SOUTHWEST YMCA ADVENTURE GUIDES

REGISTRATION FORM

(Please complete both sides of this form -- one form per child)

 

 

Child’s First Name: __________________  Child’s Last Name: __________________ Birthdate: __/__/__ Sex: M  F  Age: __________

 

Home Address: _____________________________________________ Apt # ______ City: __________________ Zip: __________

 

Home Phone: _________________  Grade in Sept. ’03: _____   School: __________________Ethnicity (optional): _________________

 

Parent/Guardian’s Name: _______________________________  Parent/Guardian’s Name: ___________________________________

 

Work #: ________________ Emergency #: _________________ Work #: ________________ Emergency #: _____________________

 

Employer: ____________________________________________ Employer: _____________________________________________

 

Occupation: ___________________________________________ Occupation: ___________________________________________

 

Email: __________________________Birth Date___/____/____  Email: _____________________________  Birth Date___/____/___

 

(Optional) We are new Y Adventure Guides and would like to be placed in the same Circle as:___________________________________

                                                                                                 

Program Payment

Program Costs (scholarships are available).  Please complete payment method section:

 

¨      I will not be applying for financial assistance.  I will pay the program fee, with payment due upon registration:

o        $25 Program Membership Fee for each child (not required for YMCA Facility Members)

o        $65 for the first child

o        $50 for each additional child in the family

 

¨      I will be applying for Financial Assistance.  Please review the enclosed Financial Assistance Application.  I will not be paying any fees at this time.  I do understand that I may not qualify for 100% scholarship.  I understand that if I do not qualify for financial assistance, I will be responsible for all fees.

 

 

Payment Method

      PROGRAM FEE:

o        Program Registration:          1st Child (named above)                       $65          Total: $___________

o        Program Registration           2nd Child (form attached):                    $50          Total: $___________

o        Program Membership:         $25 (if applicable)                                  $25         Total: $___________

o        Total Payment:                                                                                                                $___________

 

¨      Check enclosed  (check #____________)

 

¨      Charge the amount indicated above to my Credit Card: Card #: ____________________________ Exp Date: ________

 

I authorize the YMCA to draft the listed credit card for the amount indicated above.

 

Signature: ____________________________________        Date: _______________________________

 

For Returning Members

 

I am a member of the following groups:

 

Nation/Expedition: __________________________________   Tribe/Circle:________________________________

 

 

For office use only:

Staff person receiving registration: ______________________                              Date Received_________________

Financial Assistance Paperwork Turned in?     Y      N                                  Liability Waiver Signed:     Y      N

Payment Attached:  $___________                                                All payments accepted: Initial:          __________________________