2015 Summer Camp Registration Form Please print clearly and complete all the sections of this form. Return to: 1144 NE Cedar, Roseburg OR 97470 Camper Information Child’s Name: Birthdate: Address: City: Gender: Male Female State: Grade in Fall: Zip: Ethnic Information (optional): Hispanic Asian Caucasian/White Native American Native Hawaiian/Pacific Islander African American Multi-racial Other: ____________________________ Medical Problems or Allergies: Insurance Company: Insurance Policy Number: If not covered by insurance, you must initial this waiver: _____ I hereby certify that my child is not covered by insurance. I accept full financial responsibility for medical treatment if needed as a result of my child’s participation in summer camps at the Boys & Girls Club. T-Shirt Size: YS (6 – 8) YM (10 – 12) YL (14 – 16) AS (34 – 36) AM (38 – 40) AL (42 – 44) AXL (46 – 48) Each camper will receive one summer T-Shirt. Additional shirts are available at $10.00 each Parent/Guardian Contact Information Parent/Guardian: Home/Cell Phone: Work Phone: E-mail Address: Other Parent/Guardian: Home/Cell Phone: Work Phone: The Club will make every effort to reach a parent/guardian listed in case of emergency. However, in case we are unable to reach a parent/guardian, please list at least one local contact person other than the parent/guardians. Emergency Contact Person: Home/Cell Phone: Relationship to child: Work Phone: Permission to Participate Please initial your understanding of the following: I am the parent/guardian of the child named above who is registering for the Boys & Girls Club Summer Camp Program. _____ I give permission for my child to take part in Club activities. I understand reasonable measures will be taken to safeguard the health & safety of all participants. I waive any claims against the board, staff or volunteers except claims arising from gross negligence or willful acts of the board or its agents that may arise from participation in Club activities. I also give permission to use photographs in which my child appears for programming publicity. _____ I understand that my child will be participating in planned daily activities on-site. I also give my child permission to participate in any off-site activities under the supervision of Boys & Girls Club staff and volunteers. _____ I understand that the Club opens for campers at 7:30am. I may not leave my child at the Club before 7:30am and I must pick up my child no later than 5:30pm or a late fee will apply. _____ I understand that if my child is sent home at any time during a camp due to disciplinary reasons, he/she may lose privileges to participate in some or all future camps and no refund will be given. _____ I understand that if I am called to pick up my child due to illness, injury, or for disciplinary reasons, I must pick up my child within one hour or a late fee may apply. Signature___________________________________________________________ Date __________________________________ Child’s Name: Grade in Fall: ___________ Please register my child for the following Camps: Club Members: $80/week Scholarship Recipients: $20-$40/week Please register by: STEAM Camps Sports Camps STEAM Camps 2nd-5th grade 3rd-6th grade 6th-9th grade Monday June 1 June 15-19 Myth Busters June 15-19 Martial Arts Monday June 8 June 22-26 Superheroes June 22-26 Lacrosse Monday June 15 June 29-July 2 Challenge Extravaganza June 29-July 2 Disc Golf 20 max. Monday June 22 July 6-10 Infinity & Beyond July 6-10 Golf 20 max. Monday June 29 July 13-17 Outdoor Explorer July 13-17 Fishing 20 max. Monday July 6 July 20-24 H2OH! July 20-24 Bowling 20 max. Monday July 13 July 27-July 31 Fun Factor July 27-July 31 Swimming 20max. Monday July 20 Aug 3–7 Wacky Science Aug 3–7 Fun & Games Monday July 27 Aug 10-14 Under the Sea Aug 10-14 Volleyball Monday Aug 3 Aug 17-21 Endless Summer Aug 17-20 Tackle Football *M-Th 5-7pm RHS Non-Members: $90/week June 15-19 Kick-Off Field Trip 10 max. June 22-26 The Great Outdoors 10 max. June 29-July 2 Flight & Rockets 10 max. July 6-10 Robotics 10 max. July 13-17 The Land of Umpqua 10 max. July 20-24 Building & Engineering 10 max. July 27-July 31 Cars & Things that Move Us 10 max. Aug 3–7 Music & Video Editing 10 max. Aug 10-14 Robot Showdown 10 max. Aug 17-21 Grand Finale Field Trip 10 max. Late registration: $10 Late Fee Fitness Camps Payment Record 7th-12th grade (for office use only) June 15-19 Kick-Off Field Trip 10 max. Date ________ Amt. ____ Rcpt#________ Initials __ □ Cash □ Credit □ Check Date ________ Amt. ____ Rcpt#________ Initials __ □ Cash □ Credit □ Check Date ________ Amt. ____ Rcpt#________ Initials __ □ Cash □ Credit □ Check Date ________ Amt. ____ Rcpt#________ Initials __ □ Cash □ Credit □ Check Date ________ Amt. ____ Rcpt#________ Initials __ □ Cash □ Credit □ Check Date ________ Amt. ____ Rcpt#________ Initials __ □ Cash □ Credit □ Check Date ________ Amt. ____ Rcpt#________ Initials __ □ Cash □ Credit □ Check 10 max. Date ________ Amt. ____ Rcpt#________ Initials __ □ Cash □ Credit □ Check Aug 10-14 Cliffhanger 10 max. Date ________ Amt. ____ Rcpt#________ Initials __ □ Cash □ Credit □ Check Aug 17-21 Olympic Greatness 10 max. Date ________ Amt. ____ Rcpt#________ Initials __ □ Cash □ Credit □ Check June 22-26 Get Into Gear 10max. June 29-July 2 H2Oh Yeah 10 max. July 6-10 Football & Fancy Feet 10 max. July 13-17 Disc Jockeys 10 max. July 20-24 Quick & Clever 10 max. July 27-July 31 Get Pumped 10 max. Aug 3–7 Warriors Payment Options & Refund/Transfer Policy Your child is only guaranteed a place in camp if the fees are paid in full or if you authorize the Club to charge your credit card on the registration date for each camp marked. Camp fees should be paid (2) weeks prior to the scheduled week to ensure adequate staffing and supplies. There will be a $10 late fee for registering the week of camp. Select one: I am paying for each camp individually by cash, credit/debit, check, or Summer Savings account I authorize the Club to charge my credit/debit card on the registration date for each camp marked (two weeks prior to each camp) Credit Card #: ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ Expiration Date mm/yy: _____ /_____ Cardholder Name (please print) _________________________________ Signature _______________________________________ Please initial your acceptance of the following refund/transfer policies: Cancellations: _____ I understand that a full refund will be given if a camp is cancelled due to lack of enrollment. _____ I understand that, if I cancel a camp by the registration deadline, a refund minus a $25 cancellation fee will be given. _____ I understand that, if I cancel a camp after the registration deadline or if my child is asked to leave camp due to disciplinary reasons, no refund will be given. Transfers to another camp session: _____ I understand that, after the registration deadline, I can transfer a camp fee to another camp one time without penalty. I will be charged a $25 transfer fee for any additional transfers.
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