Registration Form - Ymca Camp Wapsie Seasonal Camps - 2015-2016

YMCA Camp Wapsie Seasonal Camps

2015-2016 Registration Form

Winter Camp $87

Halloween Camp $64

Spring Fling Camp $64

10 AM Sun., Dec. 27 –

10 AM Sat., March 19 -

10 AM Sat., Oct., 24 –

1:30 PM Tues., Dec. 29

1:30 PM Sun., Oct. 25

1:30 PM Sun., March 20

LIT/CIT’s from the preceding summer pay half price. (Please indicate LIT or CIT) LIT____ CIT____

Seasonal Camps are open to boys and girls in 1

st

through 10

th

grades. Camp Wapsie’s summer staff return to counsel and lead

themed activities as campers enjoy meals and heated cabins. Activities include (weather permitting): archery, canoeing, arts &

crafts, games, climbing tower, zipline, campfires, a dance, and much more fun! The camp store will be open for snacks. (Cash

only basis, no store accounts).

Register by mailing this form and payment to YMCA Camp Wapsie, 2174 Wapsie Y Rd., Coggon, IA 52218 or register online at

Registration deadline is 4 days before start date. Cancellations four days or less prior to start date will

forfeit of half of registration fees. Please call 319.435.2577 if you have any questions.

Select Your Program:

Halloween Camp 2015 $64 _____

Winter Camp 2015 $87 _____

Spring Fling Camp 2016 $64 _____

Camper Information:

*Please use a separate form for each child*

Camper’s Name: ____________________________________________________________________________ Gender: Male Female

Grade:_________________

Birth Date:__________________________________

Age: ___________________

Attended 2015 Summer Camp?

Yes

No

Address: ___________________________________________________________________________________________ City: ________________________________________________

State: __________________ Zip: __________________________________ Primary Phone number:_____________________________________________________________

Secondary Phone Number:____________________________________________ Parent Email:_______________________________________________________________

Emergency Contact & Phone Number:_______________________________________________________________________________________________________________

Cabin Mate Request (same age/grade): _____________________________________________________________________________________________________________

Does your child have a special diet or food allergies?

NO

YES

Describe: _________________________________________________

I hereby give my permission as the parent or guardian of the above to participate in activities and programs at YMCA Camp Wapsie. I acknowledge that Participant is physically and

mentally able to participate in these activities and programs, including but not limited to horseback riding, canoeing and rock climbing/rappelling. I understand there are certain risks

associated with those activities and programs, and I assume the risks to Participant associated with those activities and programs. I hereby release all staff, volunteers and agents

of the Cedar Rapids Metropolitan YMCA and YMCA Camp Wapsie from any and all responsibility in the event of injury to, or death of, Participant. I understand that I am responsible

for insurance coverage for Participant. The Cedar Rapids Metropolitan YMCA and YMCA Camp Wapsie have my permission to use any photos or videos taken of Participant during

his or her stay at YMCA Camp Wapsie for promotional materials.

Signature of Parent/Guardian: ________________________________________________________________ Date: ____________________________________

Health Insurance Co. ________________________________________________ Policy Number: ____________________________________________________

Payment Information:

TOTAL AMOUNT $______________________

Payment Option (circle):

Check

Visa

MasterCard

Discover

Card Holder Name (print): ______________________________________________________ Account #: _____________________________________________

Card Holder Signature: _________________________________________________________ Exp. Date: _____/_____ 3 Digit CVV Code____________

THANK YOU FOR SUPPORTING YMCA CAMP WAPSIE!