Butler YMCA CAMP KEYSTONE at ARMCO Park...Butler YMCA CAMP KEYSTONE at ARMCO Park Butler YMCA Child Care 339 N Washington Street Butler, PA 16001 P 724 287 0045 F 724 287 1007 YMCA

Butler YMCA

CAMP KEYSTONE at ARMCO Park

Butler YMCA Child Care ■ 339 N Washington Street ■ Butler, PA 16001

P 724 287 0045 F 724 287 1007 www.bcfymca.org

YMCA MISSION STATEMENT: To put Christian principles into practice through programs

that build healthy spirit, mind, and body for all.

PARENT HANDBOOK

Dear Parents,

Welcome to Camp Keystone! As part of the Butler YMCA,

Camp Keystone offers a summer day camp for children who have

completed Kindergarten through 6th grade.

This camp program is designed to provide challenging activities in

both large and small group settings under the guidance of caring,

well-trained staff members. We hope that the time your child

spends with us will be a positive experience and that your child

will grow in body, mind and spirit.

Please read your Parent Handbook carefully. If at any time you

have any questions, suggestions, or concerns, please let us know

by calling 724-287-0045. A parent’s input is always valued!

We are looking forward to meeting you and your child!

Sincerely,

Morgan McMillen

Summer Camp Coordinator

(724)287-0045 x137

[email protected]

Camp Keystone cell phones

(724)290-1340

(724)290-1813

TABLE OF CONTENTS

YMCA MISSION ..................................................................................................... 1 PROGRAM GOALS ................................................................................................. 1

CHILD CARE LICENSE ............................................................................................ 1 EQUAL ACCESS .................................................................................................... 1

STAFF QUALIFICATIONS ........................................................................................ 1 MANDATED REPORTERS ........................................................................................ 1

HOURS OF OPERATION .......................................................................................... 1 PHONE NUMBERS ................................................................................................. 2

ARMCO PARK ....................................................................................................... 2 DAILY SCHEDULE .................................................................................................. 3

LUNCHES ............................................................................................................. 5 SNACKS ............................................................................................................... 5

FIELD TRIPS ......................................................................................................... 5 T-SHIRTS............................................................................................................. 5

SIGN IN/OUT INFORMATION .................................................................................. 5

DROP OFF PROCEDURE .......................................................................................... 5 PICK-UP PROCEDURE ............................................................................................ 6

LATE PICK-UP ....................................................................................................... 6 DELAYED RELEASE OF CHILDREN ........................................................................... 6

PERSONAL BELONGINGS ....................................................................................... 6 DRESS CODE ........................................................................................................ 6

CELL PHONES ....................................................................................................... 7 SUNSCREEN ......................................................................................................... 7

ABSENT CHILD ..................................................................................................... 7 DISCIPLINE POLICY .............................................................................................. 7

REMOVAL FROM THE PROGRAM .............................................................................. 8 EMERGENCY PROCEDURES ..................................................................................... 8

ADMINISTRATION OF MEDICATION ......................................................................... 8 ILLNESSES ........................................................................................................... 8

PHYSICALS ........................................................................................................ 10

RAINY DAYS ....................................................................................................... 10 EXTREMELY HOT DAYS ........................................................................................ 10

PHOTOGRAPHY ................................................................................................... 10 PARENTAL CONCERNS ......................................................................................... 10

REMIND TEXT & EMAIL SERVICE ........................................................................... 10 PAYMENT POLICY ................................................................................................ 12

ESTABLISHING PROGRAM FEES.......................................................................... 12 FEE AGREEMENT .............................................................................................. 12

PAYMENT OPTIONS ........................................................................................... 12 NON-SUFFICIENT FUNDS ................................................................................... 12

COUNSELOR IN TRAINING FOR GRADES 7-11 ........................................................ 13 STAFF:CHILD RATIO ........................................................................................... 13

SWIM POLICY ..................................................................................................... 13 TEST.MARK.PROTECT .......................................................................................... 14

TEST.MARK.PROTECT FAQs .................................................................................. 15

TEST.MARK.PROTECT ZONE REFERENCE GUIDE ..................................................... 16 BABYSITTING CLAUSE ......................................................................................... 17

PARENT STATEMENT OF UNDERSTANDING ............................................................ 18

1

YMCA MISSION

To put Christian principles into practice through programs that build healthy spirit, mind, and body for all. The YMCA is a community service organization which promotes

positive values and welcomes all people. The Butler YMCA is a nationally affiliated character-building social service agency focusing on program services for individuals and

families. Christian in its heritage, it is nondenominational in its delivery of services and membership. The YMCA offers programs and services to individuals and families

regardless of age, sex, religion, or national origin.

