YMCA Camp Pinewood "Magic Steps to Growth"

2010 Au Sable River Canoe Camp Session 6 August 15 - August 20

Camper Information
* = required field.
*Camper's Full Name:
*Campers Gender:	Male Female
*Age at Camp(12-16):
*Camper's Birthday:	mm/dd/yy
*Home Phone Number:	Country Code (International phone #s only):
*Camper's Address:	Apt. or Unit #:
*City:	State: Zipcode:
One Cabin Mate Request We will do our best to honor all requests	(Within one year of each other.)
*This is the Camper's	summer at Camp Pinewood.
*How did you hear about Camp Pinewood?	Name or Location:
Parents/Guardians Information
Parent/Guardian #1
*Parent/Guardian Name(s):
*Relationship to Camper: (Mother, Father,Guardian,Other)
Address (if different from camper):
City:	State: ZIP code:
*Daytime Phone:	Country Code (International phone #s only):
Cell Phone:	Country Code (International phone #s only):
E-Mail Address:
Parent/Guardian #2
Parent/Guardian Name:
Relationship to Camper: (Mother, Father,Guardian,Other)
Address (if different from camper):
City:	State: ZIP code:
Daytime Phone:	Country Code (International phone #s only):
Cell Phone:	Country Code (International phone #s only):
E-Mail Address:
Emergency Contact Information
*Emergency Contact Name:
*Relationship to Camper (Mother, Father, Other):
*Emergency Phone #1:	Country Code (International phone #s only):
Emergency Phone #2:	Country Code (International phone #s only):


2010 Au Sable River Canoe Camp Session 6 Pricing
Session	Dates	Price	Total
* Au Sable River Canoe Trip Session 6	August 15 - August 20	$675	$

Add A Stayover Weekend (Ages 9 and up only)
Campers ages 9 and up that are registered for two consecutive sessions may stay at camp between their sessions. Activities on weekends will vary. If you need to discuss other weekend options for your camper please call our office at 231.821.2421.

Session	Dates	Price	Total
Stayover Weekend	August 21- August 22	$50	$

Transportation

Transportation by air conditioned bus is available from the metropolitan Chicago area and southeast Michigan.
The cost is $50 one way or $100 round trip.

YMCA Camp Pinewood reserves the right to change or cancel bus stops due to low enrollment from that location.

If you wish either one-way or roundtrip transportation for this camper, check below and select the pick-up/drop-off location. If you choose to drop-off or pick-up your camper, click for directions

*Transportation to camp.

*Transportation from camp.

I will be driving my camper or staying over fromthe next session
We will be using the bus service

Please select drop-off bus location:

I will be driving my camper or staying over to the next session
We will be using the bus service

Please select pick-up bus location:

Discount Name & Details	Requirements for Discounts	Discount

Payment Information & Discounts Discounts will only be applied upon verification by the camp offices. Discounts are only valid if full payment is received 30 days prior to your camper's session.
YMCA of Metro Chicago Member	Camper must be a current member of a YMCA of Metro Chicago. Please enter your information: YMCA Card # YMCA Location	$50 Off per Session

Multiple Session or Multiple Sibling Please select:	Families who have multiple siblings attending camp during the summer, or who are registering their camper for multiple sessions, are able to receive a $50 discount per week of summer camp. This discount will apply to each session / camper registered, but these two discounts may not be used in unison. These discounts will be applied upon verification by the camp.	$50 Off per Week


Your Total
Summer Camp Session (this includes Stayover total if selected)	$

Transportation Total	$

Discounts	Discounts will appear on final statement once verified by the camp offices.

Total Amount Due: $ Payment is due 30 days prior to your camp session. Note: This is NOT a secure site. We will not accept credit card information online, please submit this form and call our office at 231-821-2421 with your credit card information.

Deposit/Refund Information and Health Release

PLEASE READ ALL OF THE FOLLOWING AND CHECK YES TO COMPLETE FORM:

A $100 non-refundable deposit is required for each session and must accompany this application. Any applications submitted without payment information will be held and not processed until payment is received. Registrations received within 2 weeks of the beginning of the session are required to pay the full fee at that time. Payment is due 30 days prior to your camp session.

** I GIVE THE CAMP PERMISSION TO CHARGE MY CREDIT CARD ON FILE
FOR THE REMAINING BALANCE IF NOT PAID BY THIS DATE**

Cancellation refunds will be given for the camp fee minus the deposit up until two weeks prior to arrival. After this time there are no refunds available. There will be no refunds when a child goes home early in case of disciplinary action or homesickness.

I/We approve this application and certify that our child is in good health.

I do hereby give permission to YMCA Camp Pinewood to transport the child named above off the camp property for the purpose of medical care or program activities as deemed appropriate by the Camp Director.

I hereby authorize the Camp Health Officer to provide for and secure treatment of general health issues for the minor named above. I understand that my child may be dismissed from the program if their behavior or actions are not in keeping with camp goals and policies. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injection, anesthetic, or surgery for the child named above. The YMCA does not furnish accident/illness medical insurance. Medical expenses, including prescription drugs, will be the responsibility of the parents or guardians.

The YMCA of Chicago has my permission to use photographs taken of my child while at camp for promotional purposes.

* Yes, I or We (parents/guardians) have read and agree to the above statements.

YMCA Camp Pinewood
4230 Obenauf Road
Twin Lake, MI 49457

Fax:
(231) 821-0487

Phone:
(231) 821-2421