The B-SAFE Program (Bishop's Summer Academic & Fun Enrichment Program)

The B-SAFE Program (Bishop's Summer Academic & Fun Enrichment Program)

FAMILY CAMPERSHIP FORM 2012

Program runs from July 2-August 3Total Cost for Program is $75 or $600

Monday-Friday 8:30am – 4:00 pm (Holy Spirit 9am-4:30pm)Application is due by April 30th

Family’s Last Name

Each Child's NameAge______Gender: F / M B-SAFE Site

Each Child's NameAge______Gender: F / M B-SAFE Site

Each Child's NameAge______Gender: F / M B-SAFE Site

Parent/Guardian______

Address______City______State______Zip______

School Attending______Grade Entering in Fall______

Program and Site Preference (list above)

LEARN @ St. Stephen's (60 elementary schoolers) 419 Shawmut Avenue, South End

YLC @ St. Stephen’s (60 middle schoolers) 419 Shawmut Avenue, South End

LEARN @ St Augustine & St. Martin Church (60 elementary schoolers) 31 Lennox Street Roxbury

LEARN @ St. Mary's Episcopal Church (60 elementary schoolers) 14 Cushing Ave Dorchester

LEARN @ Epiphany School (60 elementary schoolers) 154 Centre Street Dorchester

YLC @ Epiphany School (60 middle schoolers) 154 Centre Street Dorchester

LEARN @ Holy Spirit Episcopal Church (60 elementary schoolers) 525 River Street Mattapan

LEARN @ St. Luke’s/San Lucas Episcopal Church (50 elementary schoolers) 201 Washington Ave Chelsea

Telephone:Home______Work______

Cell______Other______

PARENT/GUARDIAN NAME

BEST WAY TO REACH YOU: PHONE # Email

B-SAFE FEE

As noted in the registration materials, B-SAFE 2012 has two levels of cost.

If your family qualifies (fully or partially) for the federal free/reduced cost lunch program, the cost for the summer is $75.00.

If your family does not qualify, the cost for the summer is $600.00.

My family qualifies for the federal free lunch program(Please attach a copy of proof to this application)

My family does not qualify for the federal free lunch program

Have you attended the B-SAFE Program before? Which site?

What is your family’s annual income?

How many children/youth are you registering?

Could you pay the full amount for the first child?

If you cannot pay the full amount, how much could you pay for the first child?

How much could you pay for each additional child?

TOTAL AMOUNT DUE ($75 or $600 x number of children)

TOTAL AMOUNT YOU CAN PAY

TOTAL AMOUNT OF CAMPERSHIP BEING REQUESTED

SIGNATURE DATE

Someone will get back to you within ten days with response. We will use your “best contact information” above.

We have limited funds for camperships; we will do our best to offer every family who requests it some assistance.