YMCA - YDM - SY Change Request Form

Change Request Form
THIS FORM MUST BE COMPLETED BY THE SITE DIRECTOR OR PARENT/LEGAL GUARDIAN ON REGISTRATION FORM.
Who is the individual completing this form?
Please provide your name:

First NameLast Name
Program Location:
Program:

Other
Reason for request:

Other
Select the summer camp weeks you wish to add:
Select the summer camp weeks you wish to remove:
Participant Information
Participant's Name:

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Last Day of Service

MonthDayYear
2 digit month, 2 digit day, 4 digit yearEnter today's date if this is not applicable.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Information
Parent Phone Number:
Format: (000) 000-0000.
Parent Email:
Drop Policy: The YMCA requires advanced notification if your child will be dropping from the program. A drop form must be completed by the parent or legal guardian and submitted within five (5) business days prior to the following payment due day. The YMCA will not issue credits or refunds for missed days or weeks.

Refund Policy: The YMCA will not issue credits or refunds for missed days or weeks. Exceptions may be given for medical situations if a doctor's note is provided within five (5) business days. All refunds will be processed within thirty (30) days. Registration fees are nonrefundable.
Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
FOR STAFF USE ONLY
Approved by:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Change Request Form

Participant Information

Parent Information

FOR STAFF USE ONLY