WCAY and OLY 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

West Chester Area YMCA and Oscar Lasko YMCA and Childcare Center
2017 Summer Camp Selections
Campers Name: __________________________________________________ Age (as of 6/1): ______________ Approx. Pick Up Time: ___________
Please check the block for the camp and week of your choice.
Mem
Rate
OSCAR LASKO CAMPS Age Time
Mem
3
Non
Rate
1 2
4* 5 6 7
8
9 10 11 Notes
6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14 8/21
Camp Chestnut- Full Day 5-13 9-4 $225 $255 6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14 8/21 Financial Assistance Available
Babysitter Camp - Full Day - (Chestnut St.) 9-13 9-4 $275 $305 7/31 Financial Assistance Available
Build It Camp - Half Day - PM 6-12 1-4 $150 $180 7/24 Financial Assistance Available
Dance Camp - Half Day - AM 6-12 9-12 $150 $180 7/17 8/7 Financial Assistance Available
Diva Camp - Half Day - AM 6-12 9-12 $150 $180 6/26 Financial Assistance Available
Fencing Camp - Half Day - AM 6-8 9-12 $150 $180 7/17 Financial Assistance Available
Fencing Camp - Half Day - PM 9-12 1-4 $150 $180 7/17 Financial Assistance Available
Lego Movie Camp - Half Day - AM 6-12 9-12 $150 $180 7/24 Financial Assistance Available
Mad Scientist Camp - Half Day - AM 6-12 9-12 $150 $180 7/10 Financial Assistance Available
Mad Scientist Camp - Half Day - PM 6-12 1-4 $150 $180 6/19 Financial Assistance Available
Messy Art Camp - Half Day - PM 6-12 1-4 $150 $180 7/10 Financial Assistance Available
Mission Impossible Camp - Half Day - AM 6-12 9-12 $150 $180 8/14 Financial Assistance Available
Preschool Gymnastics/Dance - Half Day - AM 3-5 9-12 $165 $195 7/17 8/7 Financial Assistance Available
Princess Dance Camp - Half Day - AM 3-5 9-12 $150 $180 7/10 8/14 Financial Assistance Available
Progressive Gymnastics Camp - AM 6-12 9-12 $165 $195 7/24 7/31 Financial Assistance Available
Progressive Gymnastics Camp - Full Day 6-12 9-4 $300 $330 7/10 8/14 Financial Assistance Available
Sassy Dance Afternoon Camp - Half Day - PM 6-12 1-4 $150 $180 6/26 Financial Assistance Available
Thriller Survivalist Camp- Half Day - PM 6-12 1-4 $150 $180 8/14 Financial Assistance Available
Top Chef Camp - Half Day - AM 6-8 9-12 $150 $180 8/7 Financial Assistance Available
Top Chef Camp - Half Day - AM 6-12 9-12 $150 $180 6/19 Financial Assistance Available
Top Chef Camp - Half Day - PM 9-12 1-4 $150 $180 8/7 Financial Assistance Available
Tumbling/Acro/Dance Camp - Half Day - PM 6-12 1-4 $165 $195 7/17 7/24 7/31 8/7 Financial Assistance Available
YMCA Ninja Hero Camp- Full Day 6-12 9-4 $275 $305 6/26 Financial Assistance Available
Camp Registration Facts:
Deposit Fees: $25 (member) $50 (non-member) per child per week.
* Deposit paid when Registration is completed by Business Manager.
* Deposits are camp and week specific, non refundable and non transferrable.
* The amount paid will be deducted from the total camp cost.
Camp Payments are drafted 2 weeks (Monday) prior to camp.
*July 4th Week fees will be prorated as there is NO camp on July 4th.
REGISTER EARLY! Late Registrations will incur an additional fee of $50 per child per week

Campers Name: ________________________________________________ Age (as of 6/1): ______________ Approx. Pick Up Time: ___________
Please check the block for the camp and week of your choice.
AIRPORT RD CAMPS
Age
Time
Mem
Rate
Non
Mem
Rate
1 2 3
4* 5 6 7 8 9 10 11
Notes
6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14 8/21
Camp Winnipeg- Full Day 6-11 9-4 $255 $285 6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14 8/21 Financial Assistance Available
4H Camp - Extended Full Day 6-12 9-4 $325 $355 7/17
4H Camp - Half Day - AM 10-12 9-12 $200 $230 7/17
4H Camp - Half Day - PM 6-9 1-4 $200 $230 7/17
Aquatic Adventure - Full Day 8-12 9-4 $275 $305 6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14 Financial Assistance Available
Babysitter Camp - Full Day (Airport Rd) 10-13 9-4 $275 $305 6/19 Financial Assistance Available
Counselors in Training (CIT) Camp- Full Day 14-15 9-4 $255 $285 6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14 Financial Assistance Available
Creative Craft - Extended Full Day 6-12 9-4 $290 $320 8/7 Financial Assistance Available
Creative Craft - Half Day - AM 10-12 9-12 $175 $205 8/7 Financial Assistance Available
Creative Craft - Half Day - PM 6-9 1-4 $175 $205 8/7 Financial Assistance Available
Hoof Beats Camp - Full Day 9-11 9-4 $520 $550 6/19 7/17 7/31 50% Deposit.
Instructional Diving Camp - Half Day - PM 10-13 1-4 $175 $205 7/31 8/7 Financial Assistance Available
Kids Triathlon Camp - Half Day - AM 7-12 9-12 $165 $195 8/14 Financial Assistance Available
Leaders-In-Training - Full Day 12-13 9-4 $255 $285 6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14 Financial Assistance Available
Montessori Camp - Full Day 3-5 9-4 $255 $285 6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14
Montessori Camp - Half Day - AM 3-5 9-12 $150 $180 6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14
Limited Financial Assistance
Available
Limited Financial Assistance
Available
Music Camp - Extended Full Day 8-12 9-4 $290 $320 7/31 Financial Assistance Available
Music Camp - Half Day - PM 8-12 1-4 $175 $205 7/31 Financial Assistance Available
Photo Camp - Extended Full Day 8-12 9-4 $290 $320 7/31 Financial Assistance Available
Photo Camp - Half Day - AM 8-12 9-12 $175 $205 7/31 Financial Assistance Available
Pony Camp - Half Day - Full Day 6-8 9-4 $440 $470 6/26 7/10 7/24 8/7 50% Deposit.
Pony Camp - Half Day - PM 6-8 1-4 $305 $355 6/26 7/10 7/24 8/7 50% Deposit.
Preschool Explorer Camp - Full Day 3-5 9-4 $255 $285 6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14 8/21 Financial Assistance Available
Preschool Explorer Camp- Half Day - AM 3-5 9-12 $147 $177 6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14 8/21 Financial Assistance Available
Robotics Camp - Extended Full Day 6-12 9-4 $325 $355 6/26
Robotics Camp - Half Day - AM 10-12 9-12 $200 $230 6/26
Robotics Camp - Half Day - PM 6-9 1-4 $200 $230 6/26
Swim Team Conditioning - Half Day - AM 10-13 9-12 $175 $205 7/31 8/7 Financial Assistance Available
Theatre Camp - Full Day 8-12 9-4 $275 $305 7/10 Financial Assistance Available
Wilderness Adventure - Extended Full Day 6-12 9-4 $290 $320 7/24 Financial Assistance Available
Wilderness Adventure - Half Day - AM 10-12 9-12 $175 $205 7/24 Financial Assistance Available
Wilderness Adventure - Half Day - PM 6-9 1-4 $175 $205 7/24 Financial Assistance Available

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