RARITAN BAY AREA YMCA

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1 Dear Applicant, Enclosed please find the Youth Leaders & Junior Counselor In Training Application and the Camp Registration Packet. Please complete the application and return all documents with your $ registration fee no later than Friday, May 16, RARITAN BAY AREA YMCA 357 New Brunswick Avenue Perth Amboy, NJ Youth Leaders & Junior Counselor In Training Application ATTN: Lillian Perez, Youth Development Specialist If you have any questions, please contact the Y office at ext Monday through Friday 10:00 am to 6:00 pm. We will be happy to assist you. We cannot process your application until all materials are returned including your Youth Leadership application and three references. The Y will contact you once all paperwork has been returned for an interview. Thank you for your interest in the Youth Leaders & Junior Counselor In Training Program and we look forward to seeing you soon! Best regards, Lillian Perez Youth Development Specialist

2 RARITAN BAY AREA YMCA Applicant Reference Form Date: Applicant s Name: Position applying for: Branch Name: To whom it may concern: The applicant named above has submitted an application for employment with our YMCA Branch or Child Care Centers. Please complete (BOTH SIDES) and return by fax or mail (TO THE ADDRESS ABOVE). Thank you for your prompt attention. REFERENCE INFORMATION TO BE COMPLETED BY APPLICANT If no prior work history, please provide name of a teacher, guidance counselor, coach, clergy, organization volunteered for etc. who can provide a reference. Name of Reference (employer, school, etc.): Dates (employed, attended school, etc.): From: To: Address of Reference: Contact Person: Title: Phone: ( ) Fax: ( ) Applicant s Authorization to Release Information I request and give permission to the above named person to complete this reference check. Applicant s Signature: Date: TO BE COMPLETED BY REFERENCE NAMED ABOVE (not by the applicant) 1. How long have you known the applicant? 2. In what capacity? 3. Responsibilities (or extracurricular activities if student): 4. Please describe this individual (personality, character traits): 5. What were the applicant s strengths and weaknesses? 6. Do you feel this is an appropriate position for this person?

3 Please Rate Applicant s Performance 1. Quality of Work (or academic studies, volunteerism, etc.) 2. Productivity and Initiative 3. Knowledge of Job 4. Reliability and Dependability 5. Creativity 6. Interaction skills with children, peers or adults 7. Is there any reason this individual would not be suitable to work with children? No I don t know this individual well enough to comment Yes, please explain 8. Would this applicant be eligible for re-hire? Yes No, please explain 9. Additional Comments: Reference Completed by: Date: Authorized Signature: Title: An Equal Opportunity Employer - 2 -

4 JUNIOR COUNSELOR IN TRAINING WHAT IS A JUNIOR COUNSELOR IN TRAINING? The Junior Counselor in Training Program is designed to give selected students (14-15 years of age, grades 8 thru 10) the opportunity to learn and develop leadership and program skills while in the Summer Day Camp Program. This program is for those students who are interested in learning about leadership and responsibility. The program consists of training and actual work experience with a small group of campers under the supervision of a YMCA staff person. Maturity and a sincere desire to work with children are essential. THE PROGRAM: This is an eight (8) week program. Through supervised group leadership opportunities, Junior Counselor in Training learn the skills and responsibilities necessary to become a leader by participating in all camp events. While in the program, Junior Counselor in Training develops values, environmental awareness skills and the confidence necessary to make the transition from camper to counselor. It is essential that all attend the entire 8-week program. Participation in this program does not guarantee being hired as staff. Youth Leaders take from the program what they put into it. WHAT IS THE ROLE OF THE JUNIOR COUNSELOR IN TRAINING IN THE DAY CAMP PROGRAM? A. A Junior Counselor in Training is not a counselor. When Junior Counselor in Training are working with campers, they will be assisting. A member of the YMCA staff will always be present and supervising. B. A Junior Counselor in Training will meet with the Youth Development Specialist each day. The remainder of the day will be spent in activities. Reports will be given on a weekly basis. TRAINING: Junior Counselor in Training will be exposed to an extensive training program during camp. Learning opportunities include, but are not limited to pool safety, medical and health problems (what to observe and what to do), social medial policy, fire safety, an explanation of planning for and participation in games and other activities to be used with the campers, playground safety, child abuse prevention, and transportation safety. These sessions will be led by the Youth Development Specialist and members of the YMCA family who have an expertise in leadership programs. PREREQUISITES: Age: *You must be years of age and have completed eight grade. Interests: *A completed application demonstrating your interest in the program, summer camp application and written essay. *An interview with the Program Director and/or Youth Development Specialist (you will be notified to schedule an interview) *Three (3) references. The references should be two people (other than relatives) - For example: Teachers, Scout Leaders, Guidance Counselors, Family for whom you baby-sat, Coaches, former employers, etc. and one relative who can evaluate your capabilities as a potential counselor.

