2015 Summer Registration Form Address: City ______

Wellington Unit
970-568-7338
2015 Summer Registration Form
This application is required for your child/ren to attend the summer program at the Wellington Unit. Due to
capacity limits, space for your child/ren will be based on submission of this form on a first-come/first-serve
basis. Should we reach capacity, your child’s name will be put on our waiting list and we will let you know as
space becomes available. No additional fees will be charged for the summer months. Please consider a
donation to the Boys & Girls Clubs to help support our programs! See below for more information.
Membership must be current and paid in full in order to participate.
The Summer Program is offered, Monday – Friday, 10a.m-6:00 p.m.; June 2 through August 14, 2015
June 1st will serve as an summer orientation day.
Parent/Guardian Full Name ________________________________________________________________
Address: ______________________________________________________________________
City ________________________________ State _____________ Zip code ________ _______
Daytime Phone Number: _________________________________________________________
Email Address: _________________________________________________________________
PLEASE CIRCLE OPTION FOR DROP-OFF TIME AND DAYS OF WEEK NEEDED FOR EACH CHILD BELOW:
1st Member Full Name_______________________________ Member No.____________
Drop-Off Time: 7:30am-9am
9am-11am
11am-2pm
2pm-close
Days of Week: M
T
W Th
F
2nd Member Full Name_______________________________ Member No.____________
Drop-Off Time: 7:30am-9am
9am-11am
11am-2pm
2pm-close
Days of Week: M
T
W Th
F
3rd Member Full Name_______________________________ Member No.____________
Drop-Off Time: 7:30am-9am
9am-11am
11am-2pm
2pm-close
Days of Week: M
T
Check here if you have listed additional family members on the back of this page
W Th
F
□
□In order to assist with club operation and programming costs, I am including my taxdeductible donation of $_________ (Boys & Girls Clubs annual operational cost per child is around $500)
Parent/ Guardian Signature_______________________________
Office Use Only
Date Received:
Staff Initials:
Date_______________
Donation Amt Rec’d