YMCA Day Camp Registration Form
Date: Starting May 25th
Location: Monroeville Area YMCA
Hours of Operation: 7 AM to 5:30 PM
Registration Fee: $25 per child
Cost: $70 Y Member / $100 Program participants (Weekly Rate)
Morning and Afternoon Snack is provided ( Lunch is not provided Please pack your child a lunch)

For more information contact Justin Marshall / Program Director
YMCA: 251-575-9622
Cell: 251-238-3940
Email: justin@monroevilleareaymca.org

Email address *
Childs Name *
Your answer
Child Name Date of Birth (mm/dd/yyyy)
Your answer
Childs Age
Your answer
Parent / Guardian Name #1 *
Your answer
Parent / Guardian #1 Name Cell Number *
Your answer
Parent / Guardian Name #2
Your answer
Parent / Guardian #2 Cell Number
Your answer
Emergency Contact Name & Number (Besides Parent/ Guardians) *
Your answer
Authorized Pickup List (In addition to the persons listed above) Name - Cell Number
Your answer
Mailing Address *
Your answer
Please list allergies and/or medications
Your answer
Is there anything else we should know about your child? ( Medical/ Social Concerns) *
Your answer
Child Shirt Size
As the parent of the camper, I authorize my child to attend and participate in all prescribed YMCA camp activities I give the Program Director and any other designated camp staff to administer first aid in the event of an emergency, to secure a physician for any medical or surgical treatment needed for my child. I understand that a conscious effort will be made to locate me or my spouse before action is taken. I understand and accept that this expense will be my responsibility. (Type your name below to sign.
Your answer
If you are currently a YMCA member and would like us to draft your registration of $25 fee please check the box below. *
Required
I understand that weekly fees are due on Monday of each week and daily fees are due each morning. *
Required
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