2018 - Camp Chippewa (Jennersville YMCA) Registration Form

The YMCA of Greater Brandywine
Summer Day Camp Registration
2018
Brandywine Kennett Oscar Lasko
Jennersville Lionville UMLY
Octorara
West Chester
Camper Name:
_____ Gender: Male Female
Date of Birth: _____ Grade completed in 2017-2018
Address:
City:
State/Zip:
Home Phone:
Registered Siblings (A separate grid and form must be completed for each child registered.)
Sibling’s Name(s):
Parent/Guardian Name:
E-mail:
___________________
______
______
Parent/Guardian Name:
E-mail:
______
______
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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Jennersville YMCA Day Camp Selection 2018
Camper's Name _____________________________ Birth Date ___/___/___
Please note, camp groups are based on the grade your child is entering
next school year. Contact the branch for assistance if your child's
birthday is in June, July or August.
Please Circle Grade Entering as of 9/18
K 1 2 3 4 5 6 7 8 9 10
Do you qualifiy for a reduced rate? The largest qualifying discount will be applied.
YMCA Financial Assistance Staff Discount Sibling Discount
Discount will apply automatically online
Discount only be applied at branch
Early Bird Registration available until February 28, 2018. Members save $10.00 per week. Community Participants save $15.00 per week.
Jennersville YMCA Day Camps Session # 1 2 3 4 5 6 7 8 9 10 11
Camp Chippewa
Themes
Price
Value
Price
6/11 6/18 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13 8/20
Super
Heroes
Color
Wars
Survivor
Stars &
Stripes
Emergency
Services
Camp's Got
Talent
World
Carnival
Super
Soakin'
Fiesta
Week
Camp Jedi
Flashback
Full Day Entering Grades K-6 $270.00 $235.00
Teen Adventure
Price
Value
Price
Entering Grades 7 - 9 $345.00 $310.00
Teen Camps
6/11 6/18 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13 8/20
Leadership Development
Counselors in Training (Entering Gr 9 - 12) $505.00 $470.00
Field Work (Entering Grades 9 - 12) $505.00 $470.00
Camp Discovery (Ages 3-5)
Themes
Price
Value
Price
6/11 6/18 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13 8/20
Mighty
Jungle
Ooey
Gooey
Outer
Space
Stars &
Stripes
Under the
Sea
Lights,
Camera,
Action
Treasure
Island
Great
Outdoors
Water
Sports
Dinosaurs
Full Day (9am - 4pm) $285.00 $245.00
Half Day (9 am - 12 pm) $215.00 $170.00
Sports Camps
Price
Value
Price
Tradtional Sports Themes Big 5 Basketball Soccer Big 5
Ages 7 - 12 $270.00 $235.00
Water Sports (Ages 9 - 12) $320.00 $290.00
6/11 6/18 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13 8/20
Flag
Football
Basketball
Soccer
Floor
Hockey
Big 5
See reverse for Aquatics, Performing Arts, Specialty and Spark Swim Lessons.
Our camp schedule follows the Avon Grove and Oxford School District Calendars.

Jennersville YMCA Day Camp Selection 2018
(continued)
Early Bird Registration available until February 28, 2018. Members save $10.00 per week. Community Participants save $15.00 per week.
Jennersville YMCA Specialty Camps Session # 1 2 3 4 5 6 7 8 9 10 11
Aquatics Camps
Price
Value
Price
Aquatic Adventures (Ages 6-8/9-12) $345.00 $310.00
6/11 6/18 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13 8/20
Jr. Lifeguarding (Ages 10 - 14) $320.00 $285.00
Performing Arts Camps
Price
Value
Price
Dance Camp (Ages 9 - 12) $320.00 $285.00
6/11 6/18 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13 8/20
Glee (Ages 6 - 12) $320.00 $285.00
Storybook Theatre (Ages 5 - 9) $320.00 $285.00
DIY Theatre Camp (Ages 9 - 13) $320.00 $285.00
Theatre Camp Jrs. (Ages 9 - 15) $295.00 $260.00
Theatre Camp. (Ages 7 - 15) $580.00 $510.00
Theatre Kids (Ages 5 - 8) $295.00 $260.00
Specialty Camps
Price
Value
Price
Creative Crafts (Ages 6-9/9-12) $320.00 $290.00
6/11 6/18 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13 8/20
Fun with Foods (Ages 9 - 12) $320.00 $290.00
How to Make a Video (Ages 9 - 12) $320.00 $285.00
Lego Engineers (Ages 9 - 12) $320.00 $290.00
Lego Mania (Ages 6 - 12) $320.00 $290.00
Mad Science (Ages 6 -12) $320.00 $290.00
Survival (Ages 6 - 12) $320.00 $290.00
Moving Engines (Ages 6 - 12) $320.00 $290.00
Spark Time Swim Lessons
Price
Value
Price
Swim Lessons (Ages 5 1/2 - 17) $35.00 $25.00
6/11 6/18 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13 8/20
Early Bird registration discount not available on swim lessons
Thank you for choosing the Jennersville YMCA as part of your summer fun!
Our Camp schedule follows the Avon Grove and Oxford school district calendars.

PROGRAM DRAFT AUTHORIZATION FORM
BR JV KT LCY OC
OLY UMLY WC
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
Date
Card/Check Name ____________________
Credit or Debit Card
VISA MasterCard Discover
Card # __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __
Expiration Date __ __ / __ __ Security Code ______
American Express
Card # __ __ __ __ - __ __ __ __ __ __ - __ __ __ __ __
Expiration Date __ __ / __ __ Security Code ______
Bank Account
Bank Name: _____________________________
Bank Routing/Transit Number (9 digits)
__ __ __ __ __ __ __ __ __
Bank Account Number:
________________________________________
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