YMCA Camp Seymour

Zumba Retreat Registration Form

REGISTER ONLINE at: www.campseymour.org
1) Complete all sections of this form and enclose check or money order with registration form, or fill in the
appropriate blanks for credit card payment. NOTE: If a participant is not a full member of the YMCA of Pierce and
Kitsap Counties at the time of registration, the additional $4 YMCA membership fee also applies.

2) Mail completed registration form with payment to: YMCA Camp Seymour, 9725 Cramer Road KPN, Gig
Harbor, WA 98329, or register at the membership window of any branch of the YMCA of Pierce and Kitsap
Counties. Registrations will not be accepted without a valid check, money order, or credit card payment. If
payment is by credit card you may also fax it to 253-460-8897.

3) You will receive a confirmation packet by mail before this retreat. It includes a “What to Bring” list, directions with
a map to camp and other details. Questions? Call the camp office at 253-884-3392

Birth date: Age:

Name: Gender: female male
Must be 18 and older to attend retreat
Street Address: City, State, Zip:

Home Phone: Cell Phone:

E-mail:
Please list someone who is not
Emergency Contact Name: Phone: attending the weekend

List participants with whom you wish to share a cabin:

Dietary needs: Vegetarian Lactose Intolerant Food Allergies:

Mobility needs/cabin preference:

YMCA Member: Yes No YMCA Branch (if applicable):

I am aware that I will have the opportunity to participate in, and I approve my participation in camp activities
involving a degree of risk. I understand that certain dangers exist and accidents may occur. I hereby release the
YMCA of Pierce and Kitsap Counties from any and all responsibility and liability of any nature resulting from my
participation in any camp activities. I understand that I may be photographed and that photographs may be used for
future camp promotion. Included herewith is the required payment and (if necessary) membership fee. I understand
that these fees are non-refundable.

Signature: ___________________________________ Date: _________

Dates Cost

$99.00 Member
2010 ZUMBA Retreat May 21-23
$103.00 Non Member

Payment is by: Check/Money Order Visa MasterCard Discover American Express

Credit Card #_____________________________ Exp. Date__________

NOTE: Payment is due in full at time of registration. Space is limited. Reservations cannot be held without payment.

Authorized signature: _____________________________________________ Date: