Summer Camp LengthSelect A SessionSession #1: July 1 – July 5*Session #2: July 8 – July 12Session #3: July 15 – July 19Session #4: July 22 – July 26Session #5: July 29 – August 2Session #6: August 5 – August 9All 6 SessionsNeed Before Care? $25.00 additional per session Yes NoNumber of Sessions for Before CareNeed After Care? $25.00 additional per session Yes NoNumber of Sessions for After CareFirst NameMiddle InitialLast NameGender– Select –MaleFemaleChild’s BirthdayChild’s AgeCurrent School (Include State)Grade Completed

Parent(s) or Guardian(s) Information

First NameLast NameEmailAddressAddress Line 1Address Line 2CityStateZip CodeCell PhoneWork Phone

Medical and Emergency Contact Information

If the parent(s) or guardian(s) cannot be reached in an emergency, please call:

First NameLast NameEmergency Contact Relationship to ChildDoctor’s NameDoctor’s Phone NumberMedical ConditionsSpecial MedicationState Which Immunizations the Child Has HadDate of Last Tetanus Shot (Mandatory)Does your child have any psychological or behavioral problems?– Select –YesNoDo You Require Extended Daycare?– Select –YesNo I hereby grant permission for my child to participate in the BGCSM Summer camp. BGCSM has permission to photograph my child in BGCSM sponsored activities.
In consideration of the acceptance of the camper for enrollment in the Summer Camp, I hereby release and discharge BGCSM, Youth Activities Program, its agents, employees, and offices, from all claims, demands, action, judgments, and executions which the undersigned, as parents(s) of the camper, ever had or now has or may have, Youth Activities Program, its successors, or assigns for personal injuries known and injuries to property, real or personal, caused by, arising out of the campers enrollment int he Summer Camp. BGCSM reserves the right to terminate a summer camp contract. I understand this form is not to make donations or pay for membership. This form is to register and pay for Summer Camp. Registering for Summer Camp is not making a donation therefore not a tax deduction.Signature

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