Summer Camp Registration

Child's Birth Date(Required)

Child's Age(Required)

Email(Required)

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Grade: School: (Please put N/A, if this doesn't apply to you)(Required)

Which weeks are you Interested in?(Required)

NOTE: (NO Camp on Wednesday, JUNE 19th-“JUNETEENTH” (National Holiday). No Camp on Thursday, July 4th and Friday, July 5th (National Holiday)

WEEKS 1: Week 1: June 17th – July 21st

WEEK 2: June 24th – June 28th.

WEEK 3: July 1st - July 5th

WEEK 4: July 8th - July 12th

WEEK 5: July 15th – July 19th

WEEK 6: July 22nd – July 26th

WEEK 7: July 29th – August 1st

Week 8: August 5th – August 9th

* Medical Information: Allergies or intolerance to food:(Required)

If an allergic reaction occurs, please list steps to relieve reaction:(Required)

NOTE: Confidence Youth Coaching (CYC) staff (all hired employees and/or volunteers) will NOT be responsible for administering daily/hourly medications. Participants/Members must be able to independently carry inhaler and/or EpiPen for health emergencies caused by asthma/food allergies. If participants/members request assistance from the employees/volunteers to help administer inhaler and/or EpiPen, they may assist.

Emergency Medical Authorization:
I give CYC permission for my child to be given cardiopulmonary resuscitation (CPR) and first aid treatment by a staff member of CYC. I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I authorize the CYC staff to obtain immediate medical care and give consent to the hospitalization and performance of necessary diagnostic tests upon, the use of surgery on, and/or the administration of drugs to his/her child or ward if an emergency occurs when he/she cannot be located immediately. It is also understood that this agreement may only cover those situations which are true emergencies and only when he/she cannot be reached. I understand that the provider will take every effort to contact me and/or my designated emergency contacts (All medical treatment/costs will be covered by clients, parents, and personal insurance companies).

Any Diagnosis/Disabilities?(Required)

Current Diagnosis:

Parent Name(Required)

First Last

Phone(Required)

Parent Name

First Last

Phone

Emergency Contact Name(Required)

First Last

Phone

LUNCHES/SNACKS:
Participants/members are allowed to bring their own lunch. Please consider packing healthy/nutritional lunches, and drinks. Participants/members will be engaging in high levels of activity throughout the day and they may bring their own water (NO GLASS), or Gatorade bottle. Water/snacks will also be provided.

Parental Agreements:

1.) CYC agrees to notify parents/guardian whenever the child becomes ill, and parents/guardian will arrange to have the child picked up as soon as possible if requested by the CYC staff. Parent/guardian agrees to inform the CYC within 24 hours or the next business day after his child or any members of the immediate household has developed a reportable communicable disease, as defined by the State Board of Health, except for life‐threatening diseases which must be reported immediately (such as COVID-19).

2.) Injury: Moderate injuries will be communicated to parents once proper first aid procedures have been followed. If the illness or injury occurs late in the day and is moderate, you may be notified at the end of the day. In case of severe injury parent will be contacted immediately.

3.) Verbal Abuse/Fighting: CYC does NOT tolerate participants/members who harm other members or members who harm staff. This includes and is not limited to name calling, degrading, demeaning, threatening OR physically harming another child or staff person. Any member or members found to be threatening (verbally/in writing/physically), harassing, making fun of, intimidating, or any form of bullying another camper will be subject to disciplinary actions including sent home or suspended from club/camp/program.

4.) Suspension: If your child has broken rules, or policies, they are subject to suspension from camp. Refunds will NOT be given for a child suspended from camp. The amount of time suspended will be at the discretion of the Summer Club/Camp Program Director.

5.) Group Planning of Community Outings: Participants/members will collaborate as a group to brainstorm in decision making for planning daily recreational outings, or special interest actives as a cohesive team. Daily planning and activities may vary from day to day including but not limited to SEL, arts/crafts, sports, games, team building, and more. Please refer to the program brochure for a sample schedule.

6.) My child has permission to walk or take the METRO transportation system to participate in all CYC program activities and related community outings.

7.) My child has permission to participate in local swimming pools, parks, and waterfront activities.

8.) The parent/guardian authorizes the application of sunscreen and/or insect repellent for his/her child by CYC staff (if child, member requests assistance with application).

9.) I have received the client/parent /guardian contract/policies, and understand that it is my responsibility to read, understand and be aware of ALL policies outlined in client/parent contract. All information on this form is true and complete to the best of my knowledge. I understand and agree to the Emergency Medical Authorization, Parental Agreements, Policy, and Payment of Fees as outlined in the Application/Contract.

