Ymca Camp Roger Admission Card - 2016
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YMCA Camp Roger Admission Card 2016
FOR OFFICE USE ONLY
Session(s):
Cabin #:
Stay over Bus Meds Confiscated Items
Camper Name:
Last
First
Bring this form with you on check-in day. Campers cannot be accepted without this authorization. Do not mail or fax in.
List at least four (4) additional individuals, who you authorize to pick up your camper from camp or bus drop-off site.
The individual picking up your child will be required to show their photo ID, matching the name on this form.
1. ____________________________________________ ___________________________________________
Name of Authorized Individual
Relationship to the Camper
Cell Phone: (______) ________-___________
Home Phone: (______) ________-___________
2. ____________________________________________ ___________________________________________
Name of Authorized Individual
Relationship to the Camper
Cell Phone: (______) ________-___________
Home Phone: (______) ________-___________
3. ____________________________________________
___________________________________________
Name of Authorized Individual
Relationship to the Camper
Cell Phone: (______) ________-___________
Home Phone: (______) ________-___________
4. ____________________________________________
___________________________________________
Name of Authorized Individual
Relationship to the Camper
Cell Phone: (______) ________-___________
Home Phone: (______) ________-___________
Camp Dismissal Policy
A parent, guardian, or adult (age 18 and up) designated on the pick-up authorization, must sign out the
child at pick-up (PHOTO ID REQUIRED).
Those without photo ID, or persons not noted on the pick-up authorization WILL NOT be permitted to
pick-up a child.
Campers not registered for a weekend stay over or transportation to Salt Lake must be picked up by camp
closing (7pm).
**I have read and agree to the camp dismissal policy and authorize the people listed above, in addition to myself, to pick
up my camper from YMCA Camp Roger.**
/
/
Name of Parent/Guardian
Signature of Parent/Guardian
Date Signed
Cell Phone: ( ______ ) ______-________
Home Phone: ( ______ ) ______-________
FOR CHECK-OUT DAY ONLY
Staff Signature (release to authorized pick-up)
Authorized Pick-Up Signature (sign on check-out day)
Date
Meds: Yes N/A
Confiscated Items: Yes N/A
# attending family programming:
(do not include campers)
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