PROGRAM GOALS The Butler YMCA Camp Keystone seeks to provide a safe, fun-filled, creative and

educational day camp experience in which children can forge friendships while challenging themselves to experience personal growth.

CHILD CARE LICENSE

Camp Keystone is licensed by the Pennsylvania Department of Public Welfare. Our

license is posted in the child care department on the 2nd floor of the YMCA. DPW regulations can be found at http://www.pacode.com/secure/data/055/chapter3270/

chap3270toc.html.

EQUAL ACCESS The Butler YMCA, in keeping with its mission to help all people realize their fullest

potential, encourages and supports the participation of all children in YMCA programs. We serve all children regardless of gender, race, color, nationality, religion, ethnicity, or

disability. Whether a child is non-disabled or has special needs, consideration is given to the individual needs of every child and the ability of the program to meet those needs.

STAFF QUALIFICATIONS

We pride ourselves on our thorough selection of camp staff to ensure safety and fun for your child. Camp counselors have an education degree or are currently enrolled in a

college program in the fields of child development or education. Camp counselors have Act 33/34 clearances, FBI fingerprint clearances, and current CPR/Pediatric First Aid

certification. The staff has completed camp training regarding the children’s activities.

MANDATED REPORTERS Employees of Pennsylvania state licensed childcare centers are mandated reporters of

child abuse or neglect. As such, the YMCA staff is legally required to contact the PA

State hotline if there is reasonable cause to suspect physical, sexual, or emotional abuse, neglect, or maltreatment of any child enrolled in the center.

HOURS OF OPERATION

Camp Keystone Day Camp | 6:30am – 5:30pm

6:30am – 8:45am at Butler YMCA ** Second Floor 9:30am – 3:45pm at ARMCO Park

4:15pm – 5:30pm at Butler YMCA ** Second Floor

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PHONE NUMBERS

Child Care Offices

(724)287-0045

Camp Keystone cell phones (724)290-1340

(724)290-1813

Main YMCA (724)287-4733

Ext 110 for Phillips’ Hall

ARMCO PARK

Camp Keystone uses ARMCO Park for daily excursions.

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DAILY SCHEDULE Monday - Wednesday

