Boys & Girls Club of Greater New Bedford
“SUMMER FUN PROGRAM”
2010
Membership #:___
Group:_____
Registration Form
Please Print-Clearly
*Last Name: ______________________*First Name: ____________________________
*Address: _________________________*Home Phone (
) ______________________
City ________________Zip___________ ***Cell Phone # (
) ______________________
*Birthdate____/_____/____ Age______ Male____Female_________* Race_______________
Mother’s Name_______________________Work Phone (
Father’s Name_______________________Work Phone
)_______________________
( )_________________
Guardian (if different)_________________________Work Phone ( )___________________
EMERGENCY CONTACTS: (Other than parent or guardian)
Name_________________________________________PHONE_______________________
Address:________________________________________________Relationship:__________
Name.________________________________________PHONE_______________________
Address:_______________________________________________Relationship:__________
Name:_______________________________________PHONE________________________
Address:_______________________________________________Relationship:___________
**Do not release my child to the following person (s) _______________________________
___________________________________________________________________
Does your child have any allergic reactions to peanut butter, bee stings, etc. Y____ N_____
If yes, please
state_______________________________________________________________
Any additional information/comments:____________________________________________
___________________________________________________________________________
___________________________________________________________________________
Parent Waiver
I have read and agree to the registration and transportation policies as written in the SummerFun Program 2010 brochure and registration form. I also understand that all payments must be
made the Friday before the session I have selected begins
Authorized Signature____________________________Date__________________
FEES: $80.00 per two-week session per child.
*** Each additional child (same family): $70.00 ***
OR
$50.00 per one-week session per child
Each additional child (same family): $40
Early drop-off or late pick-up: $5.00 each per day per pick-up
(If need both early & late, $10.00 per day, per child.)
All Summer-Fun participants must be Club Members. Club membership (good
until December 31, 2010 ) $25.00 per child
*** FINANCIAL AID IS AVAILABLE FOR THOSE WHO QUALIFY
“FREE”
2010
SUMMER LUNCH
PROGRAM
My child ____________________________________________________________________
(Child’s Name)
Will be:
Getting a Free Lunch ____
Bringing their Lunch ____
Every day
** Your child MUST BE “SIGNED UP” for a FREE lunch
in order to receive one…….
A United Way Agency
Enrollment Agreement
. The registration fee is ($25). Two-Week Session Blocks are $80 per child/$70 for additional
children in the same family, OR, One-Week Sessions are $50 per child/$40 for additional
children in the same family (Registration will not be processed without the registration fee or
deposit).
. I agree to pay the balance of camp fees prior to each week’s attendance at camp.
. I understand that it is my responsibility to bring any special conditions or concerns about my
child to the director’s or asst. director’s attention.
. I give permission to the Boys & Girls Club of New Bedford to have, use, publish and
reproduce photographs, slides, or videotapes of my child for its records, public relations or
advertising programs.
. I grant permission for my child to participate in all Boys & Girls Club of New Bedford’s
organized activities including off campus field trips.
. I have read the Boys & Girls Club of New Bedford’s price schedule. I understand and accept
the program’s policy concerning membership, registration fees, tuition and terms of enrollment.
. I understand that once an application is accepted by the Boys & Girls Club of New Bedford,
no refunds or transfer of funds will be made for withdrawal, dismissal, failure to attend or
incomplete attendance.
. I certify that the above named child on this registration is physically and mentally prepared to
participate in all activities.
. I understand that the director reserves the right to dismiss a camper when in his/her judgment
the camper’s behavior interferes with the rights of others, the smooth functioning of the group
or activity, or violates the camp’s principles of conduct.
Parent’s Signature_________________________________________Date_______
The “Positive Place” for Summer!
Boys & Girls Club of Greater New Bedford
166 Jenney Street
New Bedford, MA 02740
508-992-8011
Transportation
Transportation will be provided along a selected route. We will attempt to accommodate transportation needs
the best of our ability. Only children who have no other way of transportation may use this service.
These are the designated stops for the Summer Fun Program. Please Circle the stop your child will be picked up
at in the morning, and dropped off at in the afternoon. If it will be a different in the morning and afternoon,
please discuss this with Bernadette.
Morning Pick-Up
Afternoon Pick-UP
North End
North End
1. Acushnet Ave. & Sawyer St. (Brooks)
2. Acushnet Ave. (Nye Street)
3. Corner of Ashley Blvd. & Nash Rd.
4. Shawmut Ave. (Shawmut Diner)
5. Harbor House
6. Potter St.
1. Acushnet Ave. & Sawyer St. (Brooks)
2. Acushnet Ave. (Nye Street)
3. Corner of Ashley Blvd. & Nash Rd.
4. Shawmut Ave. (Shawmut Diner)
5. Harbor House
6. Potter St.
South End
South End
1. Acushnet Ave. & Madison St. (PACE)
2. Acushnet Ave. & Bedford St. (Band Club)
3. County St. (St. John’s Church)
4. County St. & Cove St. (Sovereign Bank)
5. Dartmouth St. (Perry’s Funeral Home)
1. Acushnet Ave. & Madison St. (PACE)
2. Acushnet Ave. & Bedford St. (Band Club)
3. County St. (St. John’s Church)
4. County St. & Cove St. (Sovereign Bank)
5. Dartmouth St. (Perry’s Funeral Home)
West End
West End
1. Court St. & Liberty St. (Hathaway School)
2. Cedar St. & Elm St. (United Front Homes)
3. Cedar St. & Maxfield St. (West End Day
Nursery)
4. Pope St. & County St. (Parker Street School)
5. County St. & Linden St. (Linden Pizza)
6. Durfee St. & Cottage St. (Used Car Lot)
7. Durfee St. & Hathaway Blvd. (Hetland
Skating Rink)
1. Court St. & Liberty St. (Hathaway School)
2. Cedar St. & Elm St. (United Front Homes)
3. Cedar St. & Maxfield St. (West End Day
Nursery)
4. Pope St. & County St. (Parker Street School)
5. County St. & Linden St. (Linden’s Pizza)
6. Durfee St. & Cottage St. (Used Car Lot)
7. Durfee St. & Hathaway Blvd. (Hetland
Skating Rink)