Ymca Summer Day Camp Form - 2016 (Page 5 of 9) in pdf

REQUIRED INFORMATION

ANY KNOWN ALLERGIES? _______________________________________________________________________________________________________________________________

ANY KNOWN SPECIAL NEEDS OR HEALTH ISSUES? ______________________________________________________________________________________________

ANY ACTIVITIES YOUR CHILD MAY NOT ENGAGE IN? ___________________________________________________________________________________________

ANYONE UNAUTHORIZED TO PICK UP OR VISIT? _______________________________________________________________________________________________

FIRST AND LAST NAME

PAYMENT INFORMATION

CONVENIENT AUTOMATIC PAYMENT OPTIONS: We are offering automatic payment. Payment will be drafted 4 days prior to

the due date. If you would like automatic payments please check the credit card or bank draft option and fill out the informa-

tion below.

EFT/BANK DRAFT

□ Please use the account the YMCA has on file. Please be ready to verify this information at the time of registration.

□ I will provide my account information at the time of registration. Account type, checking or savings, routing number and

account number will be needed.

DEBIT/CREDIT CARD DRAFT

Card Type (check one): □ Visa

□ Mastercard

□ American Express

□ Discover

□ Please use the account the YMCA has on file. Last 4 Numbers of Credit Card: ___________________________________________________________

□ I will provide my credit card information at the time of registration.

PAYMENT AGREEMENT: Weekly payment is due on the Friday before the start of each week. Payment is due in full and your

child cannot attend camp until we have received your payment.

Signature________________________________________________________________________________________________________________Date _______________________________

□

I’D LIKE TO SPONSOR A YOUTH FOR A WEEK OF SUMMER DAY CAMP

By checking this box, I give the YMCA permission to add $__________ to my payment for a one-time tax deductible contribution to

the Strong Communities Campaign.

FEES

• The non-refundable registration fee(s), non-refundable deposit fee(s) and weekly fee(s) are due prior to your child’s participation in Summer

Day Camp and YMCA Camp Platte.

• The registration fee is a one-time $25 administrative fee.

• A minimum non-refundable $20 deposit per child is required to secure each week’s registration. Deposits must accompany the registration

form. The remaining weekly fee is due prior to the week(s) for which your child is attending.

• All weeks are filled on a first-come, first-served basis.

• You are responsible for all fees associated with each week for which your child is registered.

• Other activities will be offered throughout the summer for an additional fee.

• In order to receive the YMCA member fee for Summer Day Camp, the participant(s) must be a YMCA member for the entire summer.

Initial: ______________

YMCA OF GREATER OMAHA . . Page 5

Ymca Summer Day Camp Form - 2016 Page 5

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