week 7 (July 6-10)

□ Week 3 (June 8-12) □ Week 8 (July 13-17)

□ Week 4 (June 15-19) □ Week 9 (July 20-24)

□ Week 5 (June 2-26) □ Week 10 (July 26-30)

□ My child has qualified for a scholarship, and our rate is $_____ per week.

□ We are facility members, so our weekly rate is $75.

Weekly LIT

Fees Total:

$_______

Step 4: Annual Campaign Donation

The Y is a 501(c)(3) non-profit organization and provides financial assistance to low-income families who would not otherwise be able to participate in Y programs. If you would like to help a child in need attend camp, please designate your amount ($5+) in the box to the right. Thank you for your contribution!

Annual

Campaign

Dona!on:

$_______

Step 6: Add Totals for Steps 2, 3, and 4 Total:

$______

FEE CALCULATION – pay nothing until teen has been accepted into program

PER GEORGIA STATE LAW, YOU MUST REVIEW AND SIGN THIS DOCUMENT BEFORE YOUR CHILD CAN PARTICIPATE

IN ANY YOUTH SPORTS ACTIVITIES (SUCH AS ACTIVITIES WE OFFER IN YMCA SUMMER CAMP.)

2015 Leader in Training Application Form (must be completed by potential Leader in Training)

COVINGTON FAMILY YMCA Page 1 of 2Page 1 of 2Page 1 of 2Page 1 of 2

BASIC INFORMATION

Full Name: ____________________________________

My friends call me: __________________________

Age: _________ Birth Date: ______/______/______

Please Check One: � Male � Female

Grade Entering Fall 2015: __________

School: ________________________________________

Home Address: _______________________________

City: ______________ State: _______ Zip: ________

My Cell Phone Number: ______________________

My Email Address: ____________________________

HISTORY WITH THE COVINGTON Y

Have you ever participated in our

Summer Day Camp? � Yes � No

If so, what year(s)? ______________________

Have you ever participated in our

LIT program? � Yes � No

If so, what year(s)? ______________________

Have you ever participated in any

Y programs other than camp?

(ex. soccer, swim team, membership)

� Yes � No If so, which program(s)?

_____________________________________________

YOUR INTERESTS: Place a “�” next to the activities in which you would enjoy teaching or assisting and place a “x” next to activities in which you have little to no experience.

YOUR PERSONALITY: Using a scale of 1 to 5, with 1 meaning “not me” and 5 meaning “definitely me,” tell us how each of these words or phrases describe your personality.

ARTS AND CRAFTS SPORTS/ACTIVE MISCELLANEOUS

_____ Jewelry/Bracelets

_____ Lanyards

_____ Recycle Art

_____ Sketching

_____ Painting

_____ Mosaic/Collage

_____ Paper Mache

_____ Basketball

_____ Soccer

_____ Frisbee

_____ Flag Football

_____ Tennis

_____ Other:_________

_____ Swimming

_____ Volleyball

_____ Gym Games

_____ Baseball or

Teeball

____________________

_____ Science Experiments

_____ Reading

_____ Program Planning

_____ Community Service

Projects

_____ Board Games

_____ Skits/Singing/Dancing

_____ Energetic

_____ Proactive

_____ Problem Solver

_____ Active

_____ Shy/Introvert

_____ Works well in teams

_____ Works well independently

_____ Prefers to work independently

_____ I care what people think of me

_____ Ambitious/Competitive

_____ Friendly/Caring

_____ Helpful

_____ Quiet

_____ Creative/Artistic

_____ Silly/Goofy

PLEASE ANSWER THE FOLLOWING QUESTIONS TO THE BEST OF YOUR ABILITY.

Answers may be written in the space below or typed on a separate sheet of paper. Please attach any additional pages to the back of this application.

1. What extracurricular activities are you involved in? What are your hobbies? Describe

them and your experiences with them.

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

2. Do you have any experience working with children? Describe what you did, what you enjoyed the most, and what you enjoyed the least about your experience?

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

3. What values do you want to model for your friends, family, and community?

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

4. The LIT program requires active participation in team activities, service projects, chores, and group discussions. What do you expect to learn and what you like to accomplish by being a part of the LIT program this summer? __________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

5. Describe a group experience where you demonstrated your ability to think, act, and communicate as a leader.

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

2015 Leader in Training Reference Form (must be completed by a non-family member)

_______________________________________ has applied to the summer Leader In Training (LIT) program at the Covington Family YMCA. The purpose of this program is to teach young teens leadership skills and encourage them to enjoy outdoor fun in a supervised setting. Skills are taught through discussions, workshops, and hands-on experiences, all the while emphasizing the YMCA’s core values of caring, honesty, respect, and responsibility. LITs spend the majority of their day working with children (Day Campers) while shadowing and assisting Camp Counselors. Because of this, it is very important that we select eager and capable teens.

Please fill out the questions below to the best of your ability. Additional comments can be made on a separate sheet of paper and attached to this form. All responses will be kept confidential.

Reference’s Name: _____________________________________________ Position/Company: ____________________________

How long have you known the applicant? _______________________________________________________________________

In what capacity do you know the applicant? __________________________________________________________________

________________________________________________________________________________________________________________________

Generally, how would you rate the applicant’s ability and interest in working with children?

________________________________________________________________________________________________________________________

What specific reason(s) would you give for accepting this individual into the LIT program?

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

What are his or her strengths as a positive leader/role model in his or her community?

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

In what areas for growth does this individual need to mature to be a stronger leader/role model in his or her community?

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

COVINGTON FAMILY YMCA OVER OVER OVER OVER ����

In what areas for growth does this individual need to mature to be a stronger leader/role model in his or her community?

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

If you were a parent (or are a parent), would you be comfortable knowing that the applicant might spend most of the day camp day with your child and might eventually become your child’s counselor? Why or why not?

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Do you know any reason why this applicant should not be working with day campers?

Please explain thoroughly. Again, this will be kept confidential.

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Thank you for completing this reference form. Please note that incomplete references may affect the applicant’s acceptance. If you have any questions or concerns, please contact the Summer Day Camp Director, Erin Gorman, by phone at 770-787-3908 or by email at ering@ymcaatlanta.org.

Upon completion of this confidential form, please turn it in to the Y via one of the following ways:

Mail: Fax: Scan and email:

Erin Gorman 770.787.3909 ering@ymcaatlanta.org 2140 Newton Drive Covington, GA 30014 This form can also be returned to the applicant in a sealed envelope to be turned in with completed LIT application.

Thank you!

Covington Family YMCA

2140 Newton Drive Covington, GA 30014

770.787.3908