Camper’s Name______Campers Age______
(First) (Middle) (Last)
Date of Birth______/______/______Sex______T-Shirt Size :( child) S M L XL (adult) S M L XL
Address______Apt#_____ City______, NY or ____, Zip.______
Parents/Guardians:
Parent Name 1:______Parent 2:______
Business #: (______)______Business #: (______)______
Mobile Phone: (______)______Mobile Phone:(______)______
Email Address: ______Email Address: ______
Authorized Pick Up and Emergency Contact Information
At dismissal and/or incase of an emergency the following people are authorized to pick up my child:
Parent 1 YES NO Parent 2: YES NO
At least two additional names are required:
1. Relation: Phone #:
2. Relation: Phone #:
3. Relation: Phone #:
Please select the camp week you wish to attend and if extended care is needed:
Session Dates / Summer Camp weeks(Please check box) / $/week / Extended Care
(Please check box) / Total
Price
Session I
7/1 – 7/13 / *07/02 – 07/6 / $ / AM $40/Wk
PM $40/WK
AM & PM $ 90/Wk / $
Session I
7/1 – 7/13 / 07/09 - 07/13 / $ / AM $50/Wk
PM $50/WK
AM & PM $ 90/Wk / $
Session II
7/16 – 7/27 / 07/16 - 07/20 / $ / AM $50/Wk
PM $50/WK
AM & PM $ 90/Wk / $
Session II
7/16 – 7/27 / 07/23 - 07/27 / $ / AM $50/Wk
PM $50/WK
AM & PM $ 90/Wk / $
Session III
7/30 – 8/10 / 07/30 – 8/03 / $ / AM $50/Wk
PM $50/WK
AM & PM $ 90/Wk / $
Session III
7/30 – 8/10 / 08/06 - 08/10 / $ / AM $50/Wk
PM $50/WK
AM & PM $ 90/Wk / $
Session IV
8/13- 8/24 / 08/13 - 08/17 / $ / AM $50/Wk
PM $50/WK
AM & PM $ 90/Wk / $
Session IV
8/13- 8/24 / 08/20 - 08/24 / $ / AM $50/Wk
PM $50/WK
AM & PM $ 90/Wk / $
Sub Total / $
Membership Fee if applicable / $ +
_____ % Discount (type:______) / $ -
Please turn over and complete the reverse side
Dismissal Options
Choose one:
I______will be picking my child up from Westside YMCA between (4:30 & 5:00pm) ______PM.
(Initial)
I______will be picking up my child at between (5:00 – 6:00pm) ______PM. (Register for Extended day hours only)
(Initial)
I______give permission for my child (10 +) to walk home from the program unattended at ______PM.
(Initial)
Payments and Fees Information
Fees & Discounts (discounts cannot be combined):
Ø Membership Fees - Ages 5 -11, $216 per year and age 12 - 17, $336 per year.
Ø A $150.00 non-refundable deposit per child is required for each session you wish to register for.
Ø Siblings receive a 10% discount when both children are registered for the same number of sessions.
Ø Early Bird discount of 10% for participants who registered and paid in full by Saturday, May 19th, 2012 .
Ø Member Rates - $792-session 1 (July 2 –Jul 13), $880 per session for sessions 2- 4.
Ø Non Members - $892-session 1 (July 2 –Jul 13), $980 per session for sessions 2 - 4.
Ø Extended Day - $40 week 1 only (July 2 – Jul 6), $50 per week for weeks 2-8 or AM & PM $90 per week.
Ø No checks accepted after May 19th, 2012
Payment Deadlines:
Ø Session 1 & 2 full payment due by Friday, June 15, 2012.
Ø Session 3 & 4 full payment due by Friday, July 15, 2012.
Credit Card Information
I authorize West Side YMCA to charge my credit card account on Friday, June 15, 2012 for (Sessions 1 & 2) in the amount of $______and on Friday, July 15, 2012 for (Sessions 3 & 4 ) in the amount of $______in fulfillment of my child’s summer day camp payment obligation.
AMEX Visa Master Card Discover Card Holder’s Signature______
Credit Card # ______Expiration Date: ______Security Code: ______
Refund and Credit Policy
· Camp fees are non-refundable unless the YMCA cancels a camp and Credits will be issued at the Directors discretion.
· The YMCA reserves the right to cancel a camp if it does not meet enrollment requirements.
· The deposit of $150.00 per session is non refundable & non transferable.
· To apply for a credit you must submit a credit request application stating the reason the child cannot attend before the scheduled session. Please make sure you include any doctor’s notes and/or travel documents to support your case.
· There will be no refunds or credits granted after June 22nd, 2012.
· Refunds take 6-8 weeks to process.
Standard Release Form
I, the undersigned give permission for my child to participate in all summer camp activities for the days he/she attends. I understand that no refund or credit will be given for missed days under any circumstances. I understand that I must have a completed medical form on file BEFORE the first day of the summer camp program. I also hereby give authority to the YMCA staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible. Also, in consideration of the goodwill, public service, and community aid provided by the YMCA of Greater New York, which I support and from which I have received benefit, I hereby grant permission to the YMCA to use my child’s name, to take and publish photographs, videotapes or motion pictures of him/her which include his/her voice, in any media for any legitimate purpose. I release all rights to such photographs, videotapes, motion pictures and recordings. I acknowledge that the YMCA will be the sole owner of all rights arising out of their use for all purposes. I understand that I shall receive no compensation from their use from any source whatsoever.
Parent or Guardian’s Signature______Date______
If at any point the information on the Registration form needs to be changed, you must submit ALL changes in writing.
2012 Arts Camp West Side YMCA
Childs Name ______Age____
Shirt Size ______
Office Use Only
Application Received By ______Date __/__/__