• Copy of immunization record must be attached
• $35.00 non-refundable registration fee
• $475.00 (1^st child) - $450.00 additional child

Parents Authorization – this health history is correct so far as I know, and the person herein described has permission to engage in all prescribed Club activities except as noted by me and the examining physician. I hereby give permission to the physician selected by the Club Director to order x-rays, routine tests and treatment for the health of my child, and in the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Club Director to hospitalize, secure proper treatment for and to order infection and/or anesthesia and/or surgery for my child as named above.

I, {parentguardian}, in consideration of the benefits to be gained by our (my) child
residing at {address}, hereby consent to our (my) child's attendance and/ or participation at 2026 SUMMER CAMP TRIP, TRANSPORTATION PROGRAM and / or in event of an EMERGENCY EVACUATION from the Club facility during the months of July 6^th – August 28^th at the expense of and under the sponsorship, auspices, direction, control and jurisdiction of The Boys & Girls Club of Clifton, NJ, Inc. its agents, servants and employees.

In further consideration of the benefits to be gained by our (my) child, we (I) covenant that we (I) will never, individually or as legal guardian(s) of our (my) child, institute any action at law or in equity against The Boys & Girls of Clifton, N.J., Inc. its agents, servants and employees, on account of any injury or other loss or damage sustained or that might be sustained by us (me) or by our (my) child as a result of our (my) child's attendance at THE SUMMER, CAMP TRIP, TRANSPORTATION PROGRAM and/or EMERGENCY EVACUATION from the Club facility covenant may be used by The Boys & Girls Club of Clifton as a defense to any action or proceeding that may be brought or instituted by us (me), our (my) heirs or legal representatives in breach of this agreement, we (I) hereby give our (my) consent, in the event all reasonable attempts to contact us (me) at:

have been unsuccessful for the administration of any medical or dental treatment deemed necessary for our (my) child by any licensed physician or dentist and the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinion of two other licensed physicians or dentists concurring in the necessity for such surgery is obtained prior to the performance of such surgery.

The following information is needed by any hospital, physician or dentist not having access to the child's history:

Allergies: {allergies68}

Medications: {medications69}

Date of last tetanus shot: {dateof}

Physical impairments & other important medical problem we should be aware of must be included in the Health Examination Form questions that are part of this application.

If this agreement is signed by only one person, that person represents that he or she is the only person having custody of the minor child named herein and that no other person's agreement or authorization for the purposes hereof is required.

I grant permission to the Boys & Girls Club of Clifton, Inc. to authorize medical care for my child in an emergency.

I have read and understand the Information Sheet and Program Guide and agree to abide by the Boys & Girls Club of Clifton's policies and procedures in order for my child to participate in the summer program.

I understand that the I.S.E.E. program fee is non-refundable no refunds will be given for missed days during the program.

I believe my child to be in good health and has my permission to participate in all recognized Club activities. Unless specified above, my child has my permission to participate in any regular Club trips that will include activities off of Club property (daily park trips, scheduled outings and special events). I have listed all warnings
and restrictions.

I grant the Club my permission to use photographs, slides, and/or videotapes taken of my child while participating at the Club in future brochures, newsletters, and visual-audio presentations, and other forms of legitimate Club promotion, provided no identifications are made in those promotions.

In consideration of the permission and privilege of my child to participate in reasonable and normal Club activities, I hereby agree to indemnify and save and hold harmless Boys & Girls Club of Clifton, its staff and volunteers from all and any losses, claims or actions of any kind or nature that may arise from any act, omission, event or incident of any nature, occurring while my child is engaged in all reasonable and normal activities sponsored by the Boys and Girls Club of Clifton.

NJ STATE LAW AND CAMP REQUIREMENT: Attach a copy of camper's immunization record to the application. Your application will not be accepted without it.

4C'S RECIPIENTS: Attach a copy of your 4C's agreement listing summer service dates (July 6^th August 28^th). Questions regarding 4C's contracts can be addressed to Tara Dittus by calling (973) 773-2697 ext 127 or email at tdittus@bgcclifton.org.

LATE PICK UP NOTICE: If your child is picked up late 3 times during the camp season your child will be suspended from the program. If, after re-entry to the program, a 4^th late pick up your child will be removed from camp. Please be aware that if your child is not picked up by 4:45pm we will have to turn custody of your child over to the Clifton Police Department and notify the Department of Human Services of child abandonment.

*** There is a late pick-up charge of $1.00 per minute and must be paid upon pick up for your child to return to camp. We will use our cellphone to keep track of the time.