Please complete both pages of this registration from. LATTOF YMCA 2014 SUMMER CAMP REGISTRATION FORM Please place an x in the appropriate box for the camp(s) you want by session date. Use one form per child. Please circle the days that you will attend camp when choosing days with 3 or 5 day options.* Precamp: June 9-13 Triple Threat Sk8 8-1 Week 1: June 16-20 Leaders in Training 12-1 Aquatic Medley 6-14yrs Putt Putt Travel Lego Mania 7-10yrs Soccer Nomad Sk8 10-16yrs Week 2: June 23-27 Leaders in Training 12-1 Y Be Fit Bowling Travel 6-14yrs Windy City Tour 10-14yrs Floor Hockey 8-13yrs S.A.R. 11-16yrs Week 3: June 30-July 4 Leaders in Training 12-1 Jr. Water Polo Game Days Travel 9-14yrs Top Chef Cheerleading Nomad Archery 10-1 Week 4: July 7-11 Leaders in Training 12-1 Y Be Fit Water Park Rookie Sports of Sorts Skateboard 9-1 Week 5: July 14-18 Leaders in Training 12-1 Aquatic Medley 6-14yrs Bouncy Basketball 8-13yrs Dodgeball 8-12yrs Inline Sk8 9-1 Nomad Mt. Bike 10-16yrs Week 6: July 21-25 Leaders in Training 12-1 Y Be Fit Horseback Rookie Floor Hockey Youth Handball 10-17yrs River Bound Rafting 9-1 Skateboard 9-1 Week 7: July 28-August 1 Leaders in Training 12-1 Amazing Arcade Girls on the Go Rookie Basketball Syncro Swim 8-16yrs Achievemore 12-16yrs Week 8: August 4-8 Leaders in Training 12-1 Canoe 8-1 Y Be Fit Thrill Week 9-14yrs Nomad Mt. Bike (Wisc. Tour) 10-16yrs Art & Science Volleyball 9-14yrs Week 9: August 11-15 Leaders in Training 12-1 Horseback Music/Dance Arena Flag Football 9-13yrs Neverest 7-13yrs Week 10: August 18-22 Leaders in Training 12-1 Aquatic Medley 6-14yrs Y Be Fit Nomad Sk8 9-1 CHGO38
LATTOF YMCA 2014 SUMMER DAY CAMP INFORMATION Please print clearly. Use one form per child. both pages of this registration from. Please complete Last Name First Name Age Gender Birthdate Home Address City State Zip Father s/guardian s Name Phone Cell Mother s/guardian s Name Phone Cell Emergency Contact (other than parent) Relationship Phone Email Address T-shirt Size Would you like to receive communication via email (newsletters, payment reminders, etc?) YES NO Is the camper a YMCA Member? Yes No Membership # Membership must remain valid from the time of registration through September 1, 2014 to receive member rate. $25 non-refundable deposit due per Week, per camper for Traditional s. 50% Deposit for Sports, Specialty, Skate, and Climbing s Payment Information Return with non-refundable deposits per week, per camper to the Lattof YMCA, 300 E. Northwest HWY Des Plaines, IL 60016 I understand I am responsible for full camp payment for each week registered prior to the start of camp. No changes to a child s schedule may be made after June 1, 2014. Check enclosed: $ Please charge my credit card: $ Discover MasterCard Visa Account number Exp. date Cardholder s signature Date CREDIT CARD/BANK DRAFT AUTHORIZATION FOR SUMMER CAMP PAYMENTS: I hereby authorize the YMCA of Metropolitan Chicago and the Financial Institution designated below in the amount of my monthly summer camp dues. I acknowledge that the origination of deductions from my account must comply with provisions of U.S. Law. FOR AUTOMATIC PAYMENTS USING MY CREDIT CARD OR DEBIT CARD: Charge my Credit/Debit Card: Visa Discover Mastercard Name as it appears of the card: Account Number: Security Code Expiration Date I understand that my monthly bank/credit card statement should show the amount and date payment was made to the YMCA for camp. I understand that I am responsible for ensuring that the account designated above has sufficient funds/credit on my automatic payment date to allow for the automatic deduction/charge of my payment. AUTOMATIC DEDUCTIONS AND AUTOMATIC CHARGES: I understand that the amount of the deduction for my summer camp sessions will be: June 1 June 15 July 1 July 15 August 1 This authority shall remain in full force and effect, and the Payment Plan shall continue until: For cancellation of Summer camp fees, I have filled out the summer camp cancellation form and given the YMCA at least 15 days prior to my draft date. I understand that my summer camp payments will draft on all three dates above unless I cancel my weeks. I understand that I will receive written notice in advance of any change in the date of the payment plan or for any change in the amount due, and I authorize the YMCA to use such changed date or amount after the written notice is sent to me, unless I cancel this authority and the Payment Plan as provided above (#1). I understand that it is my responsibility to update my contact information when there is a change of name, address or financial institution or account. I understand that the YMCA of Metropolitan Chicago has the right to cancel my participation in summer camp if it unable to collect any payment due, and that I am liable for any uncollected payments and for any fees or penalties imposed by the YMCA or my Financial Institution. I understand that there is a $25 service charge assessed by the YMCA on all returned checks and declined monthly credit card/checking drafts I understand that if change my Financial Institution and/or change the type of draft account, I need to come in and sign a new authorization agreement. I acknowledge that I have read this agreement and received a copy. Printed Name of Account Holder 17 Signature of Account Holder Date CHGO38