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POMEROY GYMNASTICS, INC. SUMMER CAMP 2020 REGISTRATION FORM Student’s Name__________ Gender ______Age ____ Date of Birth ______/_____/_____ Street Address _____________________ City _____________ State _____Zip_______ Mother’s Name _______________ _____ Father’s Name _________________________ Home Phone #____-_____-____Work Phone #___-____-____ Cell Phone #___-____-___ Emergency Contact and Phone Number _____________________________________________ _______-_______-_______ Are there any medical conditions to which we should be alerted? _____________________________________________________________________ _____________________________________________________________________ CAMP INFORMATION
WK DATES AM CARE PM CARE BOTH ½ DAY FULL DAY
1 CLOSED $00.00 $00.00 $00.00 $000.00 $000.00 2 CLOSED $00.00 $00.00 $00.00 $000.00 $000.00 3 CLOSED $00.00 $00.00 $00.00 $000.00 $000.00 4 July 6-July 10 $60.00 $110.00 $150.00 $220.00 $300.00 5 July 13-July 17 $60.00 $110.00 $150.00 $220.00 $300.00 6 July 20-July 24 $60.00 $110.00 $150.00 $220.00 $300.00 7 CLOSED $00.00 $00.00 $00.00 $000.00 $000.00 8 Aug. 3-Aug. 7 $60.00 $110.00 $150.00 $220.00 $300.00 9 Aug. 10-Aug. 14 $60.00 $110.00 $150.00 $220.00 $300.00
10 Aug. 17-Aug. 21 $60.00 $110.00 $150.00 $220.00 $300.00
# OF WKS x TUITION __ ___ x __________ # OF WKS AM CARE ______ x __________
5% DISCOUNT -__________ # OF WKS PM CARE ______ x __________ SUB TOTAL __________ # OF WKS BOTH ______ x __________ TOTAL $ _______________ Deposit of 50% of tuition is due at registration. No refunds or credits will be given after June 1, 2020. Balance of tuition is due on the Monday of the scheduled week. ACKNOWLEDGMENT OF RISK AND WAIVER OF LIABILITY
_____________________________ _________________________________________________________________________________________________________________________ Parent or Legal Guardian’s Signature Date
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