Who can attend?

Any child going into grades 1 – 6 can attend the Boys & Girls Club Summer Camp.

What if I don’t want my child to attend JCPS Summer School and what about the form I received from my

child’s school already?

You are not required to send your child to JCPS Summer School though we highly recommend you take advantage

of the opportunity. Boys & Girls Club will only be open M-Th, 3 – 7 pm and 7:30 am – 5:30 pm on Fridays while

JCPS Summer School is in session (May 29 – June 22). If you chose to keep your child at home during the day in

the time frame reference above, you may bring your child to Boys & Girls Club no earlier than 3:30 pm, M-Th and

all day on Fridays. A summer school enrollment form was sent home already from JCPS. Even if you’ve already

turned in the summer school form to your child’s school, please complete the JCPS Summer School form attached

as well so we can ensure that your form is submitted to the JCPS District office as part of your BGC summer camp

enrollment.

How is the Fee Structure Set up?

Please complete the flow chart on the following page to determine your fee structure.

Will this camp be fun?

YES! Just like every other summer, we will be going on field trips, hosting fun activities and making great memo-

ries. We are staying open later from May 29 – June 22 (until 7 pm) so we can give your kids a great summer camp

experience. We ask that you consider allowing your child to stay until we close. We will feed them dinner before

you pick them up at 7 pm.

How do I reserve a spot?

Enrollment opens for currently enrolled families or families who attended BGC Summer Camp last year on March

12. Enrollment opens to the public on March 26. You must return your COMPLETE application, $25 one-time

activity fee/child + your first week’s registration fee/child. An incomplete application or an application without

payment will not be accepted. If you are approved for child care assistance after registering your child, you will

receive all or part of your first week’s registration fee refunded (amount of refund will be determined by your state

approved sliding fee co-pay amount). Once your completed application and payment is turned in you will receive

an email confirmation of enrollment.

How will transportation work?

If your child attends JCPS Summer School, a school bus will pick your child up at home OR you can take your

child to their regular school. Part of your JCPS Summer School enrollment form is a sign up for school bus trans-

portation. First Student will notify you via mail to confirm your child is signed up for school bus transportation. At

dismissal, your child will be transported to BGC, 1105 Lafayette Street. You will be responsible for picking your

child up when BGC closes at 7 pm. On Friday, JCPS will not hold summer school so BGC will be open from 7:30

am – 5:30 pm and you will be responsible for transporting your child to and from BGC. Once JCPS summer

school is over, you will be responsible for transporting your child to and from BGC camp.

Will BGC Offer Late Stay this summer?

Yes. You may purchase late stay care which will allow your child to stay at BGC until 6:30 p.m. on Fridays from

May 29 – June 22 and every day from June 24 – August 11. The late stay payment must be paid in advanced dur-

ing enrollment.

Why can’t I pick the weeks I want my child to attend?

There is a very high demand for Boys & Girls Club summer camp and each year over 100 children are on a waiting

list or are turned away. If you receive a spot in the camp, you are responsible for the fees associated with that spot

all summer.

FAMILY INFORMATION

Parent/Guardian #1: Name: ___________________________________________________________

Lives with Child: YES NO

Telephone: (____) ______-_________ Cell phone: (____) ______-_________ Work Phone: (____) ______-_________

E-Mail Address: ___________________________________________

Mailing Address: ____________________________________________________________________________________________

Parent/Guardian #2: Name: ____________________________________________________________

Lives with Child: YES NO

Telephone: (____) ______-_________ Cell phone: (____) ______-_________ Work Phone: (____) ______-_________

E-Mail Address: ___________________________________________

Mailing Address: ____________________________________________________________________________________________

Relationship to Child(ren): ____________________________________________________________

Relationship to Child(ren): ____________________________________________________________

Additional People Authorized to Pick Up Child(ren) Other Than Parents/Guardian:

Name: _______________________________ Telephone: (____) ______-_________ Relationship to Child:_________________

Name: _______________________________ Telephone: (____) ______-_________ Relationship to Child:_________________

Additional Emergency Contacts Other Than Parents/Guardian:

Name: _______________________________ Telephone: (____) ______-_________ Relationship to Child:_________________

Name: _______________________________ Telephone: (____) ______-_________ Relationship to Child:_________________

Family Yearly Income

$0- $9,999 $10,000 - $14,999 $15,000 - $22,999 $23,000 - $33,999 $34,000 - $49,999 $50,000 - $74,999 $75,000 - $99,999 $100,000 or more

Family Setting

Both Parents Single Parent Mother

Single Parent Father Grandparent(s)