5 YOUTH LEADERSHIP PROGRAM WHAT IS A YOUTH LEADER IN TRAINING? Youth Leaders In Training is an exclusive program designed to give selected students (13 years of age) an innovative summer program that focuses on leadership training, teamwork, self-government, and volunteer opportunity to help build confidence and connections. Youth Leaders In Training consists of leadership training and actual work experience with a small group of campers under the supervision of a YMCA staff person. The program will give youth the opportunity to take the roles as leaders while in the Summer Day Camp Meet other youth Build new skills Participate in your community programming Plan for your future Obtain innovative skills through Public Speaking THE PROGRAM: This is an eight (8) week program. Through supervised group leadership opportunities, Junior Counselor in Training learn the skills and responsibilities necessary to become a leader by participating in all camp events. While in the program, Junior Counselor in Training develops values, environmental awareness skills and the confidence necessary to make the transition from camper to counselor. It is essential that all attend the entire 8-week program. Participation in this program does not guarantee being hired as staff. Youth Leaders take from the program what they put into it. WHAT IS THE ROLE OF THE YOUTH LEADER IN TRAINING IN THE DAY CAMP PROGRAM? A. Youth Leaders In Training will attend leadership workshops where they will both learn and apply essential leadership skills including: Team Building, Ethical Decision Making, Cultural Diversity, Time Management, Goal Setting, Public Speaking, and Conflict Resolution. B. Youth Leaders In Training will meet with the Youth Development Specialist each day. The remainder of the day will be spent in activities. Reports will be given at a weekly basis TRAINING: Junior Counselor in Training will be exposed to an extensive training program during camp. Learning opportunities include, but are not limited to pool safety, medical and health problems (what to observe and what to do), social medial policy, fire safety, an explanation of planning for and participation in games and other activities to be used with the campers, playground safety, child abuse prevention, and transportation safety. These sessions will be led by the Youth Development Specialist and members of the YMCA family who have an expertise in leadership programs. PREREQUISITES: Age: *You must be years of age and have completed eight grade. Interests: *A completed application demonstrating your interest in the program, summer camp application and written essay. *An interview with the Program Director and/or Youth Development Specialist (you will be notified to schedule an interview) *Three (3) references. The references should be two people (other than relatives) - For example: Teachers, Scout Leaders, Guidance Counselors, Family for whom you baby-sat, Coaches, former employers, etc. and one relative who can evaluate your capabilities as a potential counselor.

6 Youth Leaders & Junior Counselor In Training Application All Youth Leader & Junior Counselor in Training applications must be received with a completed packet: Application, written essay and three references. Today's Date / / Date of Birth: / / Name: Age: Gender: M / F Current Grade: School Attending: Home Street Address: City: State: Zip: Home Telephone: Cellular Phone No.: Parent/Guardian Name: Emergency Contact Home: Street Address: City: State: Zip: Home Telephone: Cellular Phone No.: How did you hear about the program? Have you participated in a training program before? If yes, explain? Please answer the following questions in essay format, minimum of one page typed double-spaced per answer. 1. What is the reason that you want to be a Youth Leader or Junior Counselor in Training? 2. Are there any experiences, skills or qualifications, you feel would especially fit you for inclusion in this program? 3. Why should you be accepted into the Youth Leader or Junior Counselor in Training Program at the Y? Please read carefully and sign: I understand if I am accepted into YMCA Summer Day Camp Youth Leader or Junior Counselor in Training Program, I will be expected to act in a responsible manner. I will be learning things that will not just make me a responsible counselor, but a better person with leadership skills I can use in life. If I do not follow accepted guidelines, I understand I can be asked to leave the program. Camper's Signature: Parent/Guardian Signature: Date: Date:

7 RARITAN BAY AREA YMCA Summer Camp Application Participant s Information: Child s Name: Age: D.O.B.: / / Gender: M / F Home Address: City: State: Zip: SUMMER STARS DAY CAMP Ages 3 to 12 DAY CAMP MEMBER NON-MEMBER Pre-School $130 $150 School Age Check the CAMP session(s) your child will be attending: June 30 th - July 3 rd (Program Closed July 4 th ) JULY 7 th - 11 th JULY 14 th - 18 th JULY 21 st - 25 th JULY 28 th - AUGUST 1 st AUGUST 4 th 8 th AUGUST 11 th - 15 th AUGUST 18 th 22 nd REGISTRATION FEE $30 BEFORE & AFTER CARE Before Care $20 After Care $30 Before & After Care Combo $40 ($10 savings) NEW! 2 Week Sessions... * Space is limited SPORTS & SPECIALTY CAMP Ages 6 to 12 SESSION MEMBER NON-MEMBER DATES Session I Basketball Camp $269* $306 6/30 7/11 Session II Baseball Camp $299 $339 7/14 7/25 Session III Soccer Camp $299 $339 7/28 8/8 SESSION MEMBER NON-MEMBER DATES Session I Swim Camp $269 $306 6/30 7/11 Session II Martial Arts Camp $299 $339 7/14 7/25 Session III Cooking Camp $299 $339 7/28 8/8 Weekly MEMBER NON-MEMBER Week $ $ Daily MEMBER Session M T W TH F $40 I II III NON-MEMBER Session M T W TH F $55 I II III Half Day MEMBER NON-MEMBER Session 9:00-12:00pm $169 $189 I II III 1:00-4:00pm $169 $189 I II III *(Program Closed July 4 th ) T-SHIRT Size: Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large YOUTH LEADERSHIP & JUNIOR COUNSELOR IN TRAINING PROGRAMS: Youth Leadership Program Ages 13 Junior Counselor In Training Program Ages Reminder: Your child is not registered in any session until either payment has been made or the payment has been scheduled with a bank or credit card that has been scanned into the system.

