Summer Camp 2010 - Boys & Girls Clubs

2COMPLETE CA MP REGISTR ATIONCAMPER’S FIRST AND LAST NAME ___________________________________________________________________________TODAY’S DATE ________________________________________________REFER TO “CAMP AT A GLANCE” ON PAGE 11 FOR CAMP AVAILABILITYWEEK DATES NAME OF CAMP DAYS TIME LOCATION FEE1 6/14-6/182 6/21-6/253 6/28-7/24 7/6-7/9*5 7/12-7/166 7/19-7/237 7/26-7/308 8/2-8/69 8/9-8/1310 8/16-8/20Post Camp Session(Only when enrolled in Archery Camp – Week 1) Mon-Fri 12 PM-4 PM Los Cerritos Club $65.00*Camp closed on 7/5/10.TOTAL FEES:Extended care is provided free of charge when enrolled in Full-Day Programs (9 AM – 4 PM) and include the hours of 7:00 AM – 9:00 AM and 4:00 PM – 6:30 PM.METHOD OF PAYMENT: (Please do not mail cash. For mail-in and fax registrations, a receipt will be mailed.)❏ MasterCard ❏ VISA ❏ Discover ❏ Debit Card with VISA/MasterCard logo ❏ Check/Money Order - #: ________ (Make checks payable to: BGC/CLV)Print Cardholder’s First and Last Name: ______________________________________________ Signature:________________________________________VISA, MasterCard or Debit Card #:___________________________________________________ Exp Date (month/year):____________________________3READ AN D SIGN PARENT AUTHORIZATIONThis health history is correct so far as I know and the person herein described has permission to engage in all prescribed Boys & Girls Clubs Of Conejo & Las Virgenes (BGC/CLV)activities, except as noted. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the BGC/CLV Director to hospitalize, secureproper treatment for, and to order an examination, x-ray, injection, anesthesia or surgery for my child as named above. If I cannot be reached, I give my permission to the BGC/CLV,and/or its agents, to obtain whatever medical assistance is necessary for my child at my expense.The undersigned hereby agrees to defend, indemnify and hold harmless the BGC/CLV, Conejo Valley Unified School District, and its officers, employees and agents against any andall loss, liability charges, expenses (including attorney fees), and costs of whatsoever character which may arise by reason of participation in any program. (BGC/CLV does not provideaccident, medical, liability, workers’compensation insurance, or any other insurance for program participants.) I agree to carefully inspect and satisfy myself that the facilities providedare reasonably safe for their intended use. Once having conducted the inspection, I agree to expressly assume the risk of participation at the premises.• I understand the BGC/CLV retains the right to use photographs, slides or video taped material of my child taken during activities for promotional purposes.• I give permission for my child to be transported to and from program areas, on field trips, and in the case of an emergency.• I give permission for my child to walk within a one mile radius of the clubhouse with a staff member for various club activities.• I understand BGC/CLV will periodically show movies rated pg-13 or lower.• I have received a copy of the Boys & Girls Clubs Parent Handbook. I understand it is my responsibility to read the handbook, become familiar with its contents, and abide by theprogram requirements and parent responsibilities outlined in it. I have signed and provided a copy of the parent handbook agreement to the BGC/CLV. (Parent Handbook canalso be found on our website, www.bgcconejo.org.)Print name of Parent/Guardian: ______________________________________________________ Best contact number: (___________) _______________________________________10Signature of Parent/Guardian:_______________________________________________________ Date: _________________________________________________________________