Vacation Camp Registration Form

2. YMCA Camp Mataucha April Vacation Camp Days
Vacation Camp is a fun, safe way for your child to spend their days off from school with YMCA Camp Mataucha!
Campers will enjoy structured activities at camp or on a field trip, supervised by qualified, experienced staff.
Complete steps 1-3, sign and return to the Waterbury YMCA or REGISTER ONLINE at
www.campmataucha.org.
All registrations MUST be received by Friday, April 18 at Noon.
1. CAMPER INFORMATION
Childs Name Date of Birth Age
Address City ZIP
Sex (m/f) Childs School
2. HOUSEHOLD/FAMILY INFORMATION (must include at least two contacts for emergency purposes!)
Parent/Guardian Name Relationship
Address City ZIP
Home Phone Work Phone
Cell Phone Email
Parent/Guardian Name Relationship
Address City ZIP
Home Phone Work Phone
Cell Phone Email
3. CHECK WHICH DATE(S) YOU WOULD LIKE TO REGISTER FOR BELOW
DATE FIELD TRIP/ Theme Non-Member Member
o Mon. April 21 Retro Day at Camp! $50 $40
o Tues. April 22 Bowling at Thomaston Lanes! $50 $40
o Wed. April 23 CT Science Center, Hartford $50 $40
o Thurs. April 24 RockCats Baseball Game! $50 $40
o Fri. April 25 Rock Star Day at Camp! $50 $40
Total Cost: ______
4. REMINDERS
 DROP-OFF AND PICK-UP ARE AT YMCA CAMP MATAUCHA
 Parents can drop off participants as early as 7:30AM and pick up as late as 5:30PM. Notice will be given
of when we will return from field trips the day of the trip.
 Bring a bagged lunch and beverage everyday.
 Children must be signed in & out by a parent or guardian (must present ID).
 All medication (prescription and over-the-counter) must be given directly to staff in the original bottle,
with the prescription label, accompanied by a doctor’s order.
 All Campers must have a valid Physical (within 36 months) signed by a physician for our records on site.
 *Campers are encouraged to dress to the theme, but please consider the weather and outdoor play
(please pack sneakers!).
5. SIGN AND RETURN TO THE WATERBURY YMCA
Please make checks payable to the Waterbury YMCA-Payment must be sent in with the form.
Space is limited. Payment must be made in full. Day or trip may be cancelled due to low enrollment.
My signature below signifies that I agree with all information in this document. My permission is granted to the YMCA to
take/use photographs, slides, moving pictures or video tapes of the person named on this application. I give my child
permission to participate in all vacation camp activities. Permission is granted for the participant listed above to participate
in vacation camp, understanding that leadership will be provided. I authorize YMCA officials to secure medical/emergency
attention and treatment for the youth listed above.
The undersigned voluntarily agrees to hold the YMCA harmless for injuries or accidents resulting in bodily injury or property
damage during my child’s participation in the above program. I further waive, release, absolve, and indemnify the Greater
Waterbury YMCA, its Directors, Volunteers, or Employees for injuries or accidents occurring while participating in this
program.
Parents Signature_________________________ ____________ Date_______________