TIME Purple Green Orange Pink Blue BREAK

6:30 - 7:15 GYM

7:15 - 8:45 Youth Gym 1 - S1 Gym 1 - S1 Gym 2 - S2 Gym 2 - S2

8:45 BUS

9:30 - 10:00 Bathroom/Sunscreen Opening Ceremony 10:00- 10:10

10:15 - 10:45

Environment Music Art Games

Change 10:10 - 10:30

Swim 10:30 - 11:20

10:50 - 11:20

Games

Environment Music Art Change 11:20 -

11:40

11:20 - 11:30 Bathroom/Wash Hands

LUNCH 11:30 - 12:00

12:05 - 12:30

Music

Games Environment

Change 12:05-12:25

Playground

12:35 - 12:55

Change 12:30 - 1:05

Art Games Swim 12:25 - 1:05 Music

1:00 - 1:25 Swim 1:05-1:45

Counselor Directed

Playground

Change 1:05 - 1:25

Environment

Change 1:25 - 1:45

1:30 - 1:55 Change 1:45 - 2:05 Swim 1:45 - 2:25 SNACK Playground Games

2:00 - 2:25 Playground Change 2:25 - 2:45

Change 2:05 - 2:25

Music

Art

2:30 - 2:55 Art Playground Swim 2:25 - 3:05

Environment

Snack Set up

3:00 - 3:20 SNACK

Change 3:05 -

3:20

SNACK

Closing Ceremony 3:25 - 3:35

3:35 Bus DEPART AT 3:45

4:15 - 5:30 Dismissal from Child Care

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DAILY SCHEDULE Thursday

TIME Purple Green Orange Pink Blue BREAK

6:30 -7:15 GYM

7:15 - 8:45 Gym 1 - S1 Gym 1 - S1 Gym 1 - S2 Youth Gym 1 - S2

8:45 BUS

9:30 - 10:00 Bathroom/Sunscreen Opening Ceremony 10:00- 10:10

10:15 - 10:45 Camp-Wide Activity

10:50 - 11:20

11:20 - 11:30 Bathroom/Wash Hands LUNCH 11:30 - 12:00

12:05 - 12:35 Specials Rotation Team Building Boy Scouts Playground Water Games

12:40 - 1:10 Boy Scouts Special Rotation Playground Water Games Team Building

1:15 - 1:45 Playground Boy Scouts Water Games Team Building Specials Rotation

1:50 - 2:20 Water Games Playground Team Building Specials Rotation Boy Scouts

2:25 - 2:55 Team Building Water Games Specials Rotation Boy Scouts Playground

3:00 - 3:20 SNACK

Snack SNACK

Closing Ceremony 3:25 - 3:35

3:35 Bus DEPART AT 3:45

4:15 - 5:30 Dismissal from Child Care

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LUNCHES

Lunch is 11:10-11:40am daily. A healthy lunch must be packed daily in a lunch container marked with your child’s name. We do not have any way to provide a lunch for

a child while we are at ARMCO Park. The parent will be notified to bring a lunch. We do not have the ability to refrigerate or heat up lunch items. Campers may not share lunch

items with other campers. On field trip day, please send a disposable brown bag lunch so the children can throw away items. The YMCA is not responsible for lost lunch

containers.

SNACKS Camp Keystone provides two snacks daily as part of the program schedule.

AM Snack 7:15-8:20am PM Snack 3:10-3:40pm

FIELD TRIPS

All campers participate in a weekly field trip. Most field trips are scheduled on Fridays.

All children must be at the YMCA by 8:30am. Camp shirts must be worn on field trip days. Please send a disposable lunch and apply sunscreen before arrival. Please do

not send extra spending money. Alternative care is NOT provided on field trip days.

T-SHIRTS Every child attending summer camp will receive a complimentary T-shirt as a gift from

the YMCA. The camp T-shirt should be worn on field trip days. Please label your child’s shirt.

SIGN IN/OUT INFORMATION

Recording attendance is a Title 55 Licensing Regulation 3270.117(a) requirement.

The attendance sheet serves as the main accounting system in the event of an emergency or during an evacuation. Signing the log is essential every day.

When a camper arrives at a Butler YMCA program site, parents and kids must “check in” with a staff member.

Make sure the adult signs the camper in on the attendance sheet. Children should never be dropped off outside the building and allowed to go inside

without an adult.

DROP OFF PROCEDURE Butler YMCA site 6:30-8:45am Mondays, Tuesdays, Wednesdays, and Thursdays

Campers are bused from the Butler YMCA site to ARMCO Park at 8:45am.

ARMCO Park 9:30am-3:45pm Mondays, Tuesdays, Wednesdays, and Thursdays

All campers must be dropped off at the main Butler YMCA site on Fridays for field trips.

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PICK-UP PROCEDURE

Your child will be released only to the persons designated on their Emergency Contact Form. All individuals, including the parents/guardians, will need to show photo

identification. Staff will check the photo on the ID and match the address with what is listed on the Emergency Contact Form. Notify the staff in writing if someone other than

those persons authorized on the Emergency Contact Form is to pick up your child. In an emergency, you may call the YMCA Child Care Office at 724-287-0045 to authorize a

verbal request for release of a child.

Campers may be picked up at ARMCO Park before 3:45pm. There will be no Camp Keystone staff at ARMCO Park after 3:45pm. All campers will be returning to the main

Butler YMCA by 4:14pm daily.

Camp Keystone will be using the Second floor lobby & Gyms as the pick-up location from 4:15-5:30pm. Parents/guardians/other personnel on the ECF must come into the YMCA,

and up to the second floor for pick up and drop off. No child will be accepted or

dismissed without being signed in/out by an identifiable adult.

LATE PICK-UP Anyone picking up their child after 5:30 p.m. will be charged $5.00 for every 5 minutes

that they are late.

DELAYED RELEASE OF CHILDREN The staff reserves the right to delay the release of a child to a parent or other adult if

they have reasonable cause to believe the adult is impaired by alcohol and/or drugs or is in any way incapable of assuming responsibility for the child including not having a car

seat in which to transport the child. Staff shall confer with the Director, contact additional YMCA representatives or call emergency contact persons listed in the child’s

file in order to make an appropriate determination regarding the release of the child.

