Summer Enrichment Program Application

2023 Summer Enrichment Program Application

Boys & Girls Clubs of Harford & Cecil Counties
If you have multiple children, please complete a separate form for each child. All Clubs will be closed on Tuesday, July 4, 2023.
Choose a Club Location*

Aberdeen Boys & Girls ClubEdgewood Boys & Girls ClubHavre de Grace Boys & Girls ClubBel Air Boys & Girls Club
Which week(s) will your child attend?*

June 26-30July 3-7July 10-14July 17-21July 24-28July 31-August 4August 7-11August 14-18

Cost / Payment Summary
Note: $45 Registration fee and a $55 per week payment are due at registration to reserve your child's spot. Please refer to the Summer Enrichment Program webpage for more information.

Parents have the option to pay a deposit or their total summer balance at registration.
Number of weeks selected
Weeks
Deposit amount due (Includes registration fee)
Deposit
Total summer cost
Total Summer Cost (Fee reflects the weekly rate of $185. Scholarship applications must be submitted separately.)

Youth Information
Youth Information
Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*

FemaleMale
Ethnicity:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Number

Area CodePhone Number
School*
Grade*

Youth Medical Information
Youth Medical Information
Insurance Company*
Insurance Policy/Group Number:*
Health Problems/Allergies:
Please list any medications.
Disabilities/Psychological Conditions:
Physician:*
Physician Phone Number*

Area CodePhone Number
Hospital
Hospital Phone Number

Area CodePhone Number

Emergency Contacts / Pick-up Information
Pick Up Information: (Two people authorized to pick up member-OTHER THAN PARENT)

Informed Consent and Acknowledgement

I understand and agree that my child (or ward) must be picked up by closing time or a fee will be charged which must be paid before my child (or ward) can return to the Club.

I understand and agree that BGCHC has an open door policy and cannot be responsible for my child (or ward)leaving the Club without permission. I understand that all members are free to come and go from the Club at their leisure.

I understand and agree that BGCHC does not refund membership fees and that my child (or ward) must obey all rules (Code of Conduct). I further understand that behavioral problems that cannot be solved can result in my child (or ward) being suspended from BGCHC without a monetary refund.

It is expressly understood and agreed that BGCHC shall not be responsible or legally liable for any losses of personal property, for any bodily injuries, or the results thereof, incurred and suffered by the applicant on any property of the BGCHC or in connection with any activities of any of its Units, or while engaged in any of the BGCHC’s activities away from the Club.

Internet Usage Agreement: The opportunity to use Club’s computers is based upon clear guidelines and agreements: (1) always be respectful of others, (2) never give out personal information over the computer, (3) always remember you are responsible for what you do online, (4) always follow the computer lab supervisor’s instructions, (5) never agree to meet in person with anyone you meet online and (6) never visit ‘off-limits’ web sites. Failure to uphold these agreements will result in revocation of the member’s online privileges.
Code of Conduct
Play Fairly and Be Honest Be Respectful of Boys & Girls Club Staff
Say Only Good Things About Others
Resolve Disagreements in a Positive Way
Be Respectful Of Other Members and Their Property
Take Care of Your Boys & Girls Club Facility and Equipment
Avoid Use of Improper Language
Remove Hats Before Entering Building
Applaud The Efforts of Others
Run Outside Only
Participate Only In Program Areas Open To Your Age Group
Listen During Assemblies
Dress Appropriately At All Times
Smoking, Drugs, Alcohol and Other Drugs and Weapons Are Strictly Prohibited
Stealing will not be Tolerated!
I have read the completed application, understand the rules of the Boys & Girls Clubs of Harford & Cecil Counties and request that my son/daughter/ward be admitted into membership.*

YesNo
I have explained the rules to my son/daughter/ward and agree that the Boys & Girls Clubs will not be responsible for any accident to the boy/girl while on the Boys & Girls Clubs premises or while engaged in any of its activities away from the Boys & Girls Clubs.*

YesNo
I give my consent for photographs or videoing taping in which my son/daughter/ward may appear, to be used in any way the Boys & Girls Clubs may care to use them as long as it is consistent with the BGCHC mission.*

YesNo
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature of Parent/Guardian's*

First NameLast Name
Should be Empty:

2023 Summer Enrichment Program Application