YMCA @ THE PONDS SUMMER CAMP 2012 REGISTRATION FORM

YMCA @ THE PONDS SUMMER CAMP 2012 REGISTRATION FORMPlease complete both sides of this registration form. It is important that each area be completed, signed and dated.Thank you.Camper’s Name____________________________________ Age______ DOB________Parent/Guardian__________________________________________________________Home Phone__________________________________ Work Phone_________________Email Address ___________________________________________________________Address_________________________________________________________________Zip Code _____________________________ County____________________________Medical concerns/Allergies__________________________________________________Physician/Hospital__________________________________ Phone#______________________Emergency contact ___________________________ Phone #______________________People authorized to pick up camper __________________________________________________________________________________________________________________Please circle tee-shirt size: YS YM YL AS AM AL AXL AXXLRelease and Waiver of Legal LiabilityI, _________________________________________________the parent or guardian of the above mentioned, hereby giveapproval for his/her participation in any any/all camps, sport and activities.I understand that the Summerville Family YMCA assumes no responsibility for injuries or illnesses which the above referenced childmay sustain as a result of physical condition or resulting from participation in any athletic activities, sports program, and the use ofany equipment, exercise or other activities. I hereby release and discharge the Summerville SC YMCA, its agents, assigns and/oremployees from any and all claims for injury, illness, death, loss or damage which may result from the above referenced child(s)participation in these activities.I further understand that the Summerville Family YMCA is not responsible for personal property lost or stolen while members and/orprogram participants are using YMCA facilities or on the YMCA premises.I give my permission to the Summerville Family YMCA to use, without limitation or obligation, photographs, film footage, or taperecordings which may include me (or my dependent’s) image or voice for purposes of promoting or interpreting YMCA programs.I also grant permission to the Summerville Family YMCA to authorize and obtain medical care from any licensed physician, hospitalor medical clinic, should the above referenced child become ill or injured while participating in YMCA activities if I am not availableto grant authorization for emergency treatment. I realize I may be responsible for the resulting medical bills.HAVING READ, UNDERSTOOD, AND AGREED WITH THESE TERMS, I HAVE EXECUTED THIS RELEASE, TO BE EFFECTIVEIMMEDIATELY._____________________________________________Child’s name_____________________________________________Parent/Legal Guardian Signature______________DateThe YMCA mission is to be a community cornerstone that puts Christian principles into practice throughprograms that build healthy spirit, mind and body for all.

YMCA @ THE PONDS DAY CAMP 2012REGISTRATION FORMPlease complete BOTH sides of this registration form. It is important that each area be completed, signedand dated. Thank you.**Please Circle Sessions you would like**SessionMay29-June 1June 4-8June11-15June18-22June25-29July2-6July 9-13July16-20July23-27July30-Aug 3Aug.6-10AugRegistrationFee(One time$50 fee)*No Campon the 4th*Ages 5-12CITsAges 13-15Draftby$80/$124 $52/$100 May25th$100/$155 $65/$125 June1st$100/$155 $65/$125 June8th$100/$155 $65/$125 June15th$100/$155 $65/$125 June22nd$80/$124 $52/$100 June29th$100/$155 $65/$125 July6th$100/$155 $65/$125 July13th$100/$155 $65/$125 July20th$100/$155 $65/$125 July27th$100/$155 $65/$125 Aug.3rd$100/$155 $65/$125 Aug10th13-17Please note there is a $50.00 registration fee due and a draft for each additional session attendingdue upon registration. Refunds on session fees, minus a $15 administration fee, are given uponwritten notice received no later than one week prior to the first day of that session.Registration fee covers the cost of camp bag, camp supplies, and tee shirt. The registration andmembership fee are non-refundable.**I have received a copy of the Camp Handbook**_________________________________________Parent/Guardian__________________________Date