DAY PROGRAM
ARTS & CRAFTS COMPUTER LABS
GAME ROOM Activities
Educational Programs
Get Wet Fridays
Volleyball
Lunch and Snack Provided
Special Performances
Sycamore View
1910 Sycamore View
Paula Guyton, Unit Director
Akumdi “Mr. Efay”, Program Director
901-388-2087
CAMP DETAILS
HOURS:
Regular: 9 AM - 5 PM
Early Bird: 7 AM - 9 AM
Late Bird: 5 PM – 6 PM
COST:
1st Child $157, 2nd $157 and 3rd
$157 Registration Ends May 20
Early Bird: $25/week additional
Late Bird:$15/week additional
BOYS & GIRLS CLUBS OF GREATER MEMPHIS SUMMER 2016
8 FUN FILLED WEEKS!
May 31, 2016 -JULY 22, 2016
WWW.BGCM.ORG
Membership Application for May 31– July 22, 2016Fees for Summer are non-refundable
Demographics:
First Name: ______Last Name: ______
Address: ______Apt. # ______
City: ______State: ______ZIP ______
Phone: ______Date Of Birth: ______Age: ______
Gender: Male or Female
Race: Primary Language:
____ Black ____ English
____ Latino ____ Spanish
____ Caucasian ____ Bi-lingual
____ Asian ____ Other
____ Native American
____ Bi-racial
School: ______Grade: ______
Have you ever been a club member of another club before? Yes or No
If yes, which club? ______
Whom Do You Live With? (Check all that apply)
_____ Mother
_____ Father
_____ Grandparent
_____ Foster Parent
_____ Step Parent
_____ Other ______
Annual Household Income (Circle One):
$15,000 or below $16,000 - $30,000 $30,000 or over
Circle those which apply:
SSI Food Stamps Free / Reduced Lunch / Person(s) Authorized to pick up member:
Name: ______Relationship: ______
Name: ______Relationship: ______
Name: ______Relationship: ______
Emergency Contact 1: ______Phone: ______
Emergency Contact 1: ______Phone: ______
Does your child have any Medical Problems and/or Allergies? Yes or No
If yes, please describe ______
If your child currently taking any Medication? Yes or No
If yes, please list ______
A Boys & Girls Club Membership is valuable. Although members pay a small fee, the actual cost to serve your child at the Boys & Girls Club is $500 per year. PLEASE NOTE: WE ARE NOT A DAY CARE CENTER. WE OPERATE UNDER AN OPEN DOOR POLICY. By signing this application, I understand that the BGCM cannot be held liable if my child decides to leave the club premises on his/her own accord.
My child is joining the BGCM with my consent to participate in all club activities. I will not hold the Boys & Girls Club responsible for any injury, which may occur. I give the Boys & Girls Club my consent to administer first aid and contact Emergency Medical Services if deemed necessary.
Throughout the year, youth have the opportunity to participate in various educational and social field trips. It is the responsibility of the organization to inform parents/guardians of all planned events that take place off site before transporting your child. By signing this form, I give BGCM the authorization to transport my child in a company vehicle to various activities sponsored by the Boys & Girls Club.
I give my consent for the BGCM to use any photographs in which my child may appear and to publish or reprint any artwork my child creates at the Boys & Girls Club. I also hereby give my permission to release the grades of my child to the Boys & Girls Clubs of Greater Memphis in order to provide academic assistance by Boys & Girls Club staff. In our endeavor to provide services to our members, BGCM conducts annual surveys and focus groups, which my child may be randomly asked to participate in, and signing this application gives my parental consent.
______
Signature of Parent/ Guardian Date