PERSONAL BELONGINGS

Each child should have his/her own book bag clearly identified with their name for personal belongings. Required daily items are:

Healthy Lunch – No Pop/Soda

Athletic shoes swimsuit and towel

water bottle

DRESS CODE For the welfare of your child, please be sure your child is dressed according to the

weather and always dressed for active play! Please label your child’s items as we have many similar items.

For your child’s safety we ask that you send your child to camp in athletic shoes. Flip

flops can be used in the pool area only. If a child is sent to camp in sandals, they will

not be able to participate in several activities.

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CELL PHONES

No electronic items are permitted to come to camp. We are “unplugged” and play outside all day. Cell phones, any gaming systems, MP3 players, and toys are not allowed

at camp. If these items come to camp, a counselor will take them and return them to an adult at the end of the day. Cameras may come on field trip days at the parent’s

discretion. The YMCA is not responsible for lost, stolen or damaged items.

SUNSCREEN Campers will need waterproof sunscreen SPF30 or above. Please label the sunscreen

bottle with your child’s name. It will be kept in locked bags for daily use. The staff will notify you when your child needs more sunscreen for camp use.

Your child should apply sunscreen before coming to camp each morning. Campers will

be encouraged and monitored by staff to re-apply sunscreen a minimum of three times during our camp day. These designated times are before morning activities, before

swim time, and after swim time. Campers can have another camper help with sunscreen

application. Counselors are NOT permitted to apply sunscreen to campers, but will monitor body application and help with their face.

ABSENT CHILD Please call or email the Camp Keystone staff if your child will not be attending as

scheduled.

DISCIPLINE POLICY There shall be no harsh, cruel, or unusual punishments. Explanations and re-direction is

the standard method of discipline. In severe cases, “time-out” from something or someone may be necessary. Parents are contacted when serious discipline problems

occur with their child. The staff will use a blue Incident Report form to communicate in writing with parents/guardians. If problems continue, children may be asked to leave the

program.

In the event of repeated inappropriate behavior by a child, the following actions will be

taken: To immediately notify the parents in writing at the end of the day so that the

incident can be discussed. Conference with the parent/guardian.

Removal from the program.

Our intent is to work as a team with the parents or guardian for the best care for each child. Working together as a team is a necessary step to correct repeated inappropriate

behavior. Your patience, support, and follow-through are not only appreciated, but necessary.

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REMOVAL FROM THE PROGRAM

The YMCA reserves the right to remove a child from our program for the following reasons:

The camper’s needs are not being met in our small/large group settings. The camper is a safety threat to themselves, other children, or the staff. This

includes behaviors such as fighting, striking others, and wandering away from the program.

The camper has inappropriate conversations or contact, shows disrespect towards staff or other campers, or bullying.

The camper refuses to participate in the whole camp program including work and play values, sharing, and cooperation during daily activities.

Failure to submit a physical as requested.

Failure of a parent or guardian to pay weekly fees. Consistent late pick-up.

Inappropriate behavior conducted by the parent/guardian.

EMERGENCY PROCEDURES In case of a severe emergency or accident, we will:

1. Administer first aid 2. Call emergency medical transportation (911)

3. Contact parents and child's doctor 4. Contact YMCA administration

ADMINISTRATION OF MEDICATION Prescription and non-prescription medication will only be administered with daily written

consent from the parents. MEDICATION MUST BE IN THE ORIGINAL CONTAINER.

Parents need to complete and sign the medicine log before staff will administer any medication. Prescription and non-prescription medication must be labeled with child's

name. DO NOT send medications with the child, it must be given to a staff member by the parent/guardian.

ILLNESSES

List of conditions that indicate a child might need to be temporarily out of child care due to mild illness:

The child has any of the following conditions--fever, lethargy, irritability, persistent

crying, difficult breathing, or other manifestations of possible severe illness.

Fever--Fever is defined as having a temperature of 100°F or higher taken auxiliary, armpit with behavior change or other symptoms.

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Vomiting--Once during the previous 24 hours, unless the vomiting is determined

to be caused by a non-communicable condition and the child is not in danger of dehydration.

Conjunctivitis--Defined as pink eye or red conjunctivitis with white or yellow eye

discharge, often with matted eyelids after sleep and eye pain or redness of the eyelids or skin surrounding the eye. Exclude until examined by a physician and

approved for readmission, with treatment.

Diarrhea--Two loose bowel movements within a close time frame. (1-2 hours or less)

Body rash with fever--or any untreated infected rash

Sore throat--difficulty swallowing, swollen glands

Severe coughing--child gets red or blue in the face or makes high-pitched whooping sound after coughing.

