Teen Break Club Flyer Spring 2012.pdf - YMCA of Greater Rochester


Teen Break Club Flyer Spring 2012.pdf - YMCA of Greater Rochester




Spring 2012






730 Long Pond Road

Rochester, NY 14612

(585) 227-3900

Teen Break Club Information:

Teen Break Club is a full day of safe, supervised activities which promotes friendship

through games, arts & crafts, and other special activities.




6th through 8th grade

6:30am - 6:30pm

Northwest Family YMCA

Activities Include:

• Character Development

• Gym Games

• Arts & Crafts

• Outside Games and Activities

• Swimming

More Important Information:

•Snacks are provided– please pack a lunch.

Teen Break Club requires a minimum of 8 participants to run.

•Registration is on a first come, first served basis.

•Payment is due at time of registration. A $20 late fee will be applied to registrations received less

than one full business day prior to start of the program. Example: For Monday Fun Club registration and

payment is due no later than 10:00 PM on the Thursday before. For a Friday Fun Club registration payment

is due no later than 10:00 PM on the Wednesday before.

•Cancellations must be received in writing. A refund will be given if cancellation is received at least

one full business day prior to prior to start of program. After that time, YMCA credit will be given.

•Please bring a lunch, drinks, socks, sneakers, swimsuit, towel, and dress for the weather.

•Please Note: All participants must fill out a registration form prior to attendance, regardless if you

receive financial assistance or DSS funding.

•This registration form is for the Winter session only. A new registration form will come out for

the Spring session. A childcare change form may be filled out to add additional fun club days.

Teen Break Club:

Members : $38/day

Program Members $52/day

Kyle Antilla

Sherri Rawls

Teen Staff Associate

SACC/Teens Administrative Assistant

723-5466 723-5463



Teen Break ClubSpring 2012

Child’s Name_________________________________________________

YMCA Member:

Grade:________ Age:_________ Date of Birth:_______________ Yes No

Home Phone:__________________________________________

Address:__________________________________________________ City/Zip:__________________________________

Mother/Guardian’s Name_____________________________________________

Daytime phone:______________________Cell:__________________ Email address:________________________________________

Father/Guardian’s Name______________________________________________

Daytime phone:______________________Cell:___________________ Email address:________________________________________

Allergies/ Medical Conditions:_______________________________________________________________________________________


*NEW* for Teen Time participants: Please use my same authorized/emergency pick-up information

that is on file for my child’s Teen Time program. _________ (initial here)

Otherwise, please fill in information below:

Emergency Contact- will be contacted in case of an emergency (other than parents)

Name:_________________________________Relationship to child:____________________Phone:_____________________________

Name:_________________________________Relationship to child:____________________Phone:_____________________________

Persons authorized to pick up my child:

Please note that all pick-up persons, including parents/guardians, will be required to show photo ID.

Children will not be released to persons refusing to produce identification. Thank you for your

cooperation and understanding.

1:__________________________________________________Phone : ______________________________________

2:__________________________________________________Phone : ______________________________________

3:__________________________________________________Phone : ______________________________________

4:__________________________________________________Phone : ______________________________________

In case of emergency, the Program Director will make every effort to contact the parent. However, I

authorize her/him to act for me according to her/his best judgment in an emergency requiring medical

or surgical treatment. I agree to be responsible for any medical bills resulting from illness or injury

during my child’s attendance at Teen Break Club.

I give consent for any photographs of my child to be used in YMCA related promotional materials.

Signature:_____________________________________________________________________Date: _______________________

Teen Break ClubSpring 2012

Child’s Name

Please check the dates that you’d like to attend Teen Break Club. All registrations are

processed at the Northwest Family YMCA. $20 late fee per child will be added for regis-

trations received less than 1 full business day prior to program. Payment in full or EFT

commitment due at the time of registration.

Teen Break Club Rates:

Half Day Rates:

Members: $38/day

Teen Time Participants $10/day

Program Members: $52/day

Non-Teen Time Participants $20/day


Friday, April 6th

Monday, April 9th


Greece and Hilton

Greece and Hilton

Tuesday, April 10th

Greece and Hilton

Wednesday, April 11th

Greece and Hilton

Thursday, April 12th

Greece and Hilton

Friday, April 13th

Greece and Hilton

Monday, June 18th 1/2 Day Hilton

Tuesday, June 19th 1/2 Day Hilton

Wednesday, June 20th 1/2 Day Hilton

Thursday, June 21st 1/2 Day Hilton

Friday, June 22nd

Greece and Hilton

____________Pay in Full

At time of registration

____________Easy Payment Option

I authorize the YMCA to debit my credit/debit card on the 1st of the

corresponding month for the programs selected above.

I agree to give the YMCA at least 1 full business day written notice of any changes or cancellations.

Credit card number______________________________________________________________Exp. Date___________________

Credit card type: MC Visa Discover Card holder Name:_______________________________________

Authorized signature:____________________________________________________________ Date:______________________

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