Summer Camp Registration Form (DT and SMPLS)

Summer Camp Registration Form

YWCA Children's Center Downtown and South Minneapolis
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)

Other
Name of person responsible for billing

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com

Payment Types and Options
A one-time registration fee of $100 is required. Please select the payment options below.
Select your payment type:
Please note, your registration is not finalized until you've received an invoice for this payment from Procare.

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.
Upload Form

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Parent/Guardian Name

First NameLast Name
Child's Name

First NameLast Name
Cardholder Owner Signature
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.
File Upload

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Bank Name
Bank Account Number
Rounting Number
Select One
If you selected "Savings", upload voided check/deposit slip.

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Bank Account Owner Signature
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

Immunization Records

Please upload your child's Immunization Records. If you do you 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.

Summer Camp Registration Form