Evidence of lice, scabies, or other parasitic infestation

Illness that prevents the child from participating comfortably in program activities-

-Child is irritable, continuously crying, or requires more attention than you can provide without hurting the health and safety of other children in care.

Please note: We will NOT administer fever reducing medication to keep a child’s fever

below 100°F in order to stay in care. Certain conditions do not require that children stay out of childcare unless recommended by the child’s health care provider or the public

health department.

Children may be admitted back into childcare if the following are true statements:

Child has been symptom free for 24 hours = one full day. Symptom free (for 24 hours = one full day) without medicines (Acetaminophen, or

Ibuprofen) Vomiting has stopped (for 24 hours = one full day) and child can eat and keep

food down. If sent home for diarrhea, last bowel movement was normal

If seen by a physician:

Provide a note from the physician’s office stating the child is not contagious and may return to care.

Antibiotics prescribed and 2 doses given, with a note from the physician stating child may return after 2 doses.

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PHYSICALS

Children registered for camp will need a signed Child Health Report on file. Documentation of immunizations is to be included.

RAINY DAYS

Camp Keystone will go to ARMCO Park and on scheduled field trips on rainy days. ARMCO Park has indoor facilities that the campers and staff can use on days of

inclement weather.

EXTREMELY HOT DAYS Camp Keystone will go to ARMCO Park and on scheduled field trips on very hot days. On

such occasions, please send extra water and remember to apply sunscreen. We will conduct activities in the pavilions to provide shade. If your child has asthma, please

remember to give the appropriate medications to your child’s counselor. Please refer to our section ADMINISTRATION OF MEDICATION for further details.

PHOTOGRAPHY Photographs of the children participating in our program may be taken from time-to-

time and may appear in newspapers, magazines, brochures, or other publicity material. These pictures may also appear on the YMCA operated advertiement boards or social

media outlets for promotional purposes. Your permission for photographs including your child(ren) to be used without compensation is a part of this agreement unless otherwise

stated.

PARENTAL CONCERNS If you have any questions or concerns with the Butler YMCA Camp Keystone, please do

not hesitate to inform the camp counselors. If you feel your questions have not been answered or problem resolved, please contact Morgan McMillen or Mitch Hammer, Butler

Camp Coordinatory & School Age Coordinator at [email protected] or [email protected] or Rachel Campbell, Clinical Director of Youth Services at

[email protected] or by phone at (724) 287-0045.

REMIND TEXT & EMAIL SERVICE

Remind is a one-way text messaging and email system. With Remind, all personal

information remains completely confidential. Camp staff will never see your phone number, nor will you ever see theirs. The app helps the staff to connect instantly with

parents/guardians. It is an effective way to alert parents/guardians of program changes or send reminders of upcoming activities. Parents/Guardians must join to receive the

text or email alerts. Complete instructions are included below.

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12

PAYMENT POLICY

ESTABLISHING PROGRAM FEES

YMCA program fees are established to offset the costs of operation for the program within the following framework:

Because parent income rarely fluctuates, fees are established by a school year, on

a weekly basis, and do not vary during school holidays or vacations. All children in the program share equally in the cost of providing for the fixed cost

of the program, regardless of time usage. Fixed cost include insurance, directing staff, and administrative costs.

Direct costs such as snacks, program supplies, and program leadership are

considered when establishing fees. All participants to the YMCA programs need to pay a non-refundable pre-

registration fee. (Child Care fees are tax deductible, please see the billing administrator for more information.)

FEE AGREEMENT

The required financial agreement (one for each child) stipulates fees, payment due schedule, attendance, and enrollment. Appropriate billing procedures will be enacted. It

is essential that the arrangements of the financial agreement be followed and payments made on time.

Payment may not be deducted for the time a child is not in attendance because of illness, personal reasons, or during family vacations.

Schedule changes must be made in conjunction with the Camp Coordinator. Any questions about payment and/or necessary variances from this contract

should be brought to the billing administrator’s attention before payment is due. A weekly $10.00 non-refundable deposit is due at the time of registration. The

remaining balance is due the Friday prior to attendance in camp. Deposits will not be refunded or transferred to alternate weeks of camp.

PAYMENT OPTIONS

Payment arrangements can be made weekly, bi-weekly, or monthly. Select one of the three payment options on the agreement form along with the fee amount.

