YMCA - YDM - SY 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:

Reason for request:

Select the summer camp weeks you wish to add:

Select the summer camp weeks you wish to remove:

Participant's Name:

First NameLast Name

Date of Birth:

Last Day of Service

Enter today's date if this is not applicable.

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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

Approved by:

Date:

Date

Change Request Form

Participant Information

Parent Information

FOR STAFF USE ONLY