2016 Registration Form

YMCA CAMP SHADY BROOK
2016 SUMMER CAMP REGISTRATION FORM
Please complete both sides of this form
One form per camper.
Camper’s Name: ___________________________________________ Birth date:_______________________________
M
F
Address:____________________________________________________ City:________________ State:__________ Zip:________
School:_____________________________________________________ District:_______________________________________
Cabin-mate Request (if any) 1st choice:___________________________ 2nd choice:____________________________________
Note: Two cabin-mates, up to one year apart, and in the same program may be requested. No request is guaranteed.
Dietary Restrictions:______________________________________________________________________________________________
1) Parent/Guardian’s Name:_________________________________ Emergency Contact:
Alumni?
Yes
No
Yes
No
Years as camper__________ Years as Staff___________
Address:____________________________________________________ City:________________ State:__________ Zip:________
Phone:_________________ Cell Phone:__________________Email:__________________________________________________
Place of Employment:_________________________________________ Work Phone:___________________________________
2) Parent/Guardian’s Name:_________________________________ Emergency Contact:
Alumni?
Yes
No
Yes
No
Years as camper__________ Years as Staff___________
Address:____________________________________________________ City:________________ State:__________ Zip:________
Phone:_________________ Cell Phone:__________________Email:__________________________________________________
Place of Employment:_________________________________________ Work Phone:___________________________________
I would like to receive camp paperwork (forms and handbook) via:
Email
United States Postal Service (regular mail)
I will access it myself from your website at campshadybrook.org
Parent Information Packet: A Parent Handbook will be provided to me as well as all necessary paperwork needed by the YMCA. I can also get them online at
campshadybrook.org. I agree to read the Parent Handbook and return all necessary paperwork no later than two weeks before my child’s camp session. I
understand a $20 transfer fee will be charged if my child changes sessions.
*Please note that all registrations are accepted on a first-come, first-served basis. We will do our best to put you in the program you desire, pending space
availability. YMCA programs are open to all.
*$100 deposit is non-refundable after January 1, 2016.
**Cancellations made prior to June 1 will result in a refund less the $100 deposit.
Signature of Parent_________________________________ Date_________
Participant Waiver of Liability:
I, the parent/person having legal custody/guardianship of the minor(s) participating in Camp Shady Brook programs, give permission for the minor(m) and myself along with other registered
participants by me to participate in YMCA Camp Shady Brook (“Camp”) activities. We are physically able and mentally prepared to participate in all activities at the camp including activities
such as archery, horseback riding, riflery, swimming, boating, climbing wall, zip line, ropes course and hiking. In consideration of said participants being permitted to attend and participate in
the Camp, I hereby: (1) acknowledge that I have read and voluntarily sign this waiver, (2). release YMCA, USO, its directors, officers, employees, volunteers and agents (collectively “Releasees”)
from all liability for us for any loss, damage, injury, or death, whether caused by Releasees or otherwise, while we are at Camp, (3). I agree not to sue Releasees for any loss, damage, injury, or
death, and I will indemnify and hold harmless Releasees from any loss, liability, damage, or cost they may incur due to said participants participation in Camp, even if caused by the negligence
of Releasees, (4). I assume full responsibility for, and bear the risk of, any loss, damage, injury, or death, due to negligence of Releasees, (5) I do hereby authorize the YMCA, as agent for the
undersigned, to consent with respect to said participants, to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, including hospital care, which is deemed
advisable by the YMCA or any healthcare provider, whether such diagnosis or treatment is rendered at Camp, the office of a healthcare provider or at a hospital. I understand that the YMCA
is not responsible for costs incurred for medical care, and I agree to reimburse the YMCA for any medical costs paid for the care of the participants. I intend this waiver to be as broad and
inclusive as is permitted by the laws of Colorado; if any portion hereof is held invalid, I agree the balance shall continue in full force and effect.
For our participation in activities to be conducted by the YMCA of the Pikes Peak Region, I hereby give my permission and consent, now and for all time, to the YMCA of the Pikes Peak Region,
the National Council of Young Men’s Christian Associations of the United States of America (YMCA of the USA) and third parties collaborating with YMCA of the Pikes Peak Region] and/
or YMCA of the USA to make, reproduce, edit, broadcast or rebroadcast any video film, footage, sound track recordings and photo reproductions of said participants and/or our narrative
account of our experience at the YMCA of the Pikes Peak Region, for publication, display, sale or exhibition thereof in promotions, advertising and legitimate business uses without any
compensation to, and/or claim, by us. We may, or may not be, identified in such reproductions; however, we shall not be stated by name to have endorsed any particular commercial products
or commercial services.
Signature:_________________________________________________________________________________________Date:____________________________________________
Please mail or email this completed form, payment and camp paperwork to:
YMCA Camp Shady Brook
Attn: Lillian Cross
316 North Tejon Street
Colorado Springs, CO 80903
Fax: 719.329.7258
[email protected]
Questions? Call us at 719.329.7266 or email us at [email protected].
Camp Shady Brook
2016 Summer Camp Registration Form
COMPLETED CAMP PAPERWORK IS
DUE 2 WEEKS PRIOR TO CAMP DATE!
Registration available for all sessions until full.
Please check the session dates that you would like to reserve.
Y MEMBER
NON-MEMBER
AGES
Traditional Camp
$585
$620
8-16
Traditional Camp, 2-week*
$1,100
$1,225
8-16
AGES
Horsemasters Jr.
