Jennersville Y 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

Jennersville YMCA Day Camp Selection 2017
Camper's Name ____________________________________________________________
Birth Date ____/____/____ Age _____
Please Circle Grade Entering as of 9/17
K 1 2 3 4 5 6 7 8 9 10
Our camp schedule will follow Avon Grove and Oxford School District Calendars.
Do you qualifiy for a reduced rate?
YMCA Financial Assistance YMCA Sibling Discount YMCA Staff Discount Chester County Assistance
Camp Chippewa 6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14 8/21
Themes
Super
Heroes
Blast from
the Past
Disney
Stars and
Stripes
Survivor Wet & Wild Holiday Color Wars Rock Stars
Myths &
Legends
Around the
World
Full Day Entering Grades K-6
Teen Adventure Camp 6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14 8/21
Entering Grades 7 - 12
Camp Discovery 6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14 8/21
Themes
Down by the
Shore
Jurassic
Journey
Ooey Gooey
Stars and
Stripes
Under the
Sea
The Mighty
Jungle
The Great
Outdoors
Out of this
World
Wild Wild
West
Big 5 Sports
Step into
Storybooks
Full Day
Half Day
(9am - 4pm)
(9 am - 12 pm)
Traditional Sports Camp 6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14 8/21
Ages 6 to 8 or Ages 9 - 12
Themes Soccer Big 5 Basketball Soccer
Flag
Football
Basketball
Floor
Hockey
Advanced Sports Camp 6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14 8/21
Basketball (9 am - 12 pm)
Triathalon (9 am - 12 pm)
Leadership Development Camp 6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14 8/21
Counselors in Training (Entering Gr 8 - 9)
Field Work (Entering Grades 8 - 9)
Jr Counselor (Ages 16 & 17)
See reverse for Aquatics, Performing Arts, Specialty and Spark Swim Lessons

Jennersville YMCA Day Camp Selection 2017
(continued)
Aquatics Camps 6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14 8/21
Aquatic Adventures
Competitive Swim
Jr. Lifeguarding
Water Sports
Performing Arts Camps 6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14 8/21
Dance Camp
Glee
How to Make a Video
Storybook Theatre
Teen Theatre
Theatre Jrs.
Theatre Kids
Specialty Camps 6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14 8/21
Creation Station
Junior Chefs
Lego Mania
Lego Mania Jrs.
Mad Science
Outdoor Adventure
Plaines, Trains and Automobiles
Young Chefs
Spark Time Swim Lessons 6/12 6/19 6/26 7/3 7/10 7/17 7/24 7/31 8/7 8/14 8/21
Swim Lessons (Ages 5 1/2 - 17)
Thank you for choosing the Jennersville YMCA as part of your summer fun!

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