YMCA Hot Shots Summer Basketball League

Aspire Youth Development “Camp Chill Out” Respite Camp - Enrollment Form April 2017- June 2017 Session (check): [ ] April 1st – 2nd [ ] April 15th -16th [ ] May 6th – 7th [ ] May 20th – 21st [ ] June 3rd -4th [ ] June 17th – 18th [ ] July 4th – 5th [ ] July 18th – 19st

Care Manager: ______Cell Phone: ______

Group Assignment [see Sharon McMillon]: M (1st weekend) or H (3rd weekend)

Student’s Name:

Student’s Street Address:

Town, State & Zip Code:

Home Phone: Sex: Age: Date of Birth:

FATHER'S INFORMATION MOTHER'S INFORMATION

Name: Name:

Work Phone: Work Phone:

Persons authorized to pick up this child or to contact in case of emergency:

Name Relationship Phone

Is there anything we should know about child's health history or behavior?

MEDICAL INFORMATION

Is the child on any prescribed medications? Specify:

Doctor's Name: Phone:

Insurance Company: Policy #:

I give my child permission to participate in Camp “Chill Out” from April 2017 through July 2017. Furthermore, on behalf of my child, and myself I release any claim of liability arising from my child’s participation in any official activity related to the program. Additionally, I waive responsibility to the sponsoring organization, Aspire Youth Development. I also give permission to Aspire Youth Development to use any and all photographs and videos/audios of my child obtained while participating in the program to provide positive information and publicity for the program. In case of emergency and parent cannot be reached and immediate medical assistance is necessary, my child may be taken to the hospital and treated by the emergency room physician.

Parent/Guardian Signature: ______Date: ______I agree to participate fully during the Camp Chill Out and respect all persons involved both youth & adults, respect the property and the learning environment.

Youth Signature: ______Date: ______Please submit to Sharon McMillon [email to [email protected]] “Camp Chill Out”: Respite Camp

DESCRIPTION OF PROPOSED ACTIVITY: Initiated in May 2007, “Camp Chill Out” (CCO) was designed to provide weekend overnight respite for families with youth enrolled in the Burlington County’s Care Management Organization (Partners for Kids & Families). As Burlington County CMO youth were in need of appropriate psycho-social activities to support their experiences as typical teenagers, the program was designed to provide youth ages of 14-17 a respite on the 1st and 3rd Fridays-Saturdays of each month. Up to twelve (12) youth participate at each session to foster small group interactions and mentoring with three (3) Aspire staff. The “Camp Chill Out” program runs from Friday 5pm to Saturday 5pm features:

 1:4 staff/youth ratio (up to 12 youth) o Our experienced and caring staff has criminal background clearances, college degrees, and a minimum of 5 years experience working with youth. Participants are placed in smaller groups of up to 4 youth with each staff for supervision and interaction.

 Overnight hotel accommodations o Participants sleep in two bedroom suites with our staff sleeping in the common area to provide supervision throughout the evening.

 Transportation to/from the identified meeting location o Our staff meets youth at the organization’s agreed upon location for the convenience of the parents/guardians (Human Service Bldg). Our staff then reviews any special instructions and considerations including medication with the participants & parents/guardians. Participants are then transported to the host hotel for room assignments and use group consensus strategies taught by our staff to select the weekend’s meals & activities from a range of options provided.

 Three meals & snacks throughout the program o Based on participant preferences and budgetary considerations, our staff provides the following meals for the participants along with snacks for the room & during recreational activities-Friday dinner; Saturday breakfast; Saturday lunch.

 Structured Recreation o Based on participant interests and area options, our staff transport participants as a collective large group or create smaller groups to offer varied recreational opportunities include but not limited to: . Swimming Basketball Bowling . Movies Skating Game center . Cultural activities College visits Community special events

PARTICIPATION OPPORTUNITIES: Youth enrolled must be appropriate for group settings and not require intensive 1 on1 supervision. Youth must be able to compromise with others. “Camp Chill Out” will be held on the 1st & 3rd Fridays of each month (except for holidays). Drop off is on Friday at 5pm and pick-up on Saturday at 5pm. On the following weekends:  April 7th -8th April 21st -22nd  May 5th – 6th May 19th – 20th  June 2nd -3rd June 16th – 17th  July 7th -8th July 21st -22nd  August 4th -5th August 18th -19th  September 8th -9th September 15th -16th  October 6th -7th October 20th – 21st  November 3rd - 4th November 17th -18th  December 1st -2nd December 15th -16th

For more information contact: Aspire Youth Development 609-518-3500 (phone) 609-556-4190 (cell) [email protected]