Please fill out form completely and return to the Front Desk at GBBGC
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.
First Name: ______________________________ Last Name: ____________________________ Current Grade: ___________
Home Phone: ______________________ Cell Phone: _______________________ Work Phone: _________________________
Home Address: _______________________________________ Town: ______________________ Zip Code:________________
1. Parent/Guardian First Name: _______________________ Last Name:_____________________ Phone: __________________
2. Parent/Guardian First Name: _______________________ Last Name:_____________________ Phone: __________________
Are you a single-parent family?
How many people live in the household? _________
(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.