Delaware Family Ymca 2017 Summer Camp Registration Form printable pdf download

2017 Summer Camp Registration Form

oFFICE USE onLY

DELAWARE FAMILY YMCA

2564 Delaware Avenue, Buffalo, NY 14216

[ ] Received registration packet

P: (716) 875-1283 F: (716) 875-0305

Date _____________________ Initials _______

DELAWARE FAMILY YMCA

2017 Summer Camp Registration Form

ChILD’S InFoRMAtIon

Name

____________________________________________________________________________________________________

Nickname ____________________________________________

(first/middle/last)

[ ] Male [ ] Female

Date of Birth _________________________

Grade entering Sept 2017 ___________________

Phone __________________________________________

Home Address __________________________________________________ City __________________________________________________________ State ___________________ Zip _________________________

May we use your child’s picture in publicity photos?

[ ] Yes [ ] No

FAMILY InFoRMAtIon

Parent/Guardian Name ______________________________________________________________________________________________ Date of Birth _________________________________________________

Address ___________________________________________________________ City __________________________________________________________ State ___________________ Zip _________________________

Cell Phone ________________________________________________________________________ Work Phone __________________________________________________________________________________________

E-mail Address ___________________________________________________________________________________

Parent/Guardian Name ______________________________________________________________________________________________ Date of Birth _________________________________________________

Address ___________________________________________________________ City __________________________________________________________ State ___________________ Zip _________________________

Cell Phone ________________________________________________________________________ Work Phone __________________________________________________________________________________________

E-mail Address ___________________________________________________________________________________

EMERGEnCY InFoRMAtIon

In case of emergency, please contact the following first: Name _______________________________________________________________

(p) __________________________________

Emergency Contact and Youth Pickups (if mother, father or guardian cannot be reached): People listed to pick up children must be 18 years

of age or older and must have a photo ID with them when picking up children:

Name _________________________________________________________________ Relationship __________________________________________________________ (p) _____________________________________

17DL Camp Reg Form 170124

Delaware Family Ymca 2017 Summer Camp Registration Form

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