CAMP FOR A DAY.pdf - YMCA of Greater Rochester

In the event of an emergency, I understand the program director will make
every effort to contact the parent/guardian. However, I authorize him/her
to act for me according to his/her judgment in a situation requiring
emergency medical or surgical treatment. I agree to be responsible for any
medical bills resulting from illness or injury during my child's attendance at
Camp for a Day in April.
I give consent for any photographs of my child to be used in YMCA related
promotional materials.
Signature: __________________________________
Date: __________________
CAMP EASTSIDE
Camp for a Day!
April 4 and 5 from 9:00am—4:00pm
YMCA of Greater Rochester
EASTSIDE FAMILY YMCA
CAMP EASTSIDE
1835 Fairport Nine Mile Point Rd, Penfield, NY
14526
585-341-4000
rochesterymca.org/campeastside
Camp for a Day gives your child the opportunity
to try our Summer Camp activities. Each day
kids will try swimming, arts and crafts, rock
climbing, archery, and many of our campers’
favorite games!

School Age Camp for a Day
Age: Grades K-6
Program Time:
Extended Care:
(No additional fee)
9:00am-4:00pm
7:00-9:00am and 4:00-6:00pm
Day: Thursday April 4
Location:
Friday April 5
Sign in and sign out in the West
Gymnasium of the Eastside
YMCA.
For more information on School Age Camp for a Day, contact
Jennifer Houle at jenniferh@rochesterymca.org or 341-4078.
For more information on Preschool Camp for a Day, contact Jeff
Cogan at jeffc@rochesterymca.org or 341-4025.
Age:
Program Time:
Extended Care:
(No additional fee)
Preschool Camp for a Day
3-5 years old
9:00am-4:00pm
7:00-9:00am and 4:00-6:00pm
Day: Thursday April 4
Location:
Friday April 5
Sign in and sign out in the
preschool classroom of the
Eastside YMCA.
Childs Name: ________________________________________________________________________
YMCA Member: Yes
No
Circle: Male Female Date of Birth: ___________________________
Grade: _______ Age: _________
Home Phone Number: _________________
Mother/Guardian Name: __________________________Phone: ___________________________
Father/Guardian Name: ___________________________ Phone: __________________________
Address: _____________________________________________ City/Zip: ________________________
Medical Concerns (medications/allergies etc.): ____________________________________
_______________________________________________________________________________________________
Check which day(s) your child will attend:
______Thursday April 4 ($39) ______Friday April 5 ($39)
Emergency Contacts/Authorized persons to pick up
(Please note all persons including parent/guardian will be required to show
photo ID in order to pick up the child. Children will not be released unless
the Photo ID matches an authorized pick up person.)
1. ________________________________________ Phone: ____________________________
2. _______________________________________ Phone: _____________________________
3. _______________________________________ Phone: _____________________________
Payment Information
________ Pay in full (at time of registration)
________ Credit Card: MC Visa Discover
Card Holder Name: ___________________________________________________________________
Credit Card Number: _________________________________________________________________
Expiration Date: ____________
Signature: ________________________________________