Boys & Girls Club of Burbank Summer Camp

1. Is your child an ASES Member? Yes No If your child isn’t a member of the ASES program, a $75 membership fee is required prior to your child’s first day in the program. Please make checks payable to “Boys & Girls Club of Burbank.” Rate includes morning and afternoon snack. I understand there are no refunds. A late pick up fee of $5/each 15 minutes after scheduled closing time is enforced. By signing below, I agree to the terms and conditions of the Boys & Girls Club of Burbank and the policies set forth. Parent Signature: _____________________________ Date: _______ Boys & Girls Club of Burbank Summer Camp Week Dates (ASES) (Regular)Week 1 June 10 – 13th $10 $80 Week 2 June 16 – 19th $10 $80 Week 3 June 23 – 26th $10 $80 Week 4 June 30 – July 3rd $10 $80 Week 5 July 7 – 10th $10 $80 Summer School Program at Disney12:00 – 6PM Childs Name: __________________________________ Birth date: ____ /____/ ____ Sex: ______ (Please fill out one form per child)Mothers Name: __________________ Work Phone: _____________ Cell Phone:________________ Fathers Name: ___________________ Work Phone: _____________ Cell Phone: ________________Home Phone: (_____) _______ - __________Home Address: __________________________City/State/Zip: __________________________ Week 6 July 14 – 18th $10 $80 Week 7 July 21 – 25th $10 $80 Week 8 July 28 – Aug 1st $10 $80 Week 9 Aug 4 – Aug 8th $10 $80 Week 10 Aug 11 – 15th $10 $80 Week 11 Aug 18 – 22nd $10 $80 Day Camp at the Clubhouse is based on a “First Come First Serve Basis”7AM – 7PM Payment may be made in full now oryou may pay each Monday. Total Due: $_______

2. Boys & Girls Club of Burbank Summer Camp Childs Name: __________________________________ Birth date: ____ /____/ ____ Sex: ______ (Please fill out one form per child) Mothers Name: __________________ Work Phone: _____________ Cell Phone:________________ Fathers Name: ___________________ Work Phone: _____________ Cell Phone: ________________ Home Phone: (_____) _______ - __________ Home Address: __________________________ City/State/Zip: __________________________ Is your child an ASES Member? Yes No If your child isn’t a member of the ASES program, a $75 membership fee is required prior to your child’s first day in the program. Please make checks payable to “Boys & Girls Club of Burbank.” Rate includes morning and afternoon snack. I understand there are no refunds. A late pick up fee of $5/each 15 minutes after scheduled closing time is enforced. By signing below, I agree to the terms and conditions of the Boys & Girls Club of Burbank and the policies set forth. Parent Signature: _____________________________ Date: _______ Week Dates (ASES) (Regular)Week 1 June 10 – 13th $10 $80 Week 2 June 16 – 19th $10 $80 Week 3 June 23 – 26th $10 $80 Week 4 June 30 – July 3rd $10 $80 Week 5 July 7 – 10th $10 $80 Summer School Program at Washington12:00 – 6PM Week 6 July 14 – 18th $10 $80 Week 7 July 21 – 25th $10 $80 Week 8 July 28 – Aug 1st $10 $80 Week 9 Aug 4 – Aug 8th $10 $80 Week 10 Aug 11 – 15th $10 $80 Week 11 Aug 18 – 22nd $10 $80 Day Camp at the Clubhouse is based on a “First Come First Serve Basis”7AM – 7PM Payment may be made in full now oryou may pay each Monday. Total Due: $_______