Primary Contact Name(Required) Address(Required) Street Address Address Line 2 City State ZIP Home Phone(Required)Work PhoneCell PhoneEmail(Required) Group InformationAttendee #1Name (First/Last) Birth Date MM slash DD slash YYYY Address (if different than above) Attendee #2Name (First/Last) Birth Date MM slash DD slash YYYY Address (if different than above) Attendee #3Name (First/Last) Birth Date MM slash DD slash YYYY Address (if different than above) Attendee #4Name (First/Last) Birth Date MM slash DD slash YYYY Address (if different than above) Attendee #5Name (First/Last) Birth Date MM slash DD slash YYYY Address (if different than above) Dietary needs, check all that apply: None Vegetarian Gluten Free Vegetarian/Dairy Free Vegan Vegan/Gluten Free Gluten Free Gluten Free/Dairy Free Dairy Free Restriction/Allergy/Intolerance How did you learn about Camp Manito-wish YMCA? Are you a Camp Manito-wish YMCA alum? Yes No If Yes, what was your name when you were a camper? Payment OptionsPayment Total(Required) Fees are: $300/adult, $175/child 3-12 years, under 3 years of age no charge (cabin minimum of $1,300)Credit Card Type(Required) Visa Mastercard Discover American Express Credit Card Number(Required) Please confirm number before continuing.Expiration Date (mm/yyyy)(Required) Security (CVV) Code(Required) The security code on the back of your card.Cardholder Address (if different than primary contact) Street Address Address Line 2 City State ZIP Consent(Required) I hereby give permission to use any video, photographs, or written statements from my family's experience in public relations materials, including the internet, without compensation.Cancellation policy: I understand that in the event of my cancellation within 21 days of the program, Camp Manito-wish YMCA will retain the full fee. Cancellation on my part within 22-60 days of the program will result in Camp Manito-wish retaining 50% of the program fee. For any cancellation more than 60 days before a program, Camp Manito-wish will retain 25% of the pro- gram fee.Signature (your full name)(Required) Date(Required) MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
