Boys and Girls Club Summer Registration

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The Club is open to all youth entering 4th to 12th grade with an annual membership fee of $10. No one will be turned away due to an inability to pay. Youth may attend all or part of the summer. Participation in Extreme Steam is optional. The club will be open from 9:00 AM to 1:00 PM Monday through Friday from June 19th through August 18th. We will be closed Monday July 3rd and Tuesday July 4th. There are openings at the Mary Johnson Childcare Center based at St. Peter's in Vergennes for children needing a place to be after 1:00 PM. Please contact Anne Gleason at schoolage@mjccvt.org

By registering your child you are agreeing to the following: Please type your name in the last question box to indicate your permission.

I give permission for my child to participate in the Boys & Girls Club (BGC) of Greater Vergennes. My permission includes
- allowing the Boys & Girls Club staff to treat/arrange treatment for my child in the event of an accident and understand that I am responsible for any medical costs associated with medical services provided
- allowing my child to participate in its mentoring program and to survey my child for use in reports and general knowledge
-consenting photographs and/or videos, in which my child appears while engaged in club activities, to be used in any way the BGC of Greater Vergennes may care to use them
- agreeing that BGC of Greater Vergennes will not be held responsible for any accident or injury to my child while on club premises or engaged in any of its activities away from the club
- allowing my child to use the Internet for age-appropriate activities while engaged in programs.allowing my child to go on trips away from the club, whether on foot or by contracted transportation.I understand that BGC of Greater Vergennes is a drop-in program with an “Open Door” policy, so that my child is not required to be signed out by an adult. I also understand that BGC of Greater Vergennes does not provide transportation to and from the club facilities, and that I am responsible for ensuring that my child is picked up from the club by the scheduled closing time. I have read the completed application, understand the rules of the BGC of Greater Vergennes, have reviewed the rules with my child, and request that he/she be admitted into BGC membership.

Email *

Name *

Street Address *

City/State/Zip *

Birth date *

YYYY

Gender *

Male

Female

Free/Reduced Lunch *

Yes

Member lives with *

Mother

Father

Both

Other:

Mother's/Guardian's Name

Mother/Guardian's Phone Number

Mother/Guardian's E-mail

Mother/Guardian's address if different from member

Father/Guardian's Name

Father/Guardian's Phone Number

Father/Guardian's E-mail

Father/Guardian's address if different from member

Emergency Contact Name *

Emergency Contact Phone Number *

Emergency Contact Relationship to Member

Medical Problems/Allergies

I anticipate my child participating

Most days during the summer

A few days a week

Only the weeks "Extreme Steam" is running

Other:

Clear selection

Where will your child be going when the club closes at 1:00 PM

Walk or bike home or to the pool

Picked Up

Going to MJCC at St. Peter's

Other:

Clear selection

Please type your name in the box provided to give permission for your child to participate *

Submit

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