MONTGOMERY COUNTY FAMILY YMCA

2008 SUMMER CAMP REGISTRATION

DATE _______/________/___________

CHILD’S NAME ________________________________________________________

GENDER___________GRADE ENTERING IN FALL 08’_______________________

SCHOOL NAME_________________________________________________________

HOME MAILING ADDRESS______________________CITY____________SATE______ZIP_________

PARENT/GUARDIAN1 NAME______________________________________

HOME PHONE_________________WORK PHONE_____________________

PARENT/GUARDIAN 2 NAME________________________________________

HOME PHONE________________________WORK PHONE_________________

EMAIL ADDRESS___________________________________________________

MY CHILD IS IN GOOD HEALTH AND I GIVE PERMISSION FOR THEM TO PARTICIPATE IN ANY AND ALL ACTIVITIESFOR THE YMCA SUMMER CAMP PROGRAM.

PARETN/GUARDIAN SIGNATURE__________________________________________DATE____________

IMPORTANT INFORMATION AND RELEASE:

I HAVE READ THE FOLLOWING INFORMATION CONCERNING THE MONTGOMERY COINTY FAMILY YMCA’S NON-PROFIT YOUTH SUMMER CAMP PROGRAMS AND ACTIVITIES NAMED HEREIN, AND AGREE TO ITS RULES AND FORMAT AND GIVE MY CHILD PERMISSION TO PARTICIPATE IN SUCH PROGRAM(S). I UNDERSTAND THAT THE YMCA, RED OAK COMMUNITY SCHOOL DISTRICT, AND THE CITY OF RED OAK, IOWA ASSUMES NO RESPONSIBILITY IN CASE OF ACCIDENT OR INJURY, AND I ASSUME FULL RESPONSIBILITY FOR MY CHILD’S MEDICAL EXPENSES AND WAIVE ALL RIGHTS OR CAUSES OF ACTION WHICH I MAY HAVE AGAINST THE YMCA AND THE CITY OF RED OAK, IA. THE YMCA HAS PERMISSION TO USE PHOTOGRAPHS OF MY CHILD IN its PROMOTINAL MATERIAL.

PARENT OR GUARDIAN SIGNATURE___________________________________________DATE___________

YMCA SUMMER CAMP PROGRAM

PLEASE CIRCLE WHICH OF THE FOLLOWING CAMP WEEKS YOU WOULD LIKE TO ENROLL YOUR CHILD IN, AND IF THEY WILL BE ATTENDING EXTENDED CARE;

(*ALL CAMPS ARE MONDAY THROUGH FRIDAY 8-4 WITH EXCEPTION OF FRIDAY JULY 4^TH, IN WHICH CAMPER MAY MAKE-UP THEIR FRIDAY ON ANOTHER CAMP WEEK.)

SESSION 1; JUNE 2^ND – 6^TH EXTENDED CARE Y N 7-8 A.M. 4-5 P.M.

SESSION 2; JUNE 9^TH – 13^{TH EXTENDED CARE Y N} 7-8 A.M. 4-5 P.M.

SESSION 3; JUNE 16^TH - 20^{TH EXTENDED CARE Y N} 7-8 A.M. 4-5 P.M.

^{SESSION 4; JUNE 23RD – 27TH EXTENDED CARE Y N} 7-8 A.M. 4-5 P.M.

SESSION 5; JUNE 30^TH – JULY 3^{RD EXTENDED CARE Y N} 7-8 A.M. 4-5 P.M.

SESSION 6; JULY 7^TH – 11^{TH EXTENDED CARE Y N} 7-8 A.M. 4-5 P.M.

SESSION 7; JULY 14^TH – 18^{TH EXTENDED CARE Y N} 7-8 A.M. 4-5 P.M.

^{(FAIR-FUN WEEK)}

^{NAME OF CHILD REGISTERING________________________________________________}

^{TOTAL NUMBER OF CAMP WEEKS MY CHILD IS REGISTERING FOR; ______________________}

^{TOTAL NUMBER OF WEEKS MY CHILD WILL BE ATTENDING EXTENDED CARE;____________}

^{YMCA MEMBER Y N}

^{__________________________________________________________________________________}

^{OFFICE USE ONLY}

^{TOTAL AMOUNT DUE $_________________}

^{AMOUNT DUE AT REGISTRATION $_____________ (AT LEAST 50% OF TOTAL)}

^{BALANCE DUE BY FIRST DAY OF CHILDS FIRST CAMP WEEK $_____________________}

^{*MULTIPLE CHILD DISCOUNT Y N *MULTIPLE WEEK DISCOUNT Y N *YMCA MEMBER DISCOUNT Y N}

^{AMOUNT PAID $______________________ DATE___/____/_____}

^{BALANCE DUE $_______________________}

^a

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Edited: 4/21/08