2025 Summer Camp Registration Form
1st-7th Grade: Mon.-Fri. 9am-5pm --- 8th Grade: Mon.-Fri. 11am-5pm
Camper's Information
Child's Name
*
First Name
Last Name
Child's Address
*
Street Address
Apartment Number/Letter
City
State / Province
Postal / Zip Code
Child's Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
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11
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15
16
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18
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25
26
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30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
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1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Grade entering in SEPTEMBER 2025
*
Please Select
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
School attending:
*
We will work hard to provide the desired session requested, but can not guarantee that those accepted into summer camp will be in the requested sessions. The session dates below may change by a few days in either direction. Please choose the session that you would prefer your child attends
*
*WAITLIST* for Session 1 (June 23rd - July 18th)
Session 2 (July 22nd - August 15th)
Child's T-shirt size
*
Please Select
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult XX-Large
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Parent / Guardian Information
Parent/Guardian Name (1)
*
First Name
Last Name
Relationship to Child
*
Cell Phone Number
Home Phone Number
Work Number
Email
*
example@example.com
Is parent/guardian's address different than child's?
*
Yes
No
Address (if different than child)
Street Address
Apartment Number/Letter
City
State / Province
Postal / Zip Code
Parent/Guardian Name (2)
First Name
Last Name
Relationship to Child
Cell Phone Number
Home Phone Number
Work Number
Email
example@example.com
Is parent/guardian's address different than child's?
Yes
No
Address (if different than child)
Street Address
Apartment Number/Letter
City
State / Province
Postal / Zip Code
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Emergency & Medical Information
Emergency Contact (1)
*
First Name
Last Name
Relationship to Member
*
Phone Number
*
Alternate Phone Number
Permission to Pick-Up
*
Yes
No
Emergency Contact (2)
First Name
Last Name
Relationship to Member
Phone Number
Alternate Phone Number
Permission to Pick-Up
Yes
No
Current Medications
*
None
Click to enter Current Medications
Allergies or Dietary Requirements
*
None
Click to enter Allergies or Dietary Requirements
Child's Doctor
*
Doctor's Phone Number
*
Child's Dentist
Dentist's Phone Number
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Permissions
(1)This person has permission to pick up on any given day:
First Name
Last Name
(1)Phone Number
Please enter a valid phone number.
(2)This person has permission to pick up on any given day:
First Name
Last Name
(2)Phone Number
Please enter a valid phone number.
(3)This person has permission to pick up on any given day:
First Name
Last Name
(3)Phone Number
Please enter a valid phone number.
This person DOES NOT have permission to pick up:
First Name
Last Name
This person DOES NOT have permission to pick up:
First Name
Last Name
My child may walk home at 5:00pm:
*
Yes
No
My child may use the internet/ electronics for academics and age appropriate activities:
*
Yes
No
My child may watch movies/videos/tv rated up to:
*
G
PG
PG-13
R
My child may go on field trips whether by foot, van,or other contracted transportation:
*
Yes
No
BGC is allowed to take photographs/video for use by the Boys & Girls Club:
*
Yes
No
BGC is allowed to contact/speak with my child's school regarding their development, behavior & education:
*
Yes
No
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Child's Demographics
As a non-profit we rely on outside funding sources to continue to offer our services at such a low cost (in some cases, at no cost). The information collected in the section below is required to secure that funding. This information is never reported with you/your child’s name. This information is strictly confidential and does not in any way affect eligibility for Club programming.
Child's Name
*
First Name
Last Name
Gender Identity
*
Number of people living in household
*
Member's of household receive the following services
*
Food Stamps
Free/Reduced Lunch
General Assistance
Unemployment
N/A
Ethnicity (choose the one that BEST applies)
*
American Indian/Alaska Native
Asian
Black or African American
Hispanic, Latino, Spanish Origin
Native Hawaiian/Pacific Island
White
Mixed Ethnicity
Other
Unknown
Total Household Income
*
$0-$15,000
$15,001-$30,000
$30,001-$45,000
$45,001-$60,000
$60,001-$75,000
$75,001 and up
Is a parent/guardian currently incarcerated?
*
Yes
No
Is a parent/guardian an active member of the military?
*
Yes
No
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Camp Fees:
The program is offered at little to no cost to those families who are accepted. Our tuition cost is $50 per week (25% discount for each additional child). We will NEVER turn a family away due to the inability to afford our camp services. If you feel your family is unable to afford the tuition costs, and your child is accepted, we do require you to complete a CCFAA (Child Care Financial Assistance Application). If the application is not accepted by the state, then the Boys & Girls Club will provide a scholarship to your child(ren) for their tuition fees.
Child Care Financial Aid Application (CCFAA):
You can get an application at both the Main Clubhouse and our IAA Site. You can also find a printable version on our website under the Summer Camp section. If you would like assistance completing the CCFAA, please feel free to reach out to the Club and we would be happy to assist!
Do you receive Reach Up?
*
Yes
No
Boys & Girls Club 2025 Summer Camp Family & Member Handbook
*
Family Agreement
I give permission for my child to swim during the Summer Program, understanding that certified lifeguards will be present at all times. I understand my child will not be able to leave the Club for any reason without written permission or phone call from a parent/guardian. I give the Boys and Girls Club of Burlington permission to Survey my child for use in reports and general knowledge. I give permission for the Boys and Girls Club to access and report my child’s immunization records. In case of emergency, the Boys and Girls Club Staff has my permission to give first aid or take the participant to a hospital for treatment and call a doctor for medical or surgical care for my child. Should an emergency arise, I understand that a conscientious effort will be made to locate me or an emergency contact before any action is taken, but I agree to accept any expenses associated with such emergency if it is not possible to locate me in advance of treatment. I hereby, for myself, my child, my heirs, executors and administrators waiver and release any and all rights and claims for damages I or my child may have against the Boys and Girls Club of Burlington for any and all injuries suffered by my child at any activity sponsored by these listed organizations. I have been informed that the Boys & Girls Club of Burlington has a freedom of access policy and complaint procedures concerning the welfare of children outlined in the Family Handbook.
Person completing this form:
*
Parent/Guardian
Advocate/Representative
Permission:
*
Advocate/Representative
*
First Name
Last Name
Parent/Guardian
*
First Name
Last Name
Today's Date
*
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Month
-
Day
Year
Date
Submit Application
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