Foster Care Legal Guardian

Other Relative

School Lunch Program Free Reduced None

Head of Household Employed Unemployed

Student Disabled

MEMBER #1 INFORMATION

Childs Name:

Last Name First Name Nickname

Grade Child Will Be Entering: School Child Attends:

Childs Sex: Male Female

Can your child swim? YES ____ NO _____ Comments: ___________________________________________________________

________ My child may attend swimming activities while in care at Boys & Girls Club of Jefferson City. (Please initial)

Safety Section:

Childs Height: __________ Weight: _____________ Hair Color: _______________ Eye Color:_______________

Does your child have allergies or special medical conditions? YES ____ NO _____

Please List Conditions: ________________________________________________________________________________________

___________________________________________________________________________________________________________

If food allergies, you are required to have a physician complete and return the food allergy/substitution

form attached at the end of this enrollment packet.

Childs Ethnicity: African American ____ Asian ____ Caucasian ____ Hispanic____ Native American ____ Multi-Racial ____

New Member Returning Member (Currently Attending BGC or Attended Summer Camp Last Year)

Childs Birth Date:

MEMBER #2 INFORMATION

Childs Name:

Last Name First Name Nickname

Grade Child Will Be Entering: School Child Attends:

Childs Sex: Male Female

Can your child swim? YES ____ NO _____ Comments: ___________________________________________________________

________ My child may attend swimming activities while in care at Boys & Girls Club of Jefferson City. (Please initial)

Safety Section:

Childs Height: __________ Weight: _____________ Hair Color: _______________ Eye Color:_______________

Does your child have allergies or special medical conditions? YES ____ NO _____

Please List Conditions: ________________________________________________________________________________________

___________________________________________________________________________________________________________

If food allergies, you are required to have a physician complete and return the food allergy/substitution

form attached at the end of this enrollment packet.

Childs Ethnicity: African American ____ Asian ____ Caucasian ____ Hispanic____ Native American ____ Multi-Racial ____

New Member Returning Member (Currently Attending BGC or Attended Summer Camp Last Year)

Childs Birth Date:

1. I DO DO NOT give permission for field trips / excursions. I understand I will be notified in advance when they are

planned.

2. I DO DO NOT give permission for the Boys & Girls Club to transport my child.

3. When my child is ill, I understand and agree that she/he may not be accepted for care or remain in care.

4. I DO DO NOT give consent for photographs or other media in which my son/daughter may appear which will be

used to promote the mission, awareness and fundraising activities of the Boys & Girls Club of Jefferson City.

5. I DO DO NOT give permission my son/daughter to walk home. I will not hold the Boys & Girls Club of Jefferson City , its officers, or volunteers responsible for any injury or danger that occurs once my child has left the club.

6. I DO DO NOT give consent for my child to use the Boys & Girls Club of Jefferson City’s technological equipment; in-cluding but not limited to computers, printers, software, the internet (limited access), and audio-visual equipment.

7. I DO DO NOT give consent for Boys & Girls Club to have access to child’s Jefferson City Public School records such as Free/Reduced Lunch status, Title I benefits, Individual Education Plan, English Language Learner status, DESSA assess-ment and Student Identification Number as well as grades, MAP scores and attendance records. Any information obtained will be kept confidential between the Boys & Girls Club of the Jefferson City and Jefferson City Public Schools and will be used to measure the success of the program.

ACKNOWLEDGEMENTS: APPLIES TO ALL CHILDREN

Parent Printed Name: _______________________________________________________

Parent Signature: ___________________________________________________ Date: _____________________________

LATE STAY FOR ELEMENTARY SUMMER CAMP

Late Stay will be from 5:30p.m.-6:30p.m. again this year. The Late Stay fee is a one time payment of $40.00 per/child. There will be 32 open spots for Late Stay. Payment must be made to secure a spot.

IMPORTANT: If your child/children are picked-up beyond closing time (6:30p.m.) you will receive a letter the first time; but if the late pick-up reoccurs, your child/children will be removed from Late Stay with No Refund.

I am interested in securing a Late Stay spot.

Summer Sports:

Please check below if you child(ren) have interest in playing the following sports this summer:

Basketball

Soccer

Flag Football

PLEASE CHECK ONE BELOW:

My child(ren) are not on fee and reduced lunch. I will pay full rate as described above.

My child(ren) are on free/reduced lunch. ** You must complete the child care application attached

in this packet and return it with your enrollment form with 30 days of paystubs **

I’m already enrolled in

monthly ACH and I

want to use that

method for Summer

Camp.

Boys & Girls Club—Railton Center

1105 Lafayette Street

Jefferson City, Missouri 65101

(573) 634-2582