Branch: / CampSite: / CampType:
PARTICIPANT INFO
Child’sName ______Age ______
D.O.B.______Gender ______
GradeinSeptember 2016 ______School ______
MailingAddress ______Apt.# ______
City ______State ______Zip ______
HomePhone(______)______EmailAddress ______
Mychildwill:BepickedupWalkhome(Only 10yrs.orolder, please sign bottom of page 2)
T-ShirtSizeChild:SMLXLAdult:SMLXL
PARENT/GuardianINFO
NameofParent/Guardianregisteringchild ______HomePhone(______)______
WorkPhone(_____)______CellPhone(_____)______Email ______
NameofParent/Guardian ______HomePhone(______)______
WorkPhone(_____)______CellPhone(_____)______Email ______
EMERGENCY CONTACTINFO
Pleaselisttwo(2)contactsnotalreadylistedonthisform,tobeusediftheparents/guardianscannotbereached
Name ______Relation ______Home Phone (_____)______
WorkPhone(_____)______CellPhone(_____)______
Name ______Relation ______Home Phone (_____)______
WorkPhone(_____)______CellPhone(_____)______
PHYSICIANINFO
Name______TelephoneNumber(______)______Address______City______State______Zip ______
AUTHORIZATION/CONSENT
EMERGENCYAUTHORIZATION:IunderstandthatintheeventofanemergencyaffectingmychildwhileparticipatinginaYMCAprogram,adesignatedemployeeoftheYMCAwillattempttocontactmeandinformmeassoonaspossible.IntheeventIcannotbereached,IherebygivepermissionformychildtobetreatedorhospitalizedbyalicensedphysicianorhospitalselectedbytheYMCA.
______Parent/GuardianName Parent/GuardianSignature
______ParticipantSignature Date
YMCAOFGREATERNEWYORKSUMMERCAMPREGISTRATIONFORM
PERMISSIONFORM
IherebygrantpermissionformychildtouseallequipmentandparticipateinallactivitiesoftheConey IslandYMCA.
IherebygrantpermissionformychildtoleavetheConey IslandYMCApremises,underpropersupervisionofConey Island YMCAstaff,forneighborhood walks,parkactivitiesandfieldtrips.Itismyunderstandingthatthesetripswillbetakenoverthecampsessionwithoutfurtherconsentfromme.
______Child’sName Camp Type
______Parent/GuardianSignature Date
AUTHORIZEDPICK-UPFORM
Thefollowingindividuals are18 years old or older and areallowedtopickupmychildfromtheConey IslandYMCAPrograms:
IunderstandthatnooneelsewillbeallowedtopickupmychildunlessInotifytheConey IslandYMCAinadvance and inwriting.Thispersonwillalsobeaskedfortheirphoto IDforverification.
______
Parent/GuardianSignatureDate
ContactTelephoneNumber: ______
Unescorted dismissal authorization
Mychildis ten years of age or older and maygohomewithoutanescortattheendoftheday.
______
Parent/GuardianSignatureDate
ContactTelephoneNo.: ______
2016CONEY ISLAND YMCASUMMER CAMPFEE SCHEDULE
*SessiondatesDONOTincludeSaturdayandSunday.*
SESSION
SessionI
SessionII
SessionIII
SessionIV / MEMBER
$310.00
$310.00
$310.00
$310.00 / KinderCamp
Ages4to5
NON-MEMBER
$360.00
$360.00
$360.00
$360.00 / DATES
July 5 -July15
July18-July29
August 1-August12
August15-August26 / SESSION
SessionI
SessionII
SessionIII
SessionIV / MEMBER
$310.00
$310.00
$000.00
$000.00 / SwimCamp
Ages7to15
NON-MEMBER
$360.00
$000.00
$000.00
$000.00 / DATES
July 5 -July15
July18-July29
August 1-August 12
August15-August26
SESSION
SessionI
SessionII
SessionIII
SessionIV / MEMBER
$000.00
$000.00
$000.00
$000.00 / DayCamp
Ages6to11
NON-MEMBER
$000.00
$000.00
$000.00
$000.00 / DATES
July 5 -July15
July18-July29
August 1-August 12
August15-August26 / SESSION
SessionI
SessionII
SessionIII
SessionIV / MEMBER
$000.00
$000.00
$000.00
$000.00 / SportsCamp
Ages7to12
NON-MEMBERDATES
$000.00July 5 -July15
$000.00July18-July29
$000.00August 1-August12
$000.00August15-August26
SESSION
SessionI
SessionII
SessionIII
SessionIV / MEMBER
$000.00
$000.00
$000.00
$000.00 / MiddieCamp
Ages12to14
NON-MEMBERDATES
$000.00July 5-July15
$000.00July18-July29
$000.00August 1-August12
$000.00August15-August26 / SESSION
SessionI
SessionII
SessionIII
SessionIV / MEMBER
$000.00
$000.00
$000.00
$000.00 / TeenCamp
Ages14to16
NON-MEMBER
$000.00
$000.00
$000.00
$000.00 / DATES
July 5 -July15
July18-July29
August 1-August 12
August15-August26
SESSION
SessionI
SessionII
SessionIII
SessionIV / MEMBER
