Primary Contact Name - Attendee #1(Required) Address(Required) Street Address Address Line 2 City State ZIP Home PhoneWork PhoneCell Phone(Required)Email(Required) 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 HiddenAdditional ParticipantAttendee #2Name (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 HiddenHow did you learn about Camp Manito-wish YMCA? HiddenAre you a Camp Manito-wish YMCA alum? Yes No HiddenIf Yes, what was your name when you were a camper? HiddenPayment OptionsHiddenPayment Total ($275 per attendee)(Required) HiddenCredit Card Type(Required) Visa Mastercard Discover American Express HiddenCredit Card Number(Required) Please confirm number before continuing.HiddenExpiration Date (mm/yyyy)(Required) HiddenSecurity (CVV) Code(Required) The security code on the back of your card.HiddenCardholder Address (if different than primary contact) Street Address Address Line 2 City State ZIP HiddenConsent(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.HiddenSignature (your full name)(Required) HiddenDate(Required) MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
