Colonie Youth Center, Inc.
21 Aviation Rd., Albany, NY 12205
2017 Summer Camp Application
Space is limited; please call for availability prior to registering!
One child per form
Payment of $370/child is required to process enrollment
enter "n/a" in required fields where no information is available
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COLONIE YOUTH CENTER - 2017 Summer Camp Application
Child's Legal Name
Date of Birth
Grade (as of 6/1/17)
Age (as of 6/1/17)
Please select camp site & weeks below:
North Colonie Camp Selection:
Boght Hills (K-6)
Latham Ridge (K-6)
Shaker Junior (K-6)
South Colonie Camp Selection:
Community Center (K-8)
Shaker Road (K-6)
June 26 - June 30
July 3 - July 7
July 10 - July 14
July 17 - July 21 (optional trip to Waterslide World)
July 24 - July 28
July 31 - August 4
August 7 - August 11
August 14 - August 18
Optional Trip (must be registered week of July 17-21):
Yes, my child will participate in the trip to Waterslide World ($15 fee)
No, my child will NOT participate
Parent/Guardian #1 (primary account-holder)
--> Children will not be released to anyone except parents/guardians, emergency contacts & authorized pick-ups.<--
Emergency Contact Information
Emergency Contact #1
Emergency Contact #2
Authorized Pick-Up Information (in addition to Emergency Contacts)
Authorized Pick-Up #1
Authorized Pick-Up #2
IN CASE OF EMERGENCY, I UNDERSTAND THAT EVERY EFFORT WILL BE MADE TO CONTACT THE PARENTS OR GUARDIANS OF THE CHILD. IN THE EVENT THE PARENT/GUARDIAN CANNOT BE REACHED, I HEREBY GIVE PERMISSION TO THE PHYSICIAN SELECTED BY A CYC STAFF MEMBER TO HOSPITALIZE AND/OR SECURE TREATMENT FOR MY CHILD AS NAMED ABOVE.
Does your child have any disabilities, allergies, medical conditions, prescriptions, special concerns or is your child receiving services from the school that impacts your child’s participation in the CYC School-Age Childcare Program?
IMPORTANT NOTE: Only emergency medications (epi-pens, inhalers, nebulizers, and diphenhydramine i.e. Benadryl when prescribed with an epi-pen only) will be administered. A Medical Consent Form will be provided to the parent/guardian. The form must be completed and signed by the parent/guardian and the child’s physician granting permission and written instruction regarding medication administration. Medication held at the program site must be in its original packaging. The parent/guardian must transport the medication from site to the Vacation Camp or bring additional medication to the camp. Staff will not transport medication from one program to another.
CYC has permission to use photographs of my child (without child's name) for promotional purposes.
Please do not publish photographs of my child.
Do you have a legal document (court order, restraining order, etc.) that impacts your child’s participation in the CYC School-Age Childcare Program in areas such as pick-up rights and financial responsibilities?
Yes (please submit a copy to the administrative office)
Participant Waterfront Permission Slip
I give permission for my child to go on waterfront field trips offered by the CYC Summer Camps to New York State Parks, the Colonie Town Pool and other water parks.
Parental Agreement. By submitting this form, you acknowledge and agree to the following:
- I have read and understand the policies and procedures as contained in the CYC Summer Camp Handbook. - I agree to abide by the policies and procedures as contained in the CYC Summer Camp Handbook. - I agree to keep the information on this application updated as needed. - I agree to pay the fees as outlined on the Registration and Fees Sheet. - I understand that in order to avoid financial penalty for withdrawal, I must submit a written request to CYC by May 15th (with the exception of $25 cancellation fee if dropping all weeks). Furthermore, I understand that if I drop weeks after May 15th, a refund will only be issued if the spot is filled with a new paying customer. - I understand that if the childcare account is delinquent at any time, my child may be terminated from the program.
Full Name (First/Last)
Deposit - $370.00 per child
--> If you have multiple children to register, you may leave this field blank and submit all fees with final form.