THE YOUTHCENTER REGISTRATION FORM

For Camp,check box for each week you wish to register.
CAMP
2012 / Day Camp
9am-4pm / AM
Extended Hours
7-9am / PM
Extended Hours
4-6pm / Mini Treckkers Preschool Camp
Tu-W-Th 9:30-12:00
Week 1
June 18-22 / Not Available
Week 2
June 25-29 / Not Available
Week 3
July 2-6
Closed July 4 / July 3,5,6
Week 4
July 9-13
Week 5
July 16-20
Week 6
July 23-27
Week 7
July 30-Aug 3 / Not Available
Week 8-Travel
Aug 6-10 / Not Available
Week 9-Travel
Aug 13-17 / Not Available
Week 10
Aug 20-24 / Not Available
*Must be enrolled in at least one other week (between Weeks 1-6) to be eligible to attend Week 7, 8, 9 or 10.

No refunds or credits given for any reason. PLEASE COMPLETE EVERY LINE. (One per child)

PROGRAM you wish to register for: ______
Start Date:______Class Time(for Little Tykes sports)______

Child's Name: ______Gender:____ Birthdate:______Age:____Grade in Fall 2012: ___

Allergies/Restrictions/Physical Limitations: ______

Parent's/Guardian’s Names: ______

For purposes of required statistics for corporate funding, please list parent’s/guardian’s employers:
______

Address-Mailing: ______City:______St:____ Zip:______

Street Address, if different: ______City:______St:____ Zip:______

Home Phone #______Cell: ______Work: ______

Town/Township Where Child Resides: ______COUNTY: ______

Email (required field, for YouthCenter use only) ______

Public school child attends or will be attending: ______

Where did you learn about The Youth Center? ______

T-Shirt Size, please Check One:Child-MD Child-LG Adult-SM Adult-MD Adult-LG

Photo Consent, please Check One: I DO / I DO NOT consent that photos, DVD videos of myself and my child are the property of The Youth Center and may be reproduced and publicized and/or used on our website or as The Youth Center desires, free of any claim on my part.

2 Persons who are authorized to assume responsibility for child if neither parent is available:

Name: ______Relationship:______Phone: ______

Name: ______Relationship:______Phone: ______

Child’s Doctor: ______Address: ______Phone ______

By my signature I attest to the following: •That the above information is correct.

• I understand, agree and consent to all terms and conditions as described in the registration information/brochure including payment requirements.

• I will not hold The Youth Center employees or any persons affiliated responsible for any accident or injury incurred during my child’s/children’s’ presence/involvement at the Center or at the sports fields used.

• I realize there are no refunds or credits given for any reason and staff and/or scheduling may be subject to change.

In the event that the above named child is injured, and I cannot be reached in an EMERGENCY, I hereby give my permission to any physician to secure proper treatment for, and if required: to hospitalize, order injections, anesthesia, or surgery for my child.

*Parent/Guardian's Signature ______Date______

Child will not be able to participate without parent’s signature and entirely completed registration form with no alterations.

NO REFUNDS WILL BE GIVEN FOR ANY REASON

Make checks payable to: “The YouthCenter”. Mail to 16 Hampton Road, Glen Gardner, NJ08826.

For Little Tykes sports, submit registration with payment in full.

For Camp, include with registration $50 per week, per child non-refundable deposit to reserve your weeks of choice. Entire deposit will be applied to camp and balance of weekly fee is due according to the payment schedule.

Additionally, a comprehensive camp packet including health history must also be completed and is due 2 weeks prior to camp. Packet can be downloaded from obtained from the office. NO CHILD MAY ATTEND CAMP without a completed packet on file. The packet also contains additional information for parents that you are encouraged to read.

No confirmation will be mailed. Unless otherwise noted, please report to first class.