West St. Tammany YMCA Summer Camp
Child’s Name: ________________________________ Date of Birth: ________________ Please Circle One:
Member
Non-Member
Gender: ___ Grade Entering in the Fall of 2014: ___School: ______________ T-Shirt Size: ______ 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 Rates: Youth Camp (K-6th Grade)
$25 deposit per week taken at the time of registration (for both members and non-members); weekly rates will be the below amounts less the $25 deposit. Member: $150/Week Non-Member: ($30 one time registration fee) $195/Week Teen Camp and CIT’s $25 deposit per week taken at the time of registration (for both members and non-members); weekly rates will be the below amounts less the $25 deposit. Member: $120/Week Non-Member: ($30 one time registration fee) $170/Week I will be signing my camper up for (please circle one):
Youth Camp
Teen Camp
Please check off the weeks you would like your child to attend camp at the YMCA!
Week
Sign me up!
Deposit
Balance
CIT Program
I would like to purchase ____ extra shirts at $10 per shirt, size _____. Total to be added to deposits: ______. 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