Octorara Camp Registration Form

The YMCA of Greater Brandywine
Summer Day Camp Registration
2017
Brandywine Kennett Oscar Lasko
Jennersville Lionville UMLY
Octorara
West Chester
Camper Name:
_____ Gender: Male Female
Date of Birth: _____ Grade completed in 2016-2017
Address:
City:
State/Zip:
Home Phone:
Parent/Guardian Name:
E-mail:
______
______
Parent/Guardian Name:
E-mail:
______
______
Registered Siblings (A separate grid and form must be completed for each child registered.)
Sibling’s Name(s):
___________________
ATTENTION—PLEASE READ THE FOLLOWING CAREFULLY. THIS WAIVER AFFECTS YOUR LEGAL RIGHTS
In consideration of my/my child’s participation in the activities of the YMCA of Greater Brandywine, I agree to waive, release,
indemnify and hold harmless the YMCA and its respective officers, employees, volunteers, and members for injuries, accidents
and damages that result from my/my child’s participation in the programs including but not limited to liability for its own
negligence, and do hereby on behalf of myself, heirs, executors and administrators, waive, release and forever discharge any and
all rights and claims for damages which may have or which may hereafter accrue to me/my child arising out of or connected with
participation in the programs, use of the YMCA facilities and property, or use of equipment within its facilities and property.
I understand that even when every reasonable precaution is taken, accidents can sometimes occur. I further understand that the
activities of the YMCA have inherent risks and I hereby assume all risks and hazards incidental to my or my family’s participation in
programs or use of the facilities, or equipment within its facilities.
I UNDERSTAND THAT SIGNING BELOW DEMONSTRATES ACCEPTANCE OF THE ABOVE TERMS IN THEIR ENTIRETY.
Signature of Parent/Guardian: ____________________________________
Date: ____/____/_____
NEXT STEPS:
• The YMCA will use payment method specified on Draft Authorization form to process payment for camp deposits.
• The YMCA will contact payers via email requesting required emergency contact and health history information.
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Rev. 1/2017

Octorara YMCA Summer Camp 2017 Registration Form
Camper's Name:(last name, first name)
Grade Completed 2017:
Age:
Birthdate:
Spark Time
Camp Octorara
*Please see back for selections
Literacy Camp
(Octorara School District)
Leader In Training
*Please see back for selections
Spark Time
7:00am-9:00am 9:00am -4:00pm 9:00am -4:00pm 4:00pm-6:00pm
Week 1 June 12-16 □ □ □ □
Week 2 June 19-23 □ □ □ □ □
Week 3 June 26-30 □ □ □ □ □
Week 4 July 3-7 □ □ □ □ □
Week 5 July 10-14 □ □ □ □ □
Week 6 July 17-21 □ □ □ □ □
Week 7 July 24-28 □ □ □ □ □
Week 8 July 31-Aug. 4 □ □ □ □
Week 9 Aug. 7-11 □ □ □ □
Week 10 Aug. 14-18 □ □ □ □
Week 11 Aug. 21-25 □ □ □ □
What time do you expect to arrive at camp for pick up? 4:00 4:30 5:00 5:30 6:00
□ Please check here if you are registering multiple children to receive the sibling discount
$20.00 non refundable deposit per camper, per session (week) must accompany each camper's application to be registered for that session.
*Automatic Credit Card Draft payments are required. Weekly payments are deducted Monday, two weeks before selected week
No refunds are available after the start of the camp week. Any cancellations less than one week prior to the camp start date will
result in a $50.00 processing fee. Any camp registration submitted after the Wednesday before camp will result in a $50.00 late fee.

PROGRAM DRAFT AUTHORIZATION FORM
Participant’s Name(s)
Home Phone
Address on Account Check if address has changed
Street
City, State, Zip
Email
Cell Phone
Initial Appropriate Draft Authorization(s)
Fill in all that apply to this form:
Monthly Payment: Drafts on the 1 st of the month each month the
program is provided, for continuous programs. Examples include: academy
programs, gymnastics team, martial arts, etc.
Monthly Draft Amount $
Weekly Payment (Camp & Childcare only):
Childcare drafts on the Sunday prior to care. Camp drafts two Mondays prior
to camp. Weekly draft amount is based on authorized registration and
current rates.
Weekly Draft Amount $
I understand this automatic payment authorization is continuous until the end of the program. I understand I am responsible
for submitting account changes in writing 7 business days before a draft. I understand I am responsible for reviewing my
bank/credit card statement to ensure a draft has been stopped following my written notice. No refunds or credits are given. I
understand I am responsible for fees if the YMCA is unable to debit my account because of account changes or insufficient
funds. Returned drafts incur a $20 service charge. Pricing is subject to change with 30 days written notice. I have read and
understand the terms of this agreement. I authorize my bank to honor pre-verified and/or verified monthly automatic YMCA
program fees and other authorized charges. Weekly draft amount $_____________.
Print Payer Name ____ Payer Signature ____ Date
Staff Use: Initial Payment $ Receipt #
Staff Name
Card/Check Name ____________________
Date
Credit or Debit Card
VISA MasterCard Discover
Card # XXXX – XXXX – XXXX - _ _ _ _
American Express
Card # XXXX - XXXXXX - __ __ __ __ __
*Card must be saved on customer file.
Bank Account
Bank Name: _____________________________
Bank Routing/Transit Number (9 digits)
__ __ __ __ __ __ __ __ __
Bank Account Number:
________________________________________
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Rev. 1/2017