Payment Plan Application Please fill out form completely and return to the Front Desk at GBBGC. In order to be considered for payment plan you must have no outstanding balance on your account. Member Information First Name: ______________________________ Last Name: ____________________________ Current Grade: ___________ Home Phone: ______________________ Cell Phone: _______________________ Work Phone: _________________________ Home Address: _______________________________________ Town: ______________________ Zip Code:________________ Parent Information 1. Parent/Guardian First Name: _______________________ Last Name:_____________________ Phone: __________________ 2. Parent/Guardian First Name: _______________________ Last Name:_____________________ Phone: __________________ Are you a single-parent family? Yes How many people live in the household? _________ No (Please Circle One) Total Annual Gross Income: _____________ Please select the best plan that works for you: Weekly Payments of: ____________ Bi-Weekly Payments of: __________ Monthly Payments of: ____________ Start Date: _____________________ End Date: ______________________ Amount of Payments: _____________ Circle the summer program you want to apply for: 2015 Summer On Site Camp 2015 Summer Day Camp 2015 Summer Sports Camp Total Amount of Weeks: ___________________ Total Amount of Extended Day:_________ Total Amount Due: ___________________________ 2015 Summer Teen Trips I understand that it is my responsibility to make the payments on time. If I should miss a payment or not abide by the payment plan, it may result in removal from summer programs and future enrollments. If I have issues or problems with making payments, I will contact the Membership Services staff. __________________________________________________ Parent Signature _______________________________________ Date