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West Bank 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 Director. Please initial: ______ Special Custody Arrangements: _____________________________________________________ Special Medical Needs: ____________________________________________________________ Allergies : ______________________________________________________________________ PAYMENT POLICY AND PROCEDURES: Deposits are non-refundable but are transferrable within the 2014 Summer Camp season. Balances must be satisfied one week prior to the intended week of participation. Late fees will be charged in the amount of $10/day that over-due balances exist. No refunds or credits will issued to anyone withdrawing once the first day of the session has begun. Cancellations or transfers must be made in writing one week in advance. Payments can be made by 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 Week 6: 6/30—7/3: Camp Wars 6/2—6/6 : Animal Planet Week 7: 7/7—7/11: Super Heroes 6/9—6/13: Pirates Week 8: 7/14—7/18: Holiday 6/16—6/20: Rewind the Times Week 9: 7/21—7/25: Idol 6/23—6/27: Mad Scientist Week 10: 7/28—8/1: Wild, Wild West Week 11: 8/4—8/8: To Infinity and Beyond

Member Registration—$30/per week deposit at the time this form is submitted. Remaining Balance of—$100/per week due the Monday before the intended week of participation. Total Cost per Week—$130

Non-Member Registration—$30/per week deposit at the time this form is submitted. Remaining Balance of—$150/per week due the Monday before the intended week of participation. Total Cost per Week—$180

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

Week

Sign me up!

Deposit

Balance

Payment Option (Please Circle One):

1

Card on File with YMCA

2

Bank Account

3

Credit Card

4 5

Card Number _____-_____-_____-_____

6 7

Expiration Date ___/___

8

or

9

Bank Routing Number: ___________________________

10

Bank Account Number: ___________________________

11


wb-summer-camp-registration-form