Boys & Girls Club of Greater Nashua : What We Do : Summer Programming : Summer Camp Registration

Welcome to Ohana-Nash Summer Camp at the Boys & Girls Club of Greater Nashua!

We are elated that your family has chosen our Camp to serve your child for this year’s summer vacation! Ohana- Nash Summer Camp is available for children in grades K-6th. We are committed to providing a safe, inclusive and fun environment for our Campers, and are excited to welcome campers back and to meet new friendly faces. We are aiming for our best summer yet!

Please carefully read through and fill in the registration form below. If you have any questions or concerns, please do not hesitate to contact the Boys & Girls Club of Greater Nashua so that we may provide you with any additional information. We look forward to serving your family!

Welcome to Summer 2022

Camper Registration Information

Camper's Name

Camper's DOB

Camper's Age

Camper's Gender

Camper's Club Member Number

Camper's Grade

Camper's School

Parent Guardian 1

Parent Guardian 1 Name

Cell Phone

Work Phone

Parent Guardian 2

Parent Guardian 2 Name

Cell Phone

Work Phone

In the event that either parent or guardian(s) cannot be contacted, please contact:

Name

Phone Number

Authorization to Dispense Medication, Prescription & Non-Prescription (if applicable)

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Parent Guardian Name

give permission to the staff of Camp Ohana-Nash to administer the following medication(s) to my child

Child's name

MEDICINE MUST BE IN ITS ORIGINAL CONTAINER WITH YOUR CHILD'S NAME AND DOSAGE ON IT!

Name of Child:

Prescribing Physician (when applicable)

Physician's Phone Number

Name of Medication

Dosage Amount

When to administer

Continue medication until

Parent Guardian Initials,

I will provide Camp Ohana-Nash a physician's signature for the above medication to be dispensed:

Self-Declaration of Information

Federal regulations require that we obtain this information to document assistance that is being provided to low and moderate-income households. Parents or guardians should complete this form indicating all persons residing within their household, regardless of whether or not they are related. Information provided on this form is kept confidential and is not shared with any other agencies.

Ethnicity

Hispanic or Latino
Not Hispanic or Latino

Race

Household Type

Parent and Parent
Parent and Step Parent
Grandparent
Mother Only
Father Only
Other

Total number of people in your household:

Household income:

Check here if unemployed

Parent / Guardian Consents and Agreements: Please read each statement thoroughly, and type your name below each statement to confirm understanding.

I understand that the Boys & Girls Club of Greater Nashua expects all campers to abide by a set of appropriate rules designed to protect the safety and enjoyment of all campers. When necessary, the Boys & Girls Club of Greater Nashua reserves the right to suspend a camper from immediate or future attendance. Suspensions due to Club member behavior will result in forfeiture of all paid current weekly fees.

First Name *

Last Name *

Payment refunds, credits or transfers must be made at least one week prior to the start of the camp session. If a camper cancels 21 days prior to camp, a full refund may be given. If canceling 14 days or more prior to camp, a $15 administrative fee will be assessed per camper. If canceling less than seven days prior to the start of the camp week, no refund will be given. No refunds or credits will be given after the camp week has started. Please be advised that there will be no refund for missed days.

First Name *

Last Name *

Credit Card, Debit Card, Personal check, cash and money order will be accepted for camp payments. Initial registration must be done in person. A $20.00 fee will be assessed on all returned checks. Parents should keep receipts on file, as the Boys & Girls Club of Greater Nashua does not prepare year-end statements of fees paid.

First Name *

Last Name *

The Boys & Girls Club licensed exempt program is for youth ages 8-18 years old designed to provide afterschool program opportunities in three core program areas; academic success, good character & citizenship, and healthy lifestyles. The license exempt program will occur at the Boys & Girls Club facility at One Positive Place, as well as other collaborative program locations. I understand that the program is not a license child care program and children participating in the program have the right to come and go from the program and that employees will encourage, but cannot force, children to stay.

I give consent for any photographs or video in which my child may appear to be used in any way that Club staff may care to use them.

I understand the rules of the Club and request that my child be admitted into membership. I have explained the rules to my child and understand that the Club will not be responsible for any accident to my child on the premises or while engaged in any of its activities aware from the Club.

“Rules for acceptance and participation in the program are the same for everyone without regard to race, color, age, sex, handicap or national origin.”

First Name *

Last Name *

Optional Social and Emotional Wellness Services:

The Boys & Girls Club of Greater Nashua promotes and advocates for our members’ social and emotional wellness. Through grant funding and collaboration with community partners, the Boys & Girls Club of Greater Nashua has licensed clinicians and counselors on staff to provide support to our Club members at no cost to our Club families. Not signing this section indicates that you allow your child to receive counseling services.

If you do NOT want your child to be provided this free counseling service, please sign and date:

First Name *

Last Name *

Billing Information and Payment Authorization Form

Auto Debit Start Date

Amount per Cycle (Weekly)

Our billing cycle is every week, on the Monday of the week your child is receiving services, for as long as your child is enrolled. I hereby authorize the Club to initiate credit entries and if necessary, to initiate any debit entries to correct erroneous credit entries to my account indicated below and the financial institution indicated below. This authority is to remain in full force and effect until the Club has received written notification from me (or either of us) of its termination in such time and in such manner as to afford the Club and depository a reasonable opportunity to act on it.

Card Holder Name

Cardholder Address

Cardholder Phone Number

Cardholder Email

Card Type

Visa
Master Card

Credit Card Number

Credit Card Expiration Date

3-Digit Security Code

Payments will be deducted automatically on the Monday you are receiving camp services. Funds must be in the listed account by the close of business on Monday. In the event the payment is declined, another payment will be charged the NEXT business day. A second decline requires immediate action for your child to continue in our program.

2022 Payment Dates:

6/27/2022; 7/5/2022; 7/11/2022; 7/18/2022; 7/25/2022; 8/1/2022; 8/8/2022; 8/15/2022; 8/22/2022

All payments will be deducted WEEKLY. Funds must be available on these dates to avoid fees for insufficient funds. Fees will be charged to the account on file unless written notice of termination is submitted in writing to Christine Lessard, Sr. Manager, Club Operations at clessard@bgcn.com.

I have read and fully understand the above policies.

First Name *

Last Name *

Date

Camper Emergency Information

Camper's Name

Camper's Known Allergies:

Camper's Medications

Parent / Guardian 1 Name

Identifying Information for Parent/Guardian legally responsible for child:

Parent / Guardian 1 Cell Phone

Parent Guardian 1 Work Phone

Parent Guardian 1 Address

Parent Guardian 1 Email

Parent Guardian 2 Name

Parent Guardian 2 Cell Phone

Parent Guardian 2 Work Phone

Parent Guardian 2 Address

Parent Guardian 2 Email

Emergency Contact Person:

You (parent/guardian) are required to list at least one person with whom you would feel comfortable leaving your child, and who could assume responsibility if you could not be reached immediately in an emergency or if for some reason you could not pick up your child and were unable to communicate with the Camp.

Emergency Contact 1 Name

Relationship to Camper

Emergency Contact 1 Best Phone Number

Emergency Contact 1 Address

Emergency Contact 2 Name

Relationship to Camper

Emergency Contact 2 Best Phone Number

Emergency Contact 2 Address