Boys & Girls Club of Missoula County
Dear Parents,
Please review and complete the information in this packet and return it to your after school
program site director or to the Boys and Girls Club administrative office at 1515 Fairview
Avenue Suite 243. We filled up by mid-May last year, so get your form in early. Schedule
changes must be made no later the Friday, May 22nd, and in writing. After that you will be
financially responsible for the written schedule you have submitted to us.
Camp fees range from $55-125 per week. Fees are on a sliding scale for both low and middleincome families. If you are applying for a full scholarship or for the sliding scale reduced rate
make sure to fill out the scholarship form and attach proof of HOUSEHOLD income. You can
check the sliding fee scale at the end of this packet to see what your rate will be. Please note
that there is a $10 reduction per week for additional children, if your rate is $105 2nd child is
$95, 3rd is $85.
Scholarship rates apply to full weeks only. The single day rate is $25.00 per day and children
still must be scheduled even for single days. We do not have space for drop-ins. If your child
is scheduled to attend camp you will be responsible for paying for the scheduled day, the
only exception is illness. If your child is absent from camp without notification or explanation
we will give your child’s camp spot to the next child on the waiting list. A simple call to the
club office or text to your site director will keep your child’s spot.
You can check your child into their campsite after 7:30 AM and pick them up any time before
5:30 PM. We do request that children be at camp no later than 9:30 so that all campers are here
for field trips and outdoor excursion. If you drop them off later than 9:30 the group may already
be at an offsite activity and you will have to drive your child to the offsite location.
There are limited scholarships available and they are offered to children who are in the greatest
need. Only one scholarship is offered per family. Child Care Resources has also has a limited
number of scholarships for summer childcare and works with us regularly.
We will be sending out a letter instead of a parent meeting. You are responsible for the
information in the letter and will be expected to provide the items your child needs for camp
and abide by the rules and guidelines of camp i.e. dropping off times, required equipment, etc.
Please make sure the following forms are completed; please keep this top sheet for your records:
 Boys and Girls Club Membership Application
 Emergency Authorization Form
 Field Trip/Transportation/Photograph and Video Release/Parent Agreement
 Parent/Director Contract
 Summer Camp Scheduling Form
 Attach Scholarship form and income verification (if applying for scholarship or
sliding scale)
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1515 Fairview Avenue, Missoula
(406) 542-3116 (406)532-1541 Fax
visit us on the web: www.bgcmissoula.org
of Missoula County
What day do you want your child start coming to our program? _______________________
MEMBERSHIP APPLICATION for Summer Camp 20__
PLEASE PRINT NEATLY AND FILL OUT ALL INFORMATION COMPLETELY
Member Information
Member’s First Name:
Last Name
Members School:
Members phone:
Birthday:
Member’s Home Address:
Age:
M / F
Grade attending in the fall:
City:
State & Zip:
Who does member live with? Mother _____ Father _____ Both ______ Other, please specify____________________________________
New Member _________ Returning Member _________ If returning, how many years have you been a member? ______
Ethnic Heritage (as many as apply) ___White
____Hispanic ____African American ____Asian ____Native American ____Pacific Islander ___Other
Members Head of Household
Name:
Occupation:
Cell Phone:
Employer:
Home Phone:
Work Phone:
Email:
Other Parent/Guardian if applicable, leave blank if not applicable
Name:
Occupation:
Cell Phone:
Employer:
Home Phone:
Work Phone:
Email:
VERY IMPORTANT!
Medical Issues and/or Allergies____________________________________________________________________________________________________
Family or emotional Issues we should know about ____________________________________________________________________________________
____________________________________________________________________________________________________________________________
Medications Child is Taking ____________________________________________________________________________________________________
Preferred Physician___________________________________________ Preferred Hospital/Clinic____________________________________________
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Boys and Girls Club Emergency Authorization Form
PLEASE FILL OUT THIS FORM COMPLETELY FOR THE SAKE OF YOUR
CHILD’S SAFETY AND WELL BEING.
