Summer Reg Form 2015 - Boys & Girls Clubs of the Umpqua Valley

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.