Ymca Of Boulder Valley Overnight Camp Add/change/cancel Form - 2016
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12016 YMCA OF BOULDER VALLEY OVERNIGHT CAMP ADD/CHANGE/CANCEL FORM
Please utilize this form for Camp Santa Maria to add camp week(s), change camp week(s) or cancel the week you are registered.
Email completed forms to or mail to or drop off at:
YMCA of Boulder Valley, Registration, 2800 Dagny Way, Lafayette, CO 80026
CAMPER INFORMATION
(Please fill out one form for each camper.)
Camper Name: ____________________________________________________________________________________________________________________ Grade Entering: ________________________ DOB: _________________________
Parent/Guardian: ______________________________________________________________________________________________________________________________________________________________DOB: _________________________
Home Phone: ____________________________________________________ Cell Phone: _________________________________________________ Work Phone: ___________________________________________________________
Email: _____________________________________________________________________________________________ Y Member: YES /NO Card# __________________________________________________________________________
Fill in the name of the camp you are adding, changing or canceling and mark an “X” under the camp date.
Camp fees must be paid in full prior to camp start date according to registration policies. Participant must be the active member to receive member rates (M) or
non-member (NM) rates will apply.
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CAMP ADD
6/5
6/12
6/19
6/26
7/3
7/10
7/17
7/24
7/31
1)
2)
3)
Please select if adding: Horseback Riding
Rafting
Weekend Stayover (only required for multiple one week consecutive sessions)
Changes must be submitted at least one week in advance of camp start date. Fee differences must be paid according to registration policies. A $25 change fee
will be assessed per week.
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S9
MC
CAMP CHANGE
6/5
6/12
6/19
6/26
7/3
7/10
7/17
7/24
7/31
8/7
Camp changing from:
Camp changing to:
Please select if adding: Horseback Riding
Rafting
Weekend Stayover (only required for multiple one week consecutive sessions)
Payment Method
$ ____________________ Total Camp Fees
$ _______________________ Total Fees Paid At This Time
$ ______________________Balance Due
$ _________________________ Total Change Fees
I have enclosed a check for $ ______________________
Check# _________________________________________________________ OR Credit/Debit (check) VISA
MC
AMEX
DISC
Name on Card: _____________________________________________________________________________________________________Card# ____________________________________________________________________________________
Exp. __________________ VCODE ____________ Signature ____________________________________________________________________________________________________________ Date ______________________________________
CANCELLATIONS: Refunds or credits, less $100 per week will be authorized when a cancellation form is submitted at least 2 weeks in advance of camp start
date. No credits or refunds without a 2 week written notice. No refunds will be given if there is a balance owed for any Y program.
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S8
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MC
CAMP CANCEL
6/5
6/12
6/19
6/26
7/3
7/10
7/17
7/24
7/31
8/7
1)
2)
3)
$ _______________________ Total Fee Paid
$ ____________________________Less $100 Per Week
$ _____________________ Refund Amount Requested
Exception to these policies can only be made by the YMCA Vice President of Camp. Exception requests may be granted when extenuating circumstances arise.
Requests are accepted in writing on the back of this form with attached documentation (examples: doctor’s note for broken leg, written documenation of
involuntary job loss from HR department). This may take up to two weeks to process.
PARENT/LEGAL GUARDIAN Print Name: ___________________________________________________________ Signature: _________________________________________________ Date: _________________________
OFFICE USE ONLY: Intake Name: _____________________________________ Intake Date: ____________ Entry Date: ____________ Member#: _________________________________ Copied: _______________
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