Woodbridge Branch YMCA - Day Camp

YMCA at the Woodbridge Community Center
2010/2011 Schools Out! Vacation Care!

Please fill out all information as completely and accurately as possible.

Child's Information

*Child's First Name:

*Child's Last Name:

*Address:

*City:

*State: *Zip:

*Home Phone:

*Birth Date: *Age:

*Sex:

Male
Female

*Grade in School: *School:

*Current YMCA Member? Yes No Expiration Date:

Parent/Guardian Information

Name:

Home Phone:

Work Phone:

Email Address: Use email address for main contact

Name:

Home Phone:

Work Phone:

Email Address: Use email address for main contact

Please check off dates below.

September 2010 January 2011

Sept 9 Jan. 17

Sept 10

October 2010 February 2011

Oct. 11 Feb. 18

Feb. 21

November 2010 April 2011

Nov. 1 Apr. 18

Nov. 2 Apr. 19

Nov. 3 Apr. 20

Nov. 4 Apr. 21

Nov. 5 Apr. 22

Apr. 25

December 2010

Dec. 24- until 3 pm only

Dec. 27

Dec. 28

Dec. 29

Dec. 30

Dec. 31 - until 3 pm only

Fees
$35.00 per day ($25.00 p/day for 12/24 & 12/31) for Members
$48.00 per day ($35.00 p/day for 12/24 & 12/31) for Non-Members.

(Values are automatically calculated. They cannot be changed.)

per day X Days = Total Cost

Payment

Payment can be made via check or credit card (Visa and MasterCard are accepted). If you pay by check, your registration will not be processed until the check is received.

If paying by credit card, you will be charged the amount shown above.

Name on Card:

Card:

Card Number:

Exp. Date (mm/yy):

Additional Comments: