1. 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? YesNo 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: _______ WeekDates(ASES)(Regular) Week 1June 10 – 13 th $10$80 Week 2June 16 – 19 th $10$80 Week 3June 23 – 26 th $10$80 Week 4June 30 – July 3 rd $10$80 Week 5July 7 – 10 th $10$80 Summer School Program at Disney 12:00 – 6PM Week 6July 14 – 18 th $10$80 Week 7July 21 – 25 th $10$80 Week 8July 28 – Aug 1 st $10$80 Week 9Aug 4 – Aug 8 th $10$80 Week 10Aug 11 – 15 th $10$80 Week 11Aug 18 – 22 nd $10$80 Day Camp at the Clubhouse is based on a “First Come First Serve Basis” 7AM – 7PM Total Due: $_______ Payment may be made in full now or you may pay each Monday.

2. Boys & Girls Club of Burbank Summer Camp Is your child an ASES Member? YesNo 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: _______ WeekDates(ASES)(Regular) Week 1June 10 – 13 th $10$80 Week 2June 16 – 19 th $10$80 Week 3June 23 – 26 th $10$80 Week 4June 30 – July 3 rd $10$80 Week 5July 7 – 10 th $10$80 Summer School Program at Washington 12:00 – 6PM Week 6July 14 – 18 th $10$80 Week 7July 21 – 25 th $10$80 Week 8July 28 – Aug 1 st $10$80 Week 9Aug 4 – Aug 8 th $10$80 Week 10Aug 11 – 15 th $10$80 Week 11Aug 18 – 22 nd $10$80 Day Camp at the Clubhouse is based on a “First Come First Serve Basis” 7AM – 7PM Total Due: $_______ Payment may be made in full now or you may pay each Monday. 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: __________________________