$000.00
$000.00
$000.00
$000.00 / Early ChildhoodCamp
Ages2to5
NON-MEMBERDATES
$000.00July 5-July15
$000.00July18-July29
$000.00August 1-August12
$000.00August15-August26
/ ExtendedCampHours
Ages3to12
SESSIONFEETIME
AMSession$00.007:30-9:00am
PMSession$00.005:00-6:00pm
(CheckSession) 1 2 3 4
CampFees
DEPOSIT/
SESSIONFEE / EXTENDEDFEES / DISCOUNTS / SESSIONTOTAL
SessionI______/ _+ / AM/PM______/ - / ______/ = / ______
SessionII______/ _+ / AM/PM______/ - / ______/ = / ______
SessionIII______/ _+ / AM/PM______/ - / ______/ = / ______
SessionIV______/ _+ / AM/PM______/ - / ______/ = / ______
SessionTotal ______/ _+ / Total ______/ - / Total / ______/ =GrandTotal______
Payment Information
Check Credit Card Bank Draft Money Order
Credit Card # ______Exp. Date: ______
Bank Name: ______Account #: ______Routing #: ______
Authorized Signature: ______
PARENTAGREEMENT
I,theundersigned,givepermissionformychildtoparticipateinthecampforthedayshe/sheattends.Iamawarethatacompletedmedicalformsignedbyaphysicianisrequiredbeforemychildmaybegincamp. Inaddition,Iamfullyawarethatto reserveaspace,Imustmakeadepositof$(amount)pertwo-weeksessionandsubmitaregistrationform.Iamfullyawarethat shouldmychildchangecampsafterthestartofthesessionthereisa$25changefee.Ifullyunderstandandapproveofmy childbeingphotographedfor(BranchName)YMCApublicity.Lastly,Ifullyunderstandthatmychildisresponsibleforhis/her possessions.Ihaveread,signed,andagreedtotheregistrationrequirements.
SignatureofParent/Guardian:______Date:______
Thereisanon-refundable$100.00depositpersessionperchildwhichisappliedtosessionfee.
YMCAOFGREATERNEWYORKSUMMERCAMPREGISTRATIONFORM
STANDARDRELEASE FORM
Fromtimetotime,theYMCAofGreaterNewYork(the“YMCA”)takespicturesorrecordsvideosofmembersandnon-membersparticipatinginYMCAprograms,usingitsfacilities,orattendingoneofitsspecialevents.Additionally,theYMCAmaypermitmembersofthemedia(the“Media”)totakesuchpicturesorrecordsuchvideosinordertopromotetheYMCA’scharitablemissionandforotherjournalisticpurposes.
TheindividualpersonnamedbelowissigningthisReleaseforthepurposesofallowingtheYMCAandtheMediatouseoneor moresuchphotographs,videorecordings,and/orsoundrecordings(collectively,“Recordings”)ofsuchpersonforanypurposeconsistentwiththeYMCA’scharitablemission,whichincludes,butisnotlimitedto,theYMCAortheMediapublishingsuch Recordingsinnewspapers,websites,andotherprintorelectronicpublications,ontelevision,orontheradio.Bysigningthis Release,suchpersonacknowledgesthatheorshehasfreelyconsentedtobephotographed,filmed,orotherwiserecordedandhassignedthisReleaseofhisorherownfreewill.Ifthepersonnamedbelowisunderage18,aparentorguardianofsuch personmustsignonsuchperson’sbehalf.
1.IagreethatIamwillingtobephotographed,filmed,orotherwiserecordedbytheYMCA,itscontractors,andthe Media,eitherindividuallyoraspartofagroupRecording,whichmayincludemyimage,likeness,and/orvoice.furtheragreethatmynamemaybeusedtoidentifymeasasubjectofanyRecordingsfeaturingmyimage,likeness,and/orvoice.
2.IunderstandthattheYMCAwillownallrightsintheRecordingsofmethattheYMCAoraYMCAcontractortakesorrecords(“YMCARecordings”),andthattheYMCAwillhavetheexclusiverighttouse,orallowotherstouse,suchYMCARecordingsinanymediumforanypurposeconsistentwiththeYMCA’scharitablemissionasdetermined by theYMCA.
3.IunderstandthattheMediawillownallrightsintheRecordingsofmethattheMediatakesorrecords(“MediaRecordings”),andthattheMediawillhavetheexclusiverighttouse,orallowotherstouse,suchMediaRecordings inanymediumforanylawfulpurpose.
4.IunderstandthatIamwaivinganyandallrightsthatmayprecludetheYMCA’sortheMedia’suseofthe Recordingsas described above.
5.IacknowledgethatneithertheYMCAnortheMediahasanyobligationtouseanyRecordingsofmeortousesuch Recordings for any particular purpose.
6.IunderstandthatIwillreceivenomonetarypaymentorothercompensationinexchangefortherightstouseRecordingsofme.
______
______
SignatureDate
______
______
Name(printed)NameofParent/Guardian
______
______
MailingAddressPhoneNumber(optional)
______Email(optional)