8 Parent s Information: Mother s Name: Address: Father s Name: Address: Home Address: City: State: Zip: Phone No.: Cell No.: Employer: Address: Work No.: Who is Guardian? Both Parents Mother Father Grandparents Guardian Demographic Information (Optional): Race: Household Income: Marital Status: Asian/Pacific Islander African American/Black 0-$13,999 $40,000-$54,999 Single Married Alaskan Native Caucasian/White $14,000-$24,999 $55,000-$74,999 Separated Divorced Hispanic Native American $25,000-$39,999 $75,000 and over Widowed Other: Emergency Contact/Authorized Pick-Up: Person(s) authorized to pick-up and/or contact in case of emergency, if neither parent is available. These people are required to show identification when picking-up your child and must be 18-years old and over. 1. Name: Relationship to child: Phone No.: Address: City: State: Zip: 2. Name: Relationship to child: Phone No.: Address: City: State: Zip: Health and Insurance Information: Does your child have health insurance? No Yes If no, would you like information/resources regarding health insurance? No Yes Child s Physician: Address: Phone No.: Insurance Provider: Policy No.: Phone No.: Emergency Medical Information: (Please check, if the participant has a history of any of the following) Asthma Contact Lens PLEASE LIST ANY ALLERGIES, BEHAVIORAL, PHYSICAL OR MEDICAL PROBLEMS/CONCERNS: Diabetes Heart Trouble Fainting Spells High Blood Pressure Convulsions Other HEALTH VERIFICATION, ACTIVITY AUTHORIZATION, PAYMENT NOTIFICATION, and PHOTOGRAPHY RELEASE: As the parent/guardian, I verify my child is in good physical health and is authorized to participate in all activities including but not limited to HIKING, WALKING TRIPS (within the YMCA s neighborhood), WATER ACTIVITIES and SPORTS. I give consent for the YMCA to walk or transport my child. Initial I understand in the event of an emergency I give the YMCA consent to transfer my child s health record to the health provider. I understand any cost of service not reimbursable by insurance coverage shall be the responsibility of the parent and or guardian. In the event of an emergency, transportation by any necessary means to obtain medical care or assistance for my child, as circumstance may require in the discretion of the YMCA staff, its employees or agents, is hereby authorized. I further give consent to any rescue squad or emergency personnel to render transportation and/or medical care deemed necessary in their discretion and in the best interest of the life, health and well-being of my child. Initial I understand in the event of a minor accident or sudden illness my child will be treated on the premise of the YMCA by staff with emergency standard first aid procedures, as deemed necessary, for the well being of my child. I understand I will be notified immediately and will be required to pick-up my child or in my absence an authorized person I designate will pick-up my child from the YMCA. Please note the Y DOES NOT dispense medication. Initial I understand my child may be photographed while at activities, camp, and programs. I give the Y permission to use the pictures/videos of my child for the Y s promotional and marketing materials such as newsletters, local newspaper, website and or brochures. Initial I understand any balance owed for child care services is the responsibility of the parent/guardian. FOR FAMILIES RECEIVING FINANCIAL ASSISTANCE FROM A THIRD PARTY PAYER: I understand I m responsible for any and all associated fees should the Third Party Payer not cover the applicable fees. Initial REFUND AND CREDITS: I am aware that no credit or refund will be issued for vacations, incidental absences, withdrawals or dismissals from camp. Registration fee are non-transferable and non-refundable. Returned check and credit/debit card will incur a $30.00 return fee. Initial STATEMENT OF VERIFICATION: I have completed this application accurately and I understand that misinformation can result in immediate dismissal from all YMCA programs. Parent s Signature: Date: I have received the Parent Handbook which outlines the general organizational information, fees, and certain child care policies including the Required Parent Information Statement, Guidelines for Positive Discipline Policy, Child Release Policy, Expulsion Policy, and Management of Communicable Diseases. Parent s Signature Date: Revised 03/07/2014

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