CONFIDENCE YOUTH COACHING PARTICIPANT WAIVER FORM:ACKNOWLEDGEMENTI expressly acknowledge that there are certain dangers, risks, illnesses, and personal injuries inherent in participating in the programs, events, clubs/groups, the use of equipment, sports activities, community outings/activities, walking/transit transportation and/or all other activities, which may result from unavoidable accidents or injuries. I understand that CYC and its employees, coaches, mentors, counselors, representatives, and assigns assume NO responsibility for loss, damage, illness or injury to person or property of me or my minor child(ren) or ward(s); and if applicable, may sustain because of their physical condition, or resulting from their participation in any activities, programs, events, the use, or non‐use of any equipment, sports activities, community outings/field trips, pools, and parks. Not limited to waterfront activities, and any other activities, events, or programs at and/or sponsored by CYC. I expressly acknowledge, on behalf of me and my minor child(ren) and ward(s), heirs, and executors, that I voluntarily assume the sole risk for all dangers, illnesses and personal injuries that may result from me or my minor child(ren)’s or ward(s)’ participation in any events/activities/programs/community outings while at the CYC and/or sponsored by the CYC.

I also acknowledge that the CYC will/might uses photographs, videos, television programs, or other similar media for promotional purposes. I hereby consent to the use of my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es) in such materials to be exhibited and used for advertising, trade purposes, solicitation of patronage, promotional purposes, or other similar purposes, even if my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es) are an integral part of such photograph, videos, television program, or other similar media.

RELEASE In consideration of the CYC allowing me and/or my minor child(ren) or ward(s) to attend and/or participate in any programs, events, outings, or other activities at the CYC and/or sponsored by the CYC, I hereby, for myself, my minor child(ren) or ward(s), heirs, and executors, waive, release, and forever discharge the CYC and its employees, agents, coaches, counselors, tutors, mentors, consultants, representatives, successors, and assigns, from and against all rights and claims for any loss, damage, illness or injuries to person or property sustained because of my attendance and/or participation in any such programs, activities, events, clubs/groups, and other activities, whether such loss, damage or injury results from the negligence of the CYC and its employees, agents, or representatives or from some other cause. My agreement to release the CY does not include any loss, damage or injury that results from the CYC's gross negligence or willful, wanton, or reckless misconduct.I further waive all rights to inspect or approve the photograph, videos, television programs, recording or other use of my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es), including any written article, script, caption or other writing that may accompany such use of my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es). I hereby, for myself, my minor child(ren) or ward(s), heirs, and executors, waive, release and forever discharge the CYC and its employees, coaches, mentors, counselors, trainers, representatives, successors and assigns, from and against any and all liability, claims, losses, costs, expenses or damages for libel, slander, invasion of privacy, conversion, defamation, appropriation of likeness or any other claim based on the use of my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es) in any such materials.

INDEMNIFICATION:I hereby represent and warrant to Confidence Youth Coaching that I have the authority to execute this Participant/Member Waiver Form on behalf of myself and/or on behalf of my minor child(ren) or ward(s) as parent, guardian and/or next friend, if applicable. In the event of any misrepresentation or breach of the foregoing warranty by me, or in the event that I, my minor child(ren) or ward(s), or any other person nevertheless asserts any claim against Confidence Youth Coaching arising out of my minor child(ren)’s or ward(s)’ participation in any program, event, club/group, coaching/consulting, or other activity as set forth herein, I agree to indemnify, hold harmless and defend Confidence Youth Coaching LLC from and against any and all liability, claims, losses, costs, expenses or damages resulting there from, including, but not limited to, claims of loss, damage, illness or injury to person or property whether or not such loss, damage, illness or injury results from the negligence of Confidence Youth Coaching, LLC or from some other cause.ACCEPTANCE:

I expressly acknowledge and agree to the terms and conditions set forth on this CYC Participant/Member Waiver Form.

2024 Confidence Youth Coaching - SUMMER CAMP PAYMENT AGREEMENT:

To ensure proper communication, I have outlined Confidence Youth Coaching, LLC., policy related to participant/members payments. PLEASE READ CAREFULLY:

1.) Full payments are due at the time of registration to reserve the week(s) you wish to enroll your child in.
2.) Cancellations after April 15th, 2024, is non-refundable.
3.) There are no credits or refunds for missed days.
4.) Payment Options: Pay by electronic bank check, debit or credit card.

I have read and understand the above statements. I fully understand my responsibility for payment of my child’s club/camp fees. I also understand that my child may NOT attend club/camp program if fees are not paid in full.

CANCELLATION POLICY: Full refund will be honored for cancellation requests before April 15th, 2024. In the event of unforeseen circumstances, and a cancellation or withdrawal of the camper is necessary, no fees will be refunded. Payments lost due to cancellation can be transferred to new week sessions.Cancellations after April 15th, 2024, is non-refundable.Refund Policy Camp fees will not be refunded by Confidence Youth Coaching LLC due to absence from camp, regardless of situation, or if the camp is closed due to safety concerns, or any other unforeseen circumstance such as inclement weather, power outage, or for any other safety/emergency situations. Confidence Youth Coaching reserves the right to cancel under-enrolled programs/sessions, in which case, full tuition, will be fully refunded.

COMPLETE AGREEMENT: This Agreement constitutes the entire agreement of the parties and reflects a complete understanding of the parties with respect to the subject matter and supersedes all prior written and oral representations, communications or agreements. The parties agree that this Agreement shall be deemed to have been signed and performed in the state of Virginia. and the laws of Virginia will control herein. IN WITNESS WHEREOF, the Parties have duly executed this Agreement. Coach/Consultant: Rosa Gomes, M.Ed., CAGS, QMHP-C

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