PART I

Child's Name: ______

LASTFIRSTMIDDLE INITIAL

Address:______City& State: ______Home Phone:______

_____Male ____ Female Ethnicity (optional)______T-shirt Size (Please Circle One)

YS YM YL YXL AS AM AL AXL

Age: ______Birth date: ______

*The following people will be authorized to pick-up the above child from camp (Must be 18 or older).

Mother/Guardian Name: ______

Mother’s Daytime Phone:______Mother’s Cell Phone______

Email address:______

Father/Guardian Name: ______

Father’s Daytime Phone: ______Father’s Cell Phone: ______

Email address: ______

Authorized Pick-Up Name and phone number (must be 18 or older and not the parent of the child)

1.) ______2.)______3.)______

  • No transportation is provided.
  • Payment must be received by the Thursday before a session starts. Space granted on first come first serve basis. If your child plans to attend the whole summer program it is best that you pay in full to assure your child's space. Participation in initial sessions does not guarantee participation in future sessions.
  • All members must be picked up by 6:00 p.m. (See Late Policy and Pick-up in the Parent Handbook).
  • I give permission for my child to take part in all field trips taken by his/her Unit as part of the Summer Program. I also understand fees and field trips are NON-REFUNDABLE anda session is not reserved until fees for that session are paid in full. Field trips payments must be made three days before the day of the field trip.
  • I have received a copy of the Parent Handbook and a tour of the Boys & Girls Club.
  • I authorize Boys & Girls Club staff to seek emergency medical care for my child if I cannot be located immediately.

______

Parent or Guardian's SignatureDate

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PART II

FIELD TRIP & MEDICAL RELEASE

I hereby grant permission for my child to attend the activities sponsored by the Boys & Girls Clubsof Southeast Virginia during the summer camp in large and small groups (i.e. field trips). I am responsible for my child’s insurance in case of injury. Furthermore, I understand that although safety precautions will be observed, the Boys & Girls of Southeast Virginia will not be responsible for any personal property lost by my child for any injury sustained in the program. I also consent to the Boys & Girls Clubs of Southeast Virginia use of any photographs and videos.

I have read and understand the information and policies stated on this form and the Parent Handbook.

PARENT SIGNATURE:______DATE:______

FOR OFFICE USE ONLY

Session Requested / Amount paid / Date / Receipt # / Session Requested / Amount
Paid / Date / Receipt #
  1. June18 –
June 22 / June 25 –
June 29
  1. July 2
-
July 6
(7/4 closed) / July 9 –
July 13
3. July 16
- July 20 / July 23 –
July 27
  1. July 30–
Aug. 3 / Aug. 6 –
Aug. 10
  1. Aug. 13 –
Aug.17
Registration
$20.00 / Teen
Registration
$100.00