2018 Camp Chestnut & Winnipeg (WCAY & OLY) 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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Campers Name: ________________________________________________ Grade Completed: ______________ Approx. Pick Up Time: ___________
Will you need spark time care (no charge)? YES NO ( AM and/or PM )
(please circle)
Please check the block for the camp and week of your choice.
AIRPORT RD CAMPS
Completed
Grade
6/11 6/18 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13 8/20
Camp Winnipeg- Full Day K-8 9-4 $265 $300 6/11 6/18 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13 8/20
Aquatic Adventure - Full Day 2-7 9-4 $285 $320 6/11 6/18 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13
Babysitter Camp - Full Day (Airport Rd) 4-8 9-4 $300 $320 6/18
Computer Explorers Camp - Full Day 1-7 9-4 $335 $370 7/30
Computer Explorers Camp AM Age: 10-12 9-12 $210 $245 7/30
Computer Explorers Camp PM Age: 6-9 1-4 $210 $245 7/30
Counselors in Training (CIT) Camp- Full Day 8-10 9-4 $265 $300 6/11 6/18 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13
Creative Craft - Extended Full Day 1-6 9-4 $300 $335 7/23
Creative Craft - Half Day - AM Age: 10-12 9-12 $185 $220 7/23
Creative Craft - Half Day - PM Age: 6-9 1-4 $185 $220 7/23
Hoof Beats Camp - Full Day 3-6 9-4 $530 $565 6/18 7/16 7/30 50% Deposit
Instructional Diving Camp - Half Day - PM 4-8 1-4 $185 $220 7/30 8/6
Lego Robotics Camp - Extended Full Day 1-7 9-4 $335 $370 6/25 7/16
Lego Robotics Camp - Half Day - AM Age: 9-12 9-12 $210 $245 6/25 7/16
Lego Robotics Camp - Half Day - PM Age: 6-8 1-4 $210 $245 6/25 7/16
Montessori Camp - Full Day Age: 3-5 9-4 $275 $315 6/11 6/18 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13
Montessori Camp - Half Day - AM Age: 3-5 9-12 $170 $210 6/11 6/18 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13
Photo Camp - Extended Full Day 2-7 9-4 $300 $335 8/6
Photo Camp - Half Day - AM 2-7 9-12 $185 $220 8/6
Pony Camp - Full Day 1-3 9-4 $450 $485 6/25 7/9 7/23 8/6 50% Deposit.
Pony Camp - Half Day - PM 1-3 1-4 $325 $380 6/25 7/9 7/23 8/6 50% Deposit.
Preschool Explorer Camp - Full Day Age: 3-5 9-4 $275 $315 6/11 6/18 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13 8/20
Preschool Explorer Camp- Half Day - AM Age: 3-5 9-12 $170 $210 6/11 6/18 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13 8/20
Theatre Camp - Full Day 2-7 9-4 $300 $335 7/9
Time
Mem
Rate
1 2 3 4* 5 6 7 8 9 10 11
Notes
Wilderness Adventure - Extended Full Day 1-6 9-4 $300 $335 8/6
Wilderness Adventure - Half Day - PM 1-6 1-4 $185 $220 8/6
Non
Mem
Rate
SAVE MONEY - REGISTER BY 2/28 FOR EARLY BIRD PRICES - SEE CAMP GUIDE FOR DETAILS.

Please check the block for the camp and week of your choice.
West Chester Area YMCA and Oscar Lasko YMCA and Childcare Center
2018 Summer Camp Selections
Campers Name: ________________________________________________ Grade Completed: ______________ Approx. Pick Up Time: ___________
Will you need spark time care? YES NO ( AM and/or PM )
Mem
OSCAR LASKO CAMPS Age Time
Mem 1 2 3 4* 5 6 7
6/11 6/18 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13 8/20
Camp Chestnut- Full Day K-8 9-4 $235 $270 6/11 6/18 6/25 7/2 7/9 7/16 7/23 7/30 8/6 8/13 8/20
Babysitter Camp - Full Day - (Chestnut St.) 9-13 9-4 $285 $320 7/30
Build It Camp - Half Day - AM 6-12 9-12 $160 $195 8/6
Dance Camp - Half Day - AM 6-12 9-12 $160 $195 7/16 8/6
Diva Camp - Half Day - AM 6-12 9-12 $160 $195 6/25
Fencing Camp - Half Day - PM 6-12 1-4 $160 $195 7/16
Lego Movie Camp - Half Day - AM 6-12 9-12 $160 $195 7/9
Mad Scientist Camp - Half Day - AM 6-12 9-12 $160 $195 7/23
Mad Scientist Camp - Half Day - PM 6-12 1-4 $160 $195 6/18
Messy Art Camp - Half Day - PM 6-12 1-4 $160 $195 8/6
Minecraft Camp - Half Day -PM 6-12 1-4 $160 $195 7/9
Preschool Gymnastics/Dance - Half Day - AM 3-5 9-12 $185 $225 7/16 8/6
Princess Dance Camp - Half Day - AM 3-5 9-12 $170 $210 7/9 8/13
Progressive Gymnastics Camp - AM 6-12 9-12 $175 $210 7/23 7/30
Progressive Gymnastics Camp - PM 6-12 1-4 $175 $210 7/23 7/30
Progressive Gymnastics Camp - Full Day 6-12 9-4 $310 $345 7/9 7/23 7/30 8/13
Racquets and Roll Camp - Half Day- AM 6-12 9-12 $160 $195 7/16
Sassy Dance - Half Day - PM 6-12 1-4 $160 $195 6/25
Top Chef Camp - Half Day - AM 6-12 9-12 $160 $195 6/18
Top Chef Camp - Half Day - PM 6-12 1-4 $160 $195 7/23
Tumbling/Acro/Dance Camp - Half Day - PM 6-12 1-4 $175 $210 7/16 8/6
YMCA Ninja Hero Camp- Full Day 6-12 9-4 $285 $320 6/25
Rate
Non
Rate
Camp Registration Facts:
8
9 10 11
(please circle)
Notes
Early Bird Pricing! Register by 2/28 for Early Bird Pricing (see camp guide).
Camp Fees: Deposit: $25 (member) $50 (non-member) per child per week.
* Deposit is 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.
* Late Registrations (5 days prior to camp start) will incur an additional fee of $50 per child per week.

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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