2025 Summer Camp Registration Form (Midtown ONLY)

2025 Summer Camp Registration Form

YWCA Midtown
Child's Name*

First NameLast Name
Birthday*

MonthDayYear
Date
Select your child's gender:*
*If you selected other, please specify:
What grade is your child completing:*
Race/Ethnicity of Participant: (Select all that applies) (Optional)

Asian or Pacific IslanderBlack or African AmericanHispanic or LatinxIndigenous American/AlaskanWhiteOther
Name of person responsible for billing*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

Payment Options
A one-time registartion fee of $125 is required. Please select your payment option below.
Please select your payment type*

Automatic Payment Authorization Form

for Credit Card Payment
To pay by CREDIT CARD, please download and complete our Automatic Payment Authorization Form and email it to Erin Wigg OR upload the form below.
I will upload the completed form.*

Yes. I will uploaded the completed form.No, I will email the form to Erin Wigg at ewig@ywcampls.org
File Upload

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Parent/Guardian Name*

First NameLast Name
Child's Name*

First NameLast Name
Cardholder Owner Signature

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Date

MonthDayYear
Date

Automatic Payment Authorization Form

for Check Payment
To pay by CHECK, please download and complete our Automatic Payment Authorization Form and email it to Erin Wigg OR upload the form below.
I will upload the completed form.*

Yes. I will uploaded the completed form.No, I will email the form to Erin Wigg at ewigg@ywcampls.org
File Upload

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Bank Name*
Bank Account Number*
Rounting Number*
Select One*

CheckingSavings
If you selected "Savings", upload voided check/deposit slip.

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Bank Account Owner Signature*

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Date

MonthDayYear
Date

Childcare Subsidy Provider
A current “Authorization of Service” must be on file before your child’s care may be billed to a county/third party agency.

Parent/guardian is responsible for full payment until the “Authorization of Service” is received.
Our Family currently receives childcare assistance from:
    County    Third-Party Agency    Other
County:
Third-Party Agency
Other
Agency/County Worker Name*
Phone Number*
Case #*
Paperwork submitted to County/Agency*

YesNo

Immunization Records

Please upload your child's immunization records. If you do not have those records, you can email them to summercamp@ywcampls.org. NOTE: Immunization records are required before the start of camp.
File Upload

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I will email a copy of the immunization records.*

Yes, I will email the records to summercamp@ywcampls.orgNo, I have uploaded the immunization records

2025 Summer Camp Registration Form