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REGISTRATION FOR RETURNING PARTICIPANTS ONLY

March Break Camp 2023: March 13th – March 17th

9:00am-4:00pm
Price: $50 per week

* Please continue to fill out this form ONLY if your child is a returning participant to YACRO Respite Camps*

Please complete the following form if you are interested in having your child attend the 2023 Yarmouth Association for Residential Community Options March Break Camp.

Once you submit your registration, please await a confirmation of approval email that your child is able to attend camp.

* Due to limited group capacity for participants, registration will be assigned on a first come first serve basis.

RETURNING CAMPERS

Is your child a returning participant to YACRO Respite Camps? *

Please proceed to the full March Camp Registration Form HERE

Please enter below the full name and email address used for previous registrations

Child's Name *

Parent/Guardian's Email Address: *

Since you last signed your child up for camp:

Has your address or contact info changed? *

Please complete your updated address/contact info below:

Name *

Primary Phone Number: *

Secondary Phone Number:

Email Address: *

Mailing Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

I would like to receive information via: *

Phone
Email
Mail

I consent to Respite Day Camp Staff sending text information regarding my child to my phone *

If "yes", what phone number should we text? *

Emergency Contact Name(s): *

Emergency Contact Phone Number 1 *

Emergency Contact Phone Number 2

CHILD INFORMATION

Has any of your child’s health information changed ie. doctors, medications, personal care needs, new or changed behaviors, etc.? *

Please select which information has changed, making sure to check every box where information is different than in the past *

New doctor
New medications
New personal care needs
New or changed behaviors

Please take the time to answer carefully these questions

*Most answers are compulsory. If a question does not apply, please just type "n/a" in the text box.

Family Doctor: *

Other Professionals Involved: *

Diagnosis: *

Allergies: *

Medical Needs: *

Medications: *

Specific Concerns:

Please indicate the level of care that your child requires: *

heavy
moderate
light

Does your child require assistance with personal care? *

Please specify what aspects of personal care your child requires assistance with: *

Communication

Please describe your child’s method(s) of communication: *

Behaviors

Does your child exhibit any of the following behaviours: *

Elopement
Aggression towards others
Aggression towards self
Anxiety
Sensory Needs
Any Transportation Concerns

Does your child wear a project lifesaver bracelet? *

If "Yes" to any, please describe further what behaviours can be expected, frequency, any potential triggers, etc. *

Methodology

Please specify what methods are used when problematic situations occur (ie. behavior and medical problems): *

Daily Routine

Please describe a regular day in the life of your child. *

Activities/Hobbies

What are your child’s favorite activities? For example, do they enjoy music, certain television programs, a special toy or book, etc.? *

Outdoor Recreational Activities

What types of outdoor activities does your child enjoy? *

Is there any other information you feel is important for camp staff to be aware of? *

Please provide details:

Parent/Guardian Signature/Consent:

*By signing this form, I consent to sharing the above information regarding my child with the Respite Coordinator and Respite Day Camp Staff.

Signature *

PARTICIPATION WAIVER AND CONSENT

I, the under signed parent/guardian of

Child's Name *

do hereby consent to his/her participation in the Yarmouth Association for Community Residential Options March Break Camp.

I acknowledge that participation in this program may expose the above named youth/child to the possibility of injury. I grant Yarmouth Association for Community Residential Options Summer Respite Staff the authority to obtain emergency medical treatment as necessary to ensure that the above named child/youth is safe from further injury.

In consideration of Yarmouth Association for Community Residential Options and the permission to allow this child/youth to participate in its March Break Camp, I agree to waive and release Yarmouth Association for Community Residential Options from all claims for damages that may arise.

Parent/Guardian Name *

Parent/Guardian Signature *

Date *

MEDICATION AUTHORIZATION FORM

Medication will only be administered if it has been prescribed by a qualified medical practitioner, is in its original container and I have a signed permission form with directions.

Parent/Guardian name *

parent/guardian, authorize Respite Coordinator/March Break Camp Staff to administer

Medication(s) *

(medication) to my child

Child's name *

with the following instructions:

Dosage *

Time *

Special Instructions (i.e. on full/empty stomach, etc.) *

Possible Side Effects *

Parent/Guardian Signature *

Date *

COVID-19 Info for Parents/Family Service Agreement

*The Respite Coordinator will contact you directly to confirm your child’s spot in the March Break Camp.*

YACRO continues to implement health and safety measures in accordance with public health guidelines to reduce sickness among participants and staff. If you or your child are experiencing illness, please stay home and return once well again. If your child becomes ill at camp, you will be contacted to come pick them up.