In the event of an emergency we will try to contact individuals in the following order: Parents/guardians
then other people authorized on this list. Please be thoughtful of the people you select and make sure
that they have been informed of their responsibility. Update this form as needed so that it is current.
IF YOU ARE LATE AND HAVE NOT CONTACTED THE BOYS AND GIRLS CLUB, the
following procedure will be initiated. There will be a late charge of $1.00 per minute added to
parental bill. Additionally, after fifteen minutes, if the parent/guardian has not made contact, the staff
will begin to make phone calls in the order listed above for emergencies. The staff will release your
child to someone on the emergency/authorization list if they are unable to contact a parent or guardian.
After 30 minutes, if the staff is unable to reach anyone on your emergency/authorization list to arrange
for the child’s transport home, Child Protective Services will be contacted. This is our last resort and
not anything we want to do. Please make sure your contact list is responsible and willing to step up to
help you and your children if an emergency situation should occur.
We reserve the right to discontinue service to a family if late pick-ups occur more than 3 times in a
school year or summer camp period. Notice will be given before termination of services happens.
Emergency/Authorization List - 4 are not required, just use what you need
Name__________________________________________________
Phone (home)______________________(cell)___________________
Relation to Child___________________________________________
Name_________________________________________________
Phone (home)______________________(cell)___________________
Relation to Child___________________________________________
Name_________________________________________________
Phone (home)_____________________(cell)____________________
Relation to Child___________________________________________
Name_________________________________________________
Phone (home)_______________________(cell)__________________
Relation to Child___________________________________________
_______________________________________
Parent/Guardian Signature
_____________________
Date:
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TO PARENTS OR GUARDIANS OF MINOR ~ WAIVER OF LIABILITY AND DISCLAIMER: In consideration of my
son’s/daughter’s membership and participation in the activities and special programs and/or events of the Boys & Girls Club
as parent or guardian of named minor, my heirs, executors, administrators and assigns, waive, release and discharge any and
all rights and claims of damages against the Boys & Girls Club of Missoula County and/or its sponsors for all claims arising
or resulting from traveling, participation and/or being involved in the program or activities. I attest and verify that I have full
knowledge of the risks involved in said participation and that I will on behalf of the said member assume and pay any
medical or emergency expenses in the event of accident, illness or other incapacity regardless of whether I have authorized
such expenses. I attest that my son/daughter is physically fit and sufficiently able to participate in the programs or activities
of the Boys & Girls Club of Missoula County in conjunction with other youth members.
ACKNOWLEDGMENT AND CONSENT: For internal and external use, I acknowledge that the Boys & Girls Club of
Missoula County and or its sponsors may utilize photographs of the member, which may be taken during involvement in the
Boys & Girls Club of Missoula County’s programs or activities. I consent to such uses & herby waive all rights to
compensation.
EMERGENCY AUTHORIZATION: I, the undersigned (or as parent or guardian of the participant, a minor), hereby
authorize the staff of the Boys & Girls Club of Missoula County or its sponsors and/or volunteers, coaches, trainers, activity
supervisors, instructors and vehicle drivers as my agents, to consent to medical, surgical or dental examination and/or
treatment. In case of emergency, I hereby authorize treatment and/or care at any hospital or by licensed medical personnel.
Club staff will NOT medicate children. Parents/guardians are ENTIRELY responsible for medications and for personally
arranging for or ensuring the proper and timely medication of their children.
NOTE: Your signature acknowledges that you have read and accept the policies of the Boys & Girls Club of Missoula
County as described above for member info. Please call the Club at 542-3116 if you have any questions.
ACKNOWLEDGEMNT OF FEE STRUCTURE: I, the undersigned am aware that the Boys & Girls Club of Missoula
County charges $55-125 per child per week for summer camp unless a scholarship has been awarded. I also am aware that
the Boys & Girls Club of Missoula County charges $25.00 per day for single days. I agree that I am responsible for the fee
payment and will honor my financial obligation. If another adult is legally responsible for the fee payment that adult is
required to sign acknowledgement of the fee structure as well.
