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?*

I am a YMCA Site Director, completing this form because the parent is unable.I am the lawful parent/guardian seeking to adjust or terminate my YMCA services.
Please provide your name:*

First NameLast Name
Program Location:*
Program:*

Summer CampBefore CareAfter Care1 HourOther
Reason for request:*

Adding Summer WeeksRemoving Summer WeeksNot using/ no longer need serviceToo ExpensiveMovingOther
Select the summer camp weeks you wish to add:*

Week 1 (June 9-13)Week 5 (July 7-11)Week 2 (June 16-20)Week 6 (July 14-18)Week 3 (June 23-27)Week 7 (July 21-25)Week 4 (June 30-July 4)Week 8 (July 28-August 1)
Select the summer camp weeks you wish to remove:*

Week 1 (June 9-13)Week 5 (July 7-11)Week 2 (June 16-20)Week 6 (July 14-18)Week 3 (June 23-27)Week 7 (July 21-25)Week 4 (June 30-July 4)Week 8 (July 28-August 1)
Participant Information
Participant's Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Last Day of Service*

MonthDayYear
Enter 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:*
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*

Clear
Today's Date*

MonthDayYear
FOR STAFF USE ONLY
Approved by:
Date:

MonthDayYear
Date
Should be Empty:

Change Request Form

Participant Information

Parent Information

FOR STAFF USE ONLY