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Tiny Tot Tennis Academy at the West Side YMCA
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For more information about
Tennis Innovators, please visit
www.tennisinnovators.com.
CAUSE A RACQUET TINY TOT TENNIS ACADEMY SUMMER 2012
MORE INFORMATION: Tamara Heisler, Director of Healthy Lifestyles
212-912-2670 | theisler@ymcanyc.org
The Tiny Tot Tennis Academy is a program designed to help young children discover
the joy of tennis. It is a great way to keep young ones fit and introduce them to a
lifelong sport. Instructors for this program are part of the Tennis Innovators
program whose mission is to deliver a passion and commitment for tennis and
continuously develop and conduct the highest level programs for adults and children.
DATES: August 27 - 31, 2012
DAY/TIME: M - F
9:00 - 12:00 Noon
AGES: 4 - 5 yrs.
LOCATION: 4th Floor Gymnasium
FEES: $300/Week
WEST SIDE Y 5 West 63rd Street; New York, NY 10023 212-912-2600 / ymcanyc.org/westside
Need financial assistance? JUST ASK!
SPECIALTY SPORTS CAMP REGISTRATION FORM 2012
Camper’s Name____________________________________________________________________ Campers Age________
(First) (Middle) (Last)
Date of Birth_______/_______/_______ Sex_______ T-Shirt Size :( child) S M L XL (adult) S M L XL
Address_____________________________________________ Apt#_____ City___________________, NY or ____, Zip.________
Parents/Guardians:
Parent Name 1:___________________________________ Parent 2:____________________________________________
Business #: (______)________________________________ Business #: (_______)________________________________
Mobile Phone: (_______)____________________________ Mobile Phone:(_______)_____________________________
Email Address: ____________________________________ Email Address: _____________________________________
Authorized Pick Up and Emergency Contact Information At dismissal and/or incase of an emergency the following people are authorized to pick up my child:
Parent 1 YES NO Parent 2: YES NO
At least two additional names are required:
1. Relation: Phone #:
2. Relation: Phone #:
3. Relation: Phone #:
Please select the camp week you wish to attend and if extended care is needed:
Please turn over and complete the reverse side
Dismissal Options Choose one:
I_______________will be picking my child up from Westside YMCA between 12:00PM. (Tennis Camp Only)
(Initial)
I_______________ will be picking my child up from Westside YMCA between 1:00PM. (Basketball Camp Only)
(Initial)
I_______________ will be picking up my child at between (5:30 – 6:00pm) ___________PM. (Extended day hours Basketball only)
(Initial)
I_______________ give permission for my child (10 +) to walk home from the program unattended at ____________PM. (Initial)
Session Dates Summer Camp weeks
(Please check box) $/week
Extended Care (Please check box)
Total Price
Tennis Camp 6/11 – 6/15
06/11 – 06/15
$ 300 Not Available $
Tennis Camp 6/18 – 6/22
06/18 – 06/22 $ 300 Not Available $
Basketball Camp 8/13 – 8/17
08/13 - 08/17 $ 300 PM $150/WK
$
Basketball Camp 8/20 – 8/24
08/20 - 08/24 $ 300 PM $ 150/WK
$
Sub Total $
Membership Fee if applicable $ +
_____ % Discount (type:_______________) $ -
Payments and Fees Information Fees & Discounts (discounts cannot be combined):
Membership Fees - Ages 5 -11, $216 per year and age 12 - 17, $336 per year.
Payment is due in fill upon registration.
Siblings receive a 10% discount when both children are registered for the same number of sessions.
Early Bird discount of 10% for participants who registered by June 9th for Tennis and by August 1st for
Basketball Camp and payment in full by the start of the program.
Form of payment accepted credit card, debit card or cash. No checks accepted for camp payments.
Payment Deadlines:
Tennis Camp Week 1 & 2 full payment due by Friday, June 9th, 2012.
Basketball Camp full payment due by Friday, August 1st, 2012.
Credit Card Information I authorize West Side YMCA to charge my credit card account on Friday, June 9th, 2012 for (Tennis Camp
Week 1 & 2) in the amount of $_____________and on Friday, August 1st, 2012 for (Week 1 & 2 ) in the amount of
$__________ in fulfillment of my child’s summer day camp payment obligation.
Master Card Discover Card Holder’s Signature________________________________________
Credit Card # __________________________________________ Expiration Date: ______________ Security Code: ___________
Refund and Credit Policy Camp fees are non-refundable unless the YMCA cancels a camp and Credits will be issued at the Directors discretion.
The YMCA reserves the right to cancel a camp if it does not meet enrollment requirements.
A $50 per week is nonrefundable & nontransferable.
To apply for a credit you must submit a credit request application stating the reason the child cannot attend before the
scheduled session. Please make sure you include any doctor’s notes and/or travel documents to support your case.
There will be no refunds or credits granted after June 22nd, 2012.
Refunds take 6-8 weeks to process.
Standard Release Form I, the undersigned give permission for my child to participate in all summer camp activities for the days he/she attends. I
understand that no refund or credit will be given for missed days under any circumstances. I understand that I must have a
completed medical form on file BEFORE the first day of the summer camp program. I also hereby give authority to the YMCA
staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as
soon as possible. Also, in consideration of the goodwill, public service, and community aid provided by the YMCA of Greater
New York, which I support and from which I have received benefit, I hereby grant permission to the YMCA to use my child’s
name, to take and publish photographs, videotapes or motion pictures of him/her which include his/her voice, in any media for
any legitimate purpose. I release all rights to such photographs, videotapes, motion pictures and recordings. I acknowledge
that the YMCA will be the sole owner of all rights arising out of their use for all purposes. I understand that I shall receive no
compensation from their use from any source whatsoever.
Parent or Guardian’s Signature___________________________________ Date__________________
If at any point the information on the Registration form needs to be changed, you must submit ALL changes in writing.
2012 Specialty Sports Camp West Side YMCA
Childs Name Age
Shirt Size
Office Use Only
Application Received By Date __/__/__
Place a Passport
Size Photo of your
Child Here The Photo must have
been taken within 6
months from the start of camp.
Place a Passport
Size Photo of your
Child Here The Photo must have
been taken within 6
months from the start
of camp.
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