The Boys & Girls Club of Missoula County reserves the right to discontinue service to a family if payment requirements as
outlined above or on a scholarship award are not met. This is a last resort; we do not ever want a child to not come to club
because of money. Please keep us informed in a timely manner if a financial emergency arises, we are willing to help if we
are aware of an issue.
THIS MEMBERSHIP WILL NOT BE ACCEPTED UNLESS SIGNED BY PARENT.
_____________
Date Signed
________________________________________
Signature of Parent or Guardian
__________________________________
Printed Name of Parent or Guardian
_____________
Date Signed
________________________________________
Signature of Person Responsible for Fee Payment
_________________________________
Printed Name
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Boys & Girls Club Field Trip Permission Slip
Child’s Name___________________________________________________
I hereby give permission for the child listed above to participate in/attend all Boys& Girls Club sponsored
field trips. I understand that I will be notified in verbal or written form of all scheduled field trips before
they actually occur. As the weather permits we walk to parks, fields and trails, I give my child permission to
walk or take public transportation or ride in an insured club vehicle with club staff and volunteers. Children
will not be allowed to walk or ride public transportation while at club without an adult. If you chose you
may provide a letter to the club giving your child permission to ride the bus or their bike or walk home at
the end of the day.
To the best of my knowledge, my child is physically fit and able to take part in all activities. I understand
that in case of injury, every effort will be made to contact me. If this is impossible I authorize any medical
care deemed necessary.
Boys & Girls Club
Transportation Form
I, the undersigned, understand that the children of the Boys & Girls Club members are transported via
Mountain Line City Bus Line, as well as Beach Transportation buses and by Club vans. I understand that
Mountain Line and Beach Transportation vehicles DO NOT have seat belts. However, I acknowledge that
the staff will always enforce rules to insure maximum safety, i.e. sitting back in the seats and sitting down
whenever the vehicle is in motion. I consent to have my child listed above transported on Mountain Line
Bus Company as well as Beach Transportation buses and Club vans.
Boys & Girls Club Summer Kids Camp
Photograph/Video Release
I give permission for my child listed above to be photographed or videotaped while at the Boys & Girls
Club. I understand that the staff will use discretion and judgment in allowing any photographs or video to
be taken and that images of my child may appear in or on Boys & Girls Club’s brochures, advertisements or
the club website. I consent to such uses and hereby waive all rights to compensation.
Boys & Girls Club Summer Kids Camp
Parent Agreement
I have read the contents for the Boys &Girls Club Parent Packet and registration information. I understand
and will comply with all policies and procedures stated within these documents. Only one signature is
necessary but both are welcome.
______________________________
Mother/Guardian #1
Date
____________________________
Father/Guardian #2
Date
Only 1 parent signature is required unless the child splits their time during the summer between parents.
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Boys and Girls Club Summer Kids Camp
Parent Contract
THE PARENT (please initial):
______I will not drop off my child before 7:30am and will pick up my child before 5:30pm.
______I will sign my child in and out each day with a camp director or assistant director.
______I will pay a fee of $1 for every minute my child is dropped off early or picked up late.
______I will send my child appropriately dressed, bathed and equipped, and I understand that appropriate
attire includes shoes (absolutely no high heels and flip flops and are not recommended) and
clothes that will allow my child to participate in all group activities including swimming and playing
in and around the water.
______I understand that the Boys & Girls club does provide breakfast, lunch and snacks through the
summer feeding program at Russell Elementary. I know I am welcome to send food with my child
if they do not like or refuse to eat what is provided.
______I will only bring my child if s/he is in good health so s/he can fully participate in our camp.
______I understand that all payment must the first day of each week that my child is scheduled to attend
camp unless otherwise arranged in written form with stated payment plan and approved by the
Director.
______I understand that if there is a balance exceeding $200 any time during the month, my child can no
longer attend camp and his/her spot will be given to the net child on the waiting list.
