Boys & Girls Club of East Aurora School Age Program

Summer 2022

Child’s name: ___________________________________ Birth date: ____________Gender: ____

Parent(s)/Guardian: ___________________________________Home phone #: _______________

Address: _____________________________________________________Grade entering: _____

Email address: _________________________________________________

Open to children entering Kindergarten in September- 5th grade, from Monday June 27 through Wednesday August 24. Hours are 7 am- 6 pm.

I would like to register my child on the following days:

[ ] June 27-July 1: M T W Th F

[ ] July 5-8: (closed 7/4) T W Th F

[ ] July 11-15: M T W Th F

[ ] July 18 – 22: M T W Th F

[ ] July 25- 29: M T W Th F

[ ] August 1 –5: M T W Th F

[ ] August 8 – 12: M T W Th F

[ ] August 15– 19: M T W Th F

[ ] August 22-24: M T W

* You are responsible for payment for each day your child is registered, whether he/she attends the program or not. One month withdraw from Program notice is required. Tuition is $210 per week, or $45/day with a minimum of two days per any week attending. Registration is complete when all applicable forms are complete and turned in. New families must complete a Registration Packet.

I, the parent/guardian of___________________________ authorize the Boys & Girls Club to release confidential educational and /or medical information to use in pursuing their duties. This contract specifically includes permission for my child to have his /her picture taken as part of publicity and to attend and participate in field trips that are part of the program. I release the Boys & Girls Club of East Aurora and any of its staff from any liability in connection with these activities. I agree to all policies stated on this contract.

Parent/Guardian signature: __________________________________________Date: __________

Daytime phone number: _____________________________________________________