Boys & Girls Club of East Aurora School Age Program

Summer 2023

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 26 through Thursday, August 24. Hours are 7 am- 6 pm.

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

[ ] June 26- 30: M T W Th F

[ ] July 3-7: (closed 7/4) M W Th F

[ ] July 10-14: M T W Th F

[ ] July 17 – 21: M T W Th F

[ ] July 24- 28: M T W Th F

[ ] July 31- August 4: M T W Th F

[ ] August 7 – 11: M T W Th F

[ ] August 14– 18: M T W Th F

[ ] August 21-24: M T W Th

* 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 $48/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: _____________________________________________________