Staff will ensure all necessary sanitary measures are implemented throughout the day, such as proper hand washing, avoiding sharing, avoiding touching face, regular waste removal, frequent cleaning of highly touched surfaces, and regular cleaning checklists. Masks are not required by participants or staff.

Hours of Summer Day Camp will be 9:00am-4:00pm. Please ensure you arrive no earlier than 9:00am for drop off and no later than 4:00pm for pick up. You must sign in/sign out your child at the beginning and end of the day. Drop off and pick up will take place through the side door of the building located near the wheelchair ramp.

The cost of March Break Camp is $50.00. Payment will be required upon registration to secure your spot.

Your child will require a packed lunch with snacks and water for each day. Please also send an extra set of clothes and any additional items your child will require throughout the day, ie. car seat, pull-ups, medications, sensory tools, communication devices, etc.

Please note: We do not provide one on one support to individuals. If your child requires this or if you have any other specific concerns, please contact Amy Sarginson at (902)742-9258 or respite@yacro.com

Parent/Guardian Name *

Parent/Guardian Signature *

Date *

TRANSPORTATION WAIVER

Child/Youth:

Child/Youth: *

I acknowledge that the above named child/youth will be participating in activities and events organized by the Yarmouth Association for Community Residential Options March Break Camp Staff. I am aware that the participation of my child/youth may be outside the scope of his/her regular routine. I give permission for my child to be driven by March Break Camp Staff/Respite Coordinator to a program location when the daily program activities require transportation.

I acknowledge and confirm that I have read this entire document prior to signing.

Parent/Guardian Name *

Parent/Guardian Signature *

Date *

CONSENT FOR PHOTO AND VIDEO

There may be activities during the March Break Camp where photos and videos may be taken. To do this we are asking your permission to photograph and/or videotape your child/youth when participating in March Break Camp activities. YACRO hosts a Day Camp Blog on our website located at respite.yacro.com. Some of the photos taken throughout March Break Camp will be used on the blog.

MY CONSENT TO SHARE PHOTOS/VIDEO *
YES, I do consent
NO, I do not consent

Parent/Guardian name *

parent/guardian of

Child's Name *

give my permission for my child to be photographed or videotaped in a group or individual setting by the YACRO March Break Camp staff, and used on the YACRO Respite Blog.

Parent/Guardian Signature *

Date *

* Fill the spaces below ONLY to deny your consent to share photo/video.

I *

parent/guardian of

Child's Name *

DO NOT GIVE my permission for my child to be photographed or videotaped in a group or individual setting by the YACRO March Break Camp staff, and used on the YACRO Respite Blog.

Parent/Guardian Signature *

Date *

For Office Use Only:

Respite Coordinator

Date Received

REGISTRATION FOR RETURNING PARTICIPANTS ONLY

RETURNING CAMPERS

Please proceed to the full March Camp Registration Form HERE

Please enter below the full name and email address used for previous registrations

Since you last signed your child up for camp:

Please complete your updated address/contact info below:

CHILD INFORMATION

Please take the time to answer carefully these questions

Communication

Behaviors

Methodology

Daily Routine

Activities/Hobbies

Outdoor Recreational Activities

Parent/Guardian Signature/Consent:

PARTICIPATION WAIVER AND CONSENT

MEDICATION AUTHORIZATION FORM

COVID-19 Info for Parents/Family Service Agreement

TRANSPORTATION WAIVER

CONSENT FOR PHOTO AND VIDEO

For Office Use Only:

For more information regarding respite support please contact:

Amy Sarginson

Contact Us

For more information regarding respite support please contact:

Amy Sarginson

Contact Us

Application Form for Returning March Break Campers

Application Form for Returning March Break Campers

Application Form for Returning March Break Campers

REGISTRATION FOR RETURNING PARTICIPANTS ONLY

RETURNING CAMPERS

Please proceed to the full March Camp Registration Form HERE

Please enter below the full name and email address used for previous registrations

Since you last signed your child up for camp:

Please complete your updated address/contact info below:

CHILD INFORMATION

Please take the time to answer carefully these questions

Communication

Behaviors

Methodology

Daily Routine

Activities/Hobbies

Outdoor Recreational Activities

Parent/Guardian Signature/Consent:

PARTICIPATION WAIVER AND CONSENT

MEDICATION AUTHORIZATION FORM

COVID-19 Info for Parents/Family Service Agreement

TRANSPORTATION WAIVER

CONSENT FOR PHOTO AND VIDEO

For Office Use Only:

For more information regarding respite support please contact:

Amy Sarginson

Contact Us

For more information regarding respite support please contact:

Amy Sarginson

Contact Us