Ymca Of Montclair - Camp Registration Form - 2017
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4YMCA OF MONTCLAIR
2017 CAMP REGISTRATION FORM
Mail to: YMCA of Montclair, 25 Park Street, Montclair, NJ 07042, Attn: Kim Burrows
Submit in person to either Park Street Branch or Geyer Family Branch
CAMPER’S INFORMATION HERE
PLEASE PRINT LEGIBLY AND COMPLETE ALL SECTIONS
1ST SUMMER WITH US?
CAMPER’S NAME
YES
NO
STREET
CITY
STATE
ZIP
BIRTHDAY
GENDER
GRADE (ENTERING FALL 2017)
PARENT/GUARDIAN INFORMATION HERE
PLEASE PRINT LEGIBLY AND COMPLETE ALL SECTIONS
NAME
PARENT/GUARDIAN 1
HOME
WORK
CELL
E-MAIL
(PLEASE PRINT
CLEARLY)
@
GMAIL/AOL/VERIZON/ETC.
NAME
PARENT/GUARDIAN 2
HOME
WORK
CELL
E-MAIL
(PLEASE PRINT
CLEARLY)
@
GMAIL/AOL/VERIZON/ETC.
HOW DID YOU HEAR ABOUT US?
EMERGENCY CONTACTS
Please list the name and contact information for up to two people who may be contacted in an emergency should either parent/guardian be unavailable.
NAME
CELL
WORK
HOME
NAME
CELL
WORK
HOME
PICKUP AUTHORIZATIONS
In addition to parents, ONLY those on the list below will be allowed to pick up a camper from camp. (Photo ID required at pickup.) Please list up to three additional persons authorized
to pick up your child. Parent/guardian may give written permission for an individual, who is not on this list, to pick up child. No child will be released without written permission. If a
non-custodial parent has been denied visitation or has limited visitation by court order, a copy of the order must be given to the YMCA of Montclair and kept on file at the camp.
NAME
CELL
WORK
HOME
NAME
CELL
WORK
HOME
NAME
CELL
WORK
HOME
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