$750
$825
8-11
8-15
Adventure Camp 2
$795
$850
10-15
HS Jr./Sr.
Counselor in Training (2nd Year) , 4-week*
$1,675
$1,800
HS Jr./Sr.
SESSION 1: SUPERHERO
June 12-17
Y MEMBER
NON-MEMBER
Camp Corral (campcorral.org)
Counselor in Training (2nd Year) , 4-week*
$1,675
$1,800
SESSION 5: HARRY POTTER
July 10-15
Partnership Camps include Camp Corral in Session 1, YUNASA in session 2, Camp Kesem
in Session 3 and Camp Oasis in Session 5
Camp Oasis (ccfa.org)
SESSION 2: ADVENTURELAND
8-18
Stay Over weekend July 15-17**
$75
$75
All
June 19-24
Y MEMBER
NON-MEMBER
AGES
Traditional Camp
$585
$620
8-16
Traditional Camp, 2-week*
$1,100
$1,225
8-16
July 17-22
Y MEMBER
NON-MEMBER
AGES
Horsemasters Jr.
$750
$825
8-11
Traditional Camp
$585
$620
8-16
$750
$825
8-11
$75
$75
All
SESSION 6: ALOHA SUMMER
Leadership Development, 2-week*
$1,175
$1,250
HS Fr./So.
Horsemasters Jr.
Adventure Camp 1
$795
$850
10-15
Stay Over weekend July 22-24**
Stay Over Weekend June 24-26**
$75
$75
All
SESSION 3: MISSION IMPOSSIBLE
June 26-July 1
Y MEMBER
Traditional Camp
$585
Horsemasters
NON-MEMBER
$620
$750
$825
$75
$75
Camp Kesem (campkesem.org)
Stay Over Weekend July 1-3**
SESSION 7: NAVIGATOR & PIONEER
July 24-29
Y MEMBER
NON-MEMBER
AGES
AGES
Traditional Camp
$585
$620
8-16
8-16
Traditional Camp, 2-week*
$1,100
$1,225
8-16
11-14
Horsemasters
$750
$825
11-14
6-16
Leadership Development, 2-week*
$1,175
$1,250
HS Fr./So.
All
Stay Over weekend July 29-31**
$375
$375
All
AGES
July 31-August 5
Y MEMBER
NON-MEMBER
AGES
Traditional Camp
$585
$620
8-16
Advanced Horsemasters
$750
$825
13-16
Adventure Camp 3
$795
$850
10-15
SESSION 8: SUMMER OLYMPICS
SESSION 4: INTERNATIONAL FESTIVAL
July 3-8
Y MEMBER
Traditional Camp
$485
NON-MEMBER
$520
8-16
Horsemasters
$650
$725
11-14
Mini Aspen 1 (1/2 week, Sun.-Tues.)
$275
$315
6-8
Mini Aspen 1 (1/2 week, Wed.-Fri.)
$275
$315
6-8
Aspen Camp
$485
$520
6-8
Stay Over Weekend July 8-10**
$75
$75
All
* Stay Over weekends are included for two- and four-week sessions.
**Stay Over weekends can now be added to the beginning or end of a one-week session
for two extra days of fun!
YMCA Member
Non YMCA Member
Camp Session(s) Total
$__________
Add-Ons
Stayover Weekend $__________
Trail Rides
Maximum of two rides per week.
Qty.________
$__________
Tye-Dye $__________
Add-Ons Sub-Total
Sub-Total
$__________
ADD-ONS
ADDITIONAL FEE
AGES
Stayover Weekend
(Sessions 2, 3, 4, 5, 6 and 7)
$75
8-16
Trail Rides
$25
8-16
Tye-Dye
$8
All
Payment Options
We accept cash, check, money order or credit card.
Monthly payment plans may be arranged. A $20 service fee will be added to any
returned checks.
Payment Included:
Cash
Check
Money order
Please complete for credit cards:
Check One:
Deposit Only
Card Type:
Credit Card
Paid in Full
Including Add-Ons if applicable
$__________
Account No:____________________________________________________________Exp. Date:_______________________________
Amount Paid Today
$__________
Name on Card:_____________________________________________________________________________________________________
$__________
Signature:___________________________________________________________________________________________________________
Balance Due
Balance due 2 weeks prior to child’s 1st session of camp.
Above rates include all meals, and programming. Specialty services are charged separately and
based on availability. Please contact us for more information.
*A $100 non-refundable deposit is required to reserve your space.
All balances must be paid in full prior to arrival. Registration is available until full.
CANCELLATION POLICY: Cancellation prior to May 15 will result in loss of the $100
non-refundable deposit.
Parent Cancellation:
Refund Policy (PLEASE READ CAREFULLY) Please NOTE: The $100 deposit per session is non-refundable.
Cancellations prior to May 15
•
Will result in a refund of payments less than the $100 deposit or a credit to camper’s account.
Cancellations after May 15
• All payments will be forfeited or they may be held over as vouchers for 1 year. (If you choose to reschedule for 2015 or 2016 a $20 change fee will apply)
•
If cancellation is necessary due to illness, a refund will be issued less than the $100 deposit with a doctor’s notice stating the child is unable to attend Camp.
Mid–Session Cancellation:
•
Campers who must leave for medical reasons or family emergencies will be mailed a pro-rated refund.
•
No refunds will be given to campers choosing to attend late, depart early, or those sent home for behavioral or homesickness challenges.