Boys & Girls Clubs 2023 Summer Camp Registration

Welcome to the 2023 SUMMER CAMP at the Boys & Girls Clubs of St. Lucie County.

The two locations that will be offered this summer are:

Westside Complex

Windmill Point Elementary

Please complete the following forms in its entirety. Once the application has been submitted, you will get a phone call from the Director to confirm your application has been received and they will charge your account to make a payment.

The payment is what holds your spot for summer camp.

Children ages 5 - 12 will be charged the following:

$30 summer camp registration fee

$115 weekly fee

10% ($11.50 per week) down payment for each additional weeks signed up

Teens ages 13 - 18 will be charged the following:

$30 summer camp registration fee

$10 weekly fee (can pay per week or for the entire summer. 9 weeks = $120 total)

Please review our Boys & Girls Clubs of St. Lucie County Parent Handbook:

https://bgcofslc.org/wp-content/uploads/2022/08/Parent-handbook-2022-2023.pdf
Summer Camp location:*

Westside Complex (Fort Pierce)Windmill Point Elementary (Port St. Lucie)
Personal Information
Child's First Name*
Child's Middle Name
Child's Last Name*
Address*

Address: (No vo Box)

Street Address Line 2

CityState / Province

Zip
Child's DOB: (MM/DD/YYYY)*
Age*
Gender*

MaleFemaleNon- BinaryTransgender
Primary Parent/Guardian Phone # w/Area Code*
Parent Work Phone w/ Extension
Primary Parent/Guardian Email (this email will be used for your Parent Portal Account to access payments)*
Ethnicity*

African AmericanAmerican Indian/ Alaska NativeAsianCaucasianHispanic/ LatinoHatianNative Hawiian/ Pacific IslanderMulti-Racial
School Information
School*
School Lunch Program*

FreeReducedIneligible
School Release Information: I understand that as a partner of the St. Lucie County School Board, the Boys & Girls Clubs of St. Lucie County will obtain academic information to better serve my child's academic needs. I give permission for the Boys & Girls Clubs of St. Lucie County to access my child's academic school records.
School Release Information*

YesNo
Skyward Number (562#)
Skyward Password (Lunch Number)
Teacher's Name
Current Grade*
Medical Information
Doctor Name
Doctor Phone Number
Permission for Treatment by Doctor/Hospital?*
List any Allergies
List of daily medications?
List accommodations/assistance your child may need to be successful in our program
Release of Child / Emergency / Authorized Pick-up / Contact Information
Mother/Guardian Name
Place of Employment/Occupation
Cell Phone
Father/Guardian Name
Place of Employment/Occupation
Cell Phone
Additional Contacts and Authorized Pick-up List:
Name
Relationship to child
Cell Phone
Name
Relationship to child
Cell Phone
Name
Relationship to child
Cell Phone
List anyone who Is NOT authorized to pick up your child
WHERE DID YOU HEAR ABOUT US:*

SOCIAL MEDIAWEBSITECOMMUNITY EVENTFAMILY/FRIEND REFERRALNEWSPAPER / PRINTOther
Household Information

This information is used for grant writing purposes
Check all those who are living in your current household*

MotherStep-MotherGrandparentFatherStep-FatherOther
Household Income*

$0 - $9,999$10,000 - $19,999$20,000 - $29,999$30,000 - $39,999$40,000 & up
Total Number of people living In household*
Total Number of people under the age of 18*
Any people living in the household that are 65+*

YesNo
Head of Household*

MaleFemale
Single Parent*

YesNo
Is the parent/guardian a member of the military?*

YesNo
If Yes, what military branch
Terms & Conditions: Please initial that you have read each paragraph
Parent Handbook: I have received a copy of the Boys & Girls Clubs of St. Lucie County handbook and agree to abide by policies in the Parent Handbook, and that failure to do so can result in membership termination. *
Code of Conduct: I agree to review the Code of Conduct and consequences with my child. I understand that membership can be suspended or revoked should behavior warrant such action.*
Payment: Please keep record of payments, we do not provide annual statements. There are no refunds for membership fees. *
Late Fees: I will adhere to the program hours of 8:00am - 5:30pm. I understand that I will be charged a late fee $1 per minute (per child) for not picking up my child at the designated closing time. I understand that membership may be suspended until payment is made. I understand that repeated offenses can result in termination of membership. *
Photo Release: With my initial, I give permission for my child to be photographed and/or videotaped for promotional materials and published materials in local or social media. *
Medical Care: In the event that Boys & Girls Clubs of St. Lucie County is unable to reach me when my child has been injured or needs medical attention/treatment, I authorize the Boys & Girls Clubs of St. Lucie County to obtain medical or hospital care on an emergency basis, and will be financially responsible for such care. *
Open Door Policy
The Boys & Girls Clubs of St. Lucie County offers an open door policy for children 13 years and older, which means that members can sign themselves out of the Club to go home. If you grant your child permission to sign him/herself out to go home, you fully understand that your child may not return until the next day. You are also stating that you understand that your child is not being supervised during their time away.*

