Camp Crosby Summer 2022 Registration

Boys & Girls Club of East Providence

115 Williams Ave

East Providence, RI 02914

www.epbgc.org

Camp hours 8:30AM-4:15PM

Before and After Camp available for an additional fee 6:30AM-8:30 AM and 4:15 PM - 5:45PM

Please read parent handbook for all of our policies and procedures. This can be downloaded here.

Please be sure to send your child with water.

If your child will be attending Hennessey School in September do not fill this form out. Instead click here and fill out the Hennessey Scholar Camp - Camp Crosby registration form. If you fill this form out you will not be able to access special pricing made possible by our 21st CCLC grant

Camp Registration

Capacity at Camp Crosby will be limited. Once capacity has been reached we will be starting a waiting list. If no spots are available for the session you would like to register for and would like to be added to the waiting list, please check the box for the waiting list you would like to be added to. *

Session 1 June 27 - July 8 (Closed July 4) (45 remaining)

Session 2 July 11-July 22 (35 remaining)

Session 3 July 25-August 5 (38 remaining)

Session 4 August 9 - August 19 (closed August 8) (37 remaining)

Waiting list Session 1 June 27 - July 8

Waiting list Session 2 July 11-July 22

Waiting list Session 3 July 25-August 5

Waiting List Session 4 August 9 - August 19 (closed August 8)

Do you need Before Camp Care? You will choose what you need for each session in the next step *

Yes

No

Do you need After Camp Care? You will choose what you need for each session in the next step *

Yes

No

Session 1 Before and After Camp Registration

Before camp care is available beginning at 6:30 AM Price for before and after camp care is $25 per two week session and space is limited. Please check here if you need before and after camp care. If you receive state assistance, this fee will be covered if you qualify for full time care.

Before Camp Care Session 1 June 27 - July 8 (5 remaining)

Waiting List - Before Camp Care Session 1 June 27 - July 8

After camp care is available until 5:45PM. Price for before and after camp care is $25 per two week session and space is limited. Please check here if you need after camp care. If you receive state assistance, this fee will be covered if you qualify for full time care.

After Camp Care Session 1 June 27 - July 8 (0 remaining)

Waiting List - After Camp Care Session 1 June 27 - July 8

Session 2 Before and After Camp Registration

Before camp care is available beginning at 6:30 AM Price for before and after camp care is $25 per two week session and space is limited. Please check here if you need before and after camp care. If you receive state assistance, this fee will be covered if you qualify for full time care.

Before Camp Care Session 2 July 11 - July 22 (3 remaining)

Waiting List - Before Camp Care Session 2 July 11 - July 22

After camp care is available until 5:45PM. Price for before and after camp care is $25 per two week session and space is limited. Please check here if you need after camp care. If you receive state assistance, this fee will be covered if you qualify for full time care.

After Camp Care Session 2 July 11 - July 22 (0 remaining)

Waiting List - After Camp Care Session 2 July 11 - July 22

Session 3 Before and After Camp Registration

Before camp care is available beginning at 6:30 AM Price for before and after camp care is $25 per two week session and space is limited. Please check here if you need before and after camp care. If you receive state assistance, this fee will be covered if you qualify for full time care.

Before Camp Care Session 3 July 25- August 5 (2 remaining)

Waiting List - Before Camp Care Session 3 July 25- August 5

After camp care is available until 5:45PM. Price for before and after camp care is $25 per two week session and space is limited. Please check here if you need after camp care. If you receive state assistance, this fee will be covered if you qualify for full time care.

After Camp Care Session 3 July 25- August 5 (0 remaining)

Waiting List - After Camp Care Session 3 July 25- August 5

Session 4 Before and After Camp Registration

Before camp care is available beginning at 6:30 AM Price for before and after camp care is $25 per two week session and space is limited. Please check here if you need before and after camp care. If you receive state assistance, this fee will be covered if you qualify for full time care.

Before Camp Care Session 4 August 9 - August 19 (2 remaining)

Waiting List - Before Camp Care Session 4 August 9 - August 1

After camp care is available until 5:45PM. Price for before and after camp care is $25 per two week session and space is limited. Please check here if you need after camp care. If you receive state assistance, this fee will be covered if you qualify for full time care.

After Camp Care Session 4 August 9 - August 19 (0 remaining)

Waiting List - Before and After Camp Care Session 4 August 9 - August 1

Participant Information

Please note that you must fill this form out for each child you are registering.

First Name *

Middle Name

Last Name *

Nickname

Birth Date * +

Gender *

Home Address *

City *

State *

Zip *

Phone *

Email *

Ethnicity *

School Attending September 2022 *

Grade in September 2022 *

Household / Contact Information

Primary Emergency Contact Name *

Emergency Phone Number *

Mother/Guardian First Name *

Mother/Guardian Last Name *

Mother's Occupation

Mother's Employer *

Mother's Work Phone *

Mother's Cell Phone *

Mother's Email *

Father/Guardian First Name

Father/Guardian Last Name

Father's Occupation

Father's Employer

Father's Work Phone

Father's Cell Phone

Father's Email

Individuals other than parents/guardians who are authorized to pick up child. Please include their phone number. Reminder anyone picking up should have their photo ID for staff to confirm their identity.

	First Name	Last Name	Phone Number	Emergency contact(Y/N)
Contact	First Name	Last Name	Phone Number	Emergency contact(Y/N)
Contact	First Name	Last Name	Phone Number	Emergency contact(Y/N)
Contact	First Name	Last Name	Phone Number	Emergency contact(Y/N)
Contact	First Name	Last Name	Phone Number	Emergency contact(Y/N)

Member Lives With *

Household Income *

Income frequency *

Does your child receive free or reduced lunch at school *

Yes

No

Do you receive SNAP benefits *

Is anyone in the household a member of the military or National Guard *

Yes

No

Health Information

Medical Problems/Allergies *

List ALL medications the child is taking *

Any restrictions of activity due to medical activity, if yes explain *

No

Yes Yes

Physician

Physician's Phone Number

Health Insurance Provider

Subscriber#

I would prefer that my child be taken to ________________Hospital. (Choice may be limited by local rescue service.) *

This health information is correct to the best of my knowledge and the person herein described has permission to engage in all prescribed activities, except as noted by me and the physician. I authorize the Boys & Girls Club of East Providence to arrange for medical examination and/or treatment of my child should an emergency arise in any Boys & Girls Club program. It is understood that every effort will be made to contact the emergency numbers provided before any medical action is taken. *

I agree

Acknowledgements

Childcare Handbook Acknowledgement I hereby acknowledge that I received and have reviewed the Boys & Girls Club of East Providence’s Childcare Parent Handbook. Childcare Handbook can be downloaded here *

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I understand that I am responsible for payment of all sessions that I have registered my child for and that no refunds are given except when disenrolling my child(ren) by giving advanced written notice by the Tuesday prior to the session they are registered for as outlined in the Camp Crosby Parent Handbook. *

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I understand that I must provide the Boys & GIrls Club of East Providence with a valid credit card or debit card number that will be charged as outlined in the parent handbook and that if the card is declined, my child's registration will be forfeited and filled with another child from the camp waiting list. *

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Safety Policies Acknowledgement I hereby acknowledge that I received the Boys & Girls Club of East Providence’s Child Safety Policies. The safety policies can be downloaded here Please type your name below to acknowledge *

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