CAMPER INFORMATION

First Name

Last Name

Gender:                            Male Female

Name Child is Called

Address

City

State

ST AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA MN MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY OTHER   Zip

Home Telephone

(xxx-xxx-xxxx)

Email

Date of Birth

//

Age at Camp

School

Grade Fall '08

This my

1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th summer attending Camp Classen

I HEARD ABOUT CAMP FROM

1st Cabin Mate Request (must be same age/gender)

2nd Cabin Mate Request (must be same age/gender)

PARENT INFORMATION

Parent 1 Name:

Employer:

Business:

Cell Phone:

Parent 2 Name:

Employer:

Business:

Cell Phone:

Address for Parent 2 (if Different)

Address

City

State

ST AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA MN MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY OTHER   Zip     

With whom does the Child Live?

Parent 1 Parent 2 Other (Please Specify)

Emergency Contact

Name:

Phone:

Do you have a Family membership at the YMCA of Greater Oklahoma City Yes No

If yes, which branch?

ADDITIONAL PROGRAM OPTIONS - Space is Limited Register TODAY!

Yes  

Transportation $35 from Oklahoma City only - return transportation NOT provided

Yes  

If you are interested in you child staying over between sessions there will be an additional fee of $50.

Stay over for Session 2 Stay over for Session 3 Stay over for Session 4

A $100 nonrefundable, nontransferable deposit is required to complete registration.

READ CAREFULLY before submitting this form: Permission to attend and Parent Authorization.

I hereby apply for reservation for my child at Camp Classen. If he/she is accepted for enrollment, my credit card will be charged for the non-refundable, non-transferable deposit. I understand the terms covering payment, and hereby give my approval and consent to the application.

IN CASE OF MEDICAL EMERGENCY, I hereby also give my permission to the physician selected by the Camp Director to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child. I accept the responsibility for medical and surgical treatment charges which may be incurred on my child's behalf.

I AUTHORIZE the YMCA to use photographs, slides, or video tapes of the person named on this application for its records, public relations, or internet programs.

Submission of this form constitutes acceptance of the above Parent's Authorization.