Yes, my child is 13 years or older and has permission to sign him/herself out to go home.No, my child does not have permission to sign him/herself out to go home
Membership Agreement
IParent/Guardian Name* do hereby give my son/daughter permission to attend and participate in activites sponsored by the Boys & Girls Clubs of St. Lucie County, Inc., including the SMART family of prevention programs and release Boys & Girls Clubs of St. Lucie County Inc., its employees, directors, associates, and contributors from injury, loss, or theft incurred by my child while participating. I further understand that the information provided here m
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Minor Participant Waiver, Release, Indemnification of All Claims & Covenant Not to Sue
NOTICE TO THE MINOR CHILD'S NATURAL GUARDIAN: READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF BOYS & GIRLS CLUBS OF ST. LUCIE COUNTY USES REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM YOU ARE GIVING UP YOUR CHILD'S RIGHT AND YOUR RIGHT TO RECOVER FROM [ORGANIZATION] IN A LAWSUIT FOR ANY PERONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITY, OU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND [ORGANIZATION] HAS THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM.
Assumption of Risk

I, in my legal capacity as the parent/guardian of the minor named below ("Minor"), acknowledge and agree that any use of Boys & Girls Clubs of St. Lucie County facilities, services, equipment and premises ("Facilities") and any participation in Boys & Girls Clubs of St. Lucie County programs and activities ("Programs") comes with inherent risks including, but in no way limited to: (1) moderate and severe personal injury, (2) property damage, (3) disability, (4) death, and (5) sickness or disease including, without limitation, COVID-19. I voluntarily, for myself and Minor, accept and assume full responsibility for these risks as well as any and all other risks of the use of Facilities and participation in Programs. I agree that I have full knowledge of the nature and extent of all such risks and am not relying on all such risks being described in this document.
Minor Name (Print Clearly)*
Date*

MonthDayYear
Date
Parent/Guardian Signature*

Clear
Parent/Guardian Name (Print Clearly)
Summer 2023 Registration
Name*

Child's First NameChild's Last Name
Child's Age*
Please select the weeks you would like your child to attend. By doing so, this indicates your commitment to pay for the weeks registered. The $30 membership fee, the first week fee, and 10% for each week signed up will be required at time of registration. Please note: There will be no refunds or credits for any kind of unattended weeks or behavioral removal.*

Week 2 June 12 - 16Week 3 June 19 - 23Week 4 June 26 - 30Week 5 July 3 - 7 (closed on July 4th)Week 6 July 10 - 14Week 7 July 17 - 21Week 8 July 24 - 28Week 9 July 31 - Aug 4 (Week 9 is only offered at Westside in Fort Pierce)
Child T-Shirt Size - Please select one size*

Youth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult X-Large
Parent/Guardian Name (Please Print)*
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Daytime Contact Phone Number*
Summer 2023 Payment Procedures and Policies
In order to secure your summer registration, we will require each registration to pay the following: $30 Summer Registration Fee, $115 weekly fee for first week signed up, and 10% on every additional week signed up (non-refundable)

Example: Johnny signs up for week 1 - 9 for summer camp. Johnny pays the following:

$30 registration fee

$115 for week 1

$11.50 deposit (per week) for weeks 2 - 9

All payments will be made on our Parent Portal Account online. If you are brand new to Boys & Girls Club, we will walk you through how to access this account after the registration forms have been submitted.

All accounts will be charged on Thursdays after 4pm. Parents have Thursday at 4pm through Monday at 7:30am to make a payment. Payments received after 7:30am on Monday's will receive a $10 late fee per child.

By Signing, I understand the following:

I understand the Boys & Girls Clubs of St. Lucie County's payment procedures for the 2023 summer for the Westside Complex

I understand that failure to pay on time will result in a $10 late fee per child and possible membership suspension

I understand that the 10% payment of all weeks signed up will be non-refundable during the 2023 Summer Camp at Boys & Girls Club Westside Complex
Parent/Guardian's Name*
Parent/Guardian's Signature*

Clear
Date*

MonthDayYear
Date
After submitting your application, you will be contacted by our Summer Camp Team to go over payment. Please give us up to 24 hours to contact you.

For any additional questions, please refer back to our website for contact information.
Should be Empty:

Personal Information

School Information

Medical Information

Release of Child / Emergency / Authorized Pick-up / Contact Information

Household Information

Terms & Conditions: Please initial that you have read each paragraph

Open Door Policy

Membership Agreement

Minor Participant Waiver, Release, Indemnification of All Claims & Covenant Not to Sue

Summer 2023 Registration

Summer 2023 Payment Procedures and Policies