2018 - Camp Octorara (Octorara 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.
Page 1 of 2

Octorara YMCA Summer Camp 2018 Registration Form
Camper's Name:(last name, first name) EARLY BIRD PRICING before March 1st
Grade Completed 2017:
Age:
Birthdate:
3 Day Preschool-
$175.00
3 Day-K-6th Grade
$165.00
5 Day-$215
Spark Time
3 Day Camp
Preschool:
$185.00
K-6th: $175.00
5 Day Camp
$225.00
Literacy Camp $180.00
Leader In Training
$215.00
Spark Time
7:00am-9:00am 9:00am - 4:00pm 9:00am -4:00pm Octorara School District 9:00am -4:00pm 4:00pm-6:00pm
Week 1 June 11-15 □ □ □ □ □
Week 2 June 18-22 □ □ □ □ □ □
Week 3 June 25-29 □ □ □ □ □ □
Week 4 July 2-6 □ □ □ □ □ □
Week 5 July 9-13 □ □ □ □ □ □
Week 6 July 16-20 □ □ □ □ □ □
Week 7 July 23-27 □ □ □ □ □ □
Week 8 July 30-Aug. 3 □ □ □ □ □
Week 9 Aug. 6-10 □ □ □ □ □
Week 10 Aug. 13-17 □ □ □ □ □
Week 11 Aug. 20-24 □ □ □ □ □
What time do you expect to arrive at camp for pick up? 4:00 4:30 5:00 5:30 6:00
$25.00 non refundable deposit per camper, per session (week) must accompany each camper's application to be
registered for that session. Parent Initials: ___________
*Automatic Credit Card Draft payments are required. Weekly payments are deducted Sunday, two weeks before
selected week. Parent Initials: _________
Camp Changes:
I understand that weekly camp deposits are non-refundable and non-transferable. No refunds will be given. I
understand the following charges may be processed to my account: $50.00 will be applied to cancellations requested
less than seven days prior to the start of the camp session or when registration is requested less than four days prior
to the start of the session. There will be a $25.00 charge for all changes made after the original registration. Parent
Intials: _________

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:
________________________________________
Page 2 of 2