______I will share any concerns or important information relating to my child’s well-being with my child’s
director so that we can fix the problem and have a give your child a good experience.
______I will provide sunscreen for my child and replace it when it is empty or pay BGCM to purchase
sunscreen for my child.
______I will provide a container for water for my child to carry during the day or purchase a water bottle
from BGCM on the days I do not provide one.
______I agree to make sure that my child is taking his/her daily-prescribed medication. (Summer Camp
staff is not authorized to administer any medication to children)
_____________________________
Parent/Guardian Signature
________________________
Date
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Summer Camp Scheduling Form
1. Indicate which camp your child belongs in. We can be flexible across the age groups especially in the case of
siblings who want to be together or who do not or should not be together.
 Juno - kids entering 5th grade and up (City Life Community Center, meet on the 1st floor)
 Middsies - kids entering 3rd and 4th grades (City Life Community Center, meet in the basement)
 Littles – kids entering 1st and 2nd grades (City Life Community Center, meet in the basement)
2. Summer camp is divided into 11 weeks. Please check the weeks that you would like to enroll your child. For all
10 weeks, please check ALL. You will be held financially responsible for the weeks you schedule unless we
are notified of changes on or before May 23rd.
Week 0 (June 8 – June 12) For Bonner and Target Range kids.
____All 5 days or single days (please mark) M ___T ___W ___TH ___F___
Week 1 (June 15 – June 19) ____All 5 days or single days (please mark) M ___T ___W ___TH ___F___
Week 2 (June 22 – June 26) ____All 5 days or single days (please mark) M ___T ___W ___TH ___F___
Week 3 (June 29 – July 2)
____All 5 days or single days (please mark) M ___T ___W ___TH ___
Please note: No club on Friday July 3rd in celebration of Independence Day
Week 4 (July 6– July 10)
____All 5 days or single days (please mark) M ___T ___W ___TH ___F___
Week 5 (July 13 – July 17) ____All 5 days or single days (please mark) M ___T ___W ___TH ___F___
Week 6 (July 20 – July 24) ____All 5 days or single days (please mark) M ___T ___W ___TH ___F___
Week 7 (July 27 – July 31) ____All 5 days or single days (please mark) M ___T ___W ___TH ___F___
Week 8 (Aug. 3 – Aug. 7) ____All 5 days or single days (please mark) M ___T ___W ___TH ___F___
Week 9 (Aug. 10– Aug. 14) ____All 5 days or single days (please mark) M ___T ___W ___TH ___F___
Week 10 (Aug. 17–Aug. 21) ____All 5 days or single days (please mark) M ___T ___W ___TH ___F___
ALL 10 Weeks ____All 5 days or single days (please mark) M ___T ___W ___TH ___F___
3. Please check 1 box:
 I would like to be considered for the sliding fee scale and have attached the scholarship form and my
household financial income information to my parent packet.
 I would not like to be considered for the Boys and Girls Club sliding fee scale.
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Boys & Girls Club of Missoula County
Sliding Fee Scale for Summer Camp 2014
Scale is based on HOUSEHOLD income, and requires the scholarship form
and proof of income to be utilized.
$0 - $24999 – Full scholarship – 3 available per age level, 1 full
scholarship per family only
$25,000 - $28,000 - $55 per week – scholarship
$28,001 – $32,000 – $65 per week - scholarship
$32,001 – $36,000 - $75 per week - scholarship
$36,001 – $40,000 - $85 per week - scholarship
$40,001 – $45,000 – $95 per week
$45,001 – $50,000 – $105 per week
$50,001 - $60,000 per week - $115
$60,000 and up - $125
For full time or 5 day a week there is a $10.00 break for 2nd & sequential
children. (For example, if your first child is $105.00 a week your second
child would be $95.00 per week & your third child $85.00 per week.)
Part time attendance is $25.00 per day per child regardless of full
week fee scale or number of children registered. Scholarship rates
only apply to full week registration.
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