Payments are due on the Friday prior to the week of service. Make checks payable to

Butler YMCA.

If your payment is not made by the Wednesday during the week of service, you will be charged a $10 late fee and you have until the following Friday to make that payment. If

the payment has not been made by 5:30 p.m. on Friday of the week of service, then services will be denied.

Payments can be given to the child care billing administrator or staff at the Membership

Desk. Do not give payments to the camp counselors.

NON-SUFFICIENT FUNDS A $10.00 charge will be required for checks returned due to non-sufficient funds.

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COUNSELOR IN TRAINING FOR GRADES 7-11

The Counselor In Training (CIT) program promotes leadership in young teenagers by allowing them to take an active part with the campers in a mentor capacity and to train

future counselors by giving them the opportunity to learn about working with children in a camp setting. CITs are scheduled for two week sessions. All teens interested in a CIT

position must schedule an interview with the camp coordinator.

STAFF: CHILD RATIO Young School Age (Kindergarten thru 3rd grade) 1:12

Older School Age (4th thru 6th grade) 1:15

SWIM POLICY Campers will swim at ARMCO Pool in four groups with up to 24 swimmers per group.

Any camper not dressed to swim will be included in the activities with one of the groups not currently in the pool area. The ratio of staff with swimmers in the pool area is 1:6.

Camp Keystone will follow the guidelines of the new Child Aquatic Safety Program that

the Butler YMCA adopted as of December 1, 2014. (Complete information regarding the program is included on the following pages.)

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TEST.MARK.PROTECT

15

TEST.MARK.PROTECT FAQs

16

TEST.MARK.PROTECT ZONE REFERENCE GUIDE

17

BABYSITTING CLAUSE

I ___________________________am employing ______________________________

for a babysitting position for my child(ren)____________________________________

____________________________________________.

Although _________________________is an employee of the Butler County Family

YMCA Child Care department this employment agreement is a personal choice and will

not be in competition with her/his position at the YMCA.

Any arrangements, for care, must be made on personal time and not on the YMCA

property.

If the arrangement above is in need of termination, for poor performance or other

reasons, I __________________________________, agree not to hold liable the Butler

County Family YMCA Child Care.

Parent Signature_______________________________ Date_________________

Employee Signature____________________________ Date_________________

YMCA Supervisor Signature______________________ Date_________________

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PARENT STATEMENT OF UNDERSTANDING

The following information is important for the safety and protection of your child. Please read the information, sign this form and return it to the YMCA.

Please keep and refer to your copy of YMCA Program Policies. Your signature below indicates that you have received them.

I understand that YMCA staff and volunteers are not allowed to babysit or transport children at any time outside of the YMCA programs. The YMCA will take immediate disciplinary action

toward staff & volunteers if a violation is discovered. I understand that I am not to leave my child at the YMCA or program site unless a YMCA staff or

volunteer is there to receive and supervise my child. I understand that my child will not be allowed to leave the program with an unauthorized

person. Any person authorized to pick-up my child must be listed with the YMCA or other arrangements must be made by calling the YMCA office to inform them of a change.

I understand that should a person arrive to pick up my child who appears to be under the influence of drugs or alcohol, staff may have no recourse but to contact the police for the child’s

safety. Please do not put staff in the position where they have to make this judgment call. I understand that state law mandates the YMCA to report any suspected cases of child abuse or

neglect to the appropriate authorities for investigation.

PHOTO RELEASE Photographs of the children participating in our program may be taken from time-to-time and

may appear in newspapers, magazines, brochures, or other publicity material. These pictures may also appear on the YMCA operated advertiement boards or social media outlets for

promotional purposes. Your permission for photographs including your child(ren) to be used without compensation is a part of this agreement unless otherwise stated.

In consideration of gaining membership or being allowed to participate in the activities and programs of the Butler YMCA and to use its facilities, equipment, and

machinery, I do hereby waive, release, and forever discharge the YMCA and its officers, agents, employees, representatives, executors, and all others from any and all responsibilities or liability for injuries or damages resulting from my participation

in any activities or my use of equipment or machinery in the above mentioned facilities or arising out of my participation in any activities at said facility.

I have read and understand the statements above.

_____________________________ ________________________ Parent/Guardian Signature Date

_____________________________ _________________________ Parent/Guardian Printed Name Child’s Name

COPY OF STATEMENT FILED WITH CHILD’S RECORD