lower-plaquemines-summer-camp-registration-form

Plaquemines Partnership YMCA Summer Camp

Child’s Name: ________________________________ Date of Birth: ________________ Please Circle One:

Member

Non-Member

Shirt Size: ____________________

Gender: __________ Grade Entering in the Fall of 2014: __________School: _________________ Address: ________________________________________________________________________ Mother’s Name: ______________________________ Place of Work : _______________________ Work Phone: _____________ Home Phone: ______________ Cell Phone: ____________________ Father’s Name: _______________________________ Place of Work: _______________________ Work Phone: _____________ Home Phone: ______________ Cell Phone: ___________________ Email Address 1: ________________________ Email Address 2: ___________________________ AUTHORIZED PICK UP INFORMATION (other than parents): Name: ______________________ Phone: _______________ Relationship: ___________________ Name: ______________________ Phone: _______________ Relationship: ___________________ Name: ______________________ Phone: _______________ Relationship: ___________________ I understand that any changes/additions/deletions made to the authorized pick up list must be done in writing and given directly to the on-duty Camp Coordinator.

Please initial: ______ Special Custody Arrangements: _____________________________________________________ Special Medical Needs: ____________________________________________________________ Allergies : ______________________________________________________________________ PAYMENT POLICY AND PROCEDURES: Registration fees are non-refundable. Balances must be satisfied the Thursday prior to the intended week of participation. Late fees will be charged in the amount of $5/day that over-due balances exist. No refunds or credits will issued to anyone withdrawing once the first day of the session has begun. Payments can be made by cash, automatic withdraw from the account on file at the YMCA or a separate bank account or credit card. ______________________________________

_______________________________

Signature of Parent or Legal Guardian

Date

Weekly Dates and Themes Week Week Week Week Week

1: 2: 3: 4: 5:

5/27—5/30 : Core Values 6/2—6/6 : Animal Planet 6/9—6/13: Pirates 6/16—6/20: Rewind the Times 6/23—6/27: Mad Scientist

Week Week Week Week Week

6: 6/30—7/3: Camp Wars 7: 7/7—7/11: Super Heroes 8: 7/14—7/18: Holiday 9: 7/21—7/25: Idol 10: 7/28—8/1: Wild, Wild West

Registration - $20 one-time registration fee required upon registering Weekly pricing is as follows (MUST PROVIDE 1040):  Annual income under $20,000

$23 per child

 Annual income $21,000 - $30,000

$38 per child

 Annual income $31,000 - $40,000

$54 per child

 Annual income $41,000 +

$75 per child

Base Price: $100 If your child is attending Summer Camp (ages 5-14) the first week of attendance must be paid upon registering. Each additional week must be paid in full the Thursday before the week begins, after Thursday there will be a $5.00 late fee per day late.

If your child is attending Kiddie Camp (ages 3-4) a $10 deposit per week is required; weekly rates will be the above amounts less the $10 deposit. Each week must be paid in full the Thursday before the week begins, after Thursday there will be a $5.00 late fee per day late.

Please check off the weeks you would like your child to attend camp at the YMCA!

Week 1

Sign me up! Kiddie Camp Initial Please Deposit

Balance

Payment Option (Please Circle One): Card on File with YMCA

2

Bank Account-One Time

3

Credit Card– One Time

4

Cash

5

Card Number _____-_____-_____-_____

6 7

Expiration Date ___/___

8

or

9

Bank Routing Number: ___________________________

10

Bank Account Number: ___________________________