2017 SUMMER CAMP PACKET

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Contacting Staff and Campers During Camp:

If you need to get information to the staff about your child during the camp day, call 203-438-8821 ext. 10 and leave a message on the voicemail. We retrieve messages from this voicemail at 9am, noon and 4pm. If your message is urgent or you need to speak to your child directly, call the camp cell phone at 203-501-6051. If we do not answer the cell phone, please leave a message and we will call you back.

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Contents

What to Bring and Wear to Camp ............................................ 4

Daily Procedures for Attending Camp ...................................... 5

Payment Procedures for Camp ................................................ 6

Medical Policies and Procedures ............................................. 7

Behavior Management Policy .................................................. 8

Camp Schedule and Hours ....................................................... 9

2017 Summer Camp Sample Schedule ...................................................... 9

Aquatics ................................................................................ 10

Camp Groups, Activities & Program Areas ............................. 11

Food & Refreshments ............................................................ 12

Lunch Schedule .......................................................................................... 12

Snack Shack & Ice Cream Café ............................................................... 12

In-Town Lunch - Thursdays ..................................................................... 13

Summer Camp Activities 2017 ............................................... 15

Authorization for the Administration of Medication ............. 18

Sunscreen Application and Off-Site Permission Form ............ 19

Sunscreen Opt-out Form ....................................................... 20

Credit Card Authorization Form ............................................. 21

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What to Bring and Wear to Camp

Items to Bring to Camp Each day your child should bring a backpack with the items they need for camp. Included in the backpack should be the following:

• Sunscreen

• Lunch/snacks

• Water Bottle

• Bathing suit

• Towel

The campers will have a designated area to keep their belongings throughout the day, and along with their counselor, it will be their responsibility to maintain this area. It is very important for your child’s personal belongings to be labeled so they do not get lost.

Lost and Found We will display the items left behind on a table in the front lobby so that they may be easily identified and retrieved. We bring items to Goodwill on a weekly basis. Please be sure to check lost and found regularly.

Personal Electronic Devices and Toys Personal electronic devices and toys are not permitted at camp. If they are brought to camp, staff will hold these items and return them at the end of the day.

What to Wear to Camp Camp is very active and all campers should be dressed to participate in the activities of the day. Comfortable shorts or pants and tee shirts are ideal for campers to wear each day. Campers must wear a closed toe shoe to camp each day. Sandals such as Keens or crocs that have a closed front foot are acceptable. Flip-flops, slides or other shoes that have an open toe should not be worn to camp; campers may bring these in their backpacks to wear on the pool deck only.

Sunscreen We suggest that campers apply sunscreen in the morning before arriving at camp. Our Staff will remind campers to apply sunscreen several times throughout the day especially before swim time. You must provide sunscreen for your child on a daily basis. The Club staff will work with all campers to ensure proper usage. We do have sunscreen on campus for certain situations, such as if a child forgets his or her sunscreen or runs out. The active ingredients in the sunscreen are listed at the back of this packet on the Sunscreen Opt-out Form (page 20) which includes an option to request that your child NOT have sunscreen applied by staff. The Sunscreen Application and Off-Site Permission Form (page 19) gives staff permission to assist with the application of sunscreen. If you prefer that your child not use our sunscreen for any reason, you must complete the Sunscreen Opt-out Form.

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Daily Procedures for Attending Camp

Drop-off Because we do not have parking for all campers’ families in our main parking lot, our driveway is designed to allow parents to pull in, stop at the designated stop, and drop-off and pick-up their children without leaving their cars. The vehicles travel in a circular pattern. Our staff is available in the driveway to help locate your children, and to help facilitate their arrival and departure. Please pull all the way forward to allow for more cars to enter the driveway. Please turn off your car while waiting. We have adopted a no-idling policy to help with air quality.

Pick-up Our daily schedule is structured to facilitate pick up from camp beginning at 4:00 pm. All campers will be out of the pool by 3:45 pm allowing them to change and be ready for pick-up. Even with proper scheduling it can sometimes take time for campers to collect their things and get to the car. If you need to be somewhere following pick-up, please allow adequate time for this process. If you arrive for pickup prior to 4:00 pm, campers will be in structured activities on the Boys & Girls Club campus. Please allow for additional time as your child may not be ready quickly. Campers must be picked up by 5:00 pm (or 6:00 pm if they are registered for late pick-up). We allow for a 15 minute grace period. After the grace period, families will be billed $1 per minute that they are late. Please make every effort to pick–up on time.

Check-In Upon arrival each morning it will be the camper’s responsibility to check-in at our designated spot located outside the front entrance. They will then proceed to their designated area to check-in with their group leader. We have additional staffing at the check-in area to assist younger campers with the check-in process. This allows them to check in without assistance from a parent or guardian. This helps parents to use the driveway drop off without concerns for assisting with the check-in process. Campers who are not pre-registered will need to pay for camp at check in and will be charged an additional fee for same-day registration. Payment for lunch can be made in the morning upon check-in.

Parking If you need to come into the Club, please park in a designated parking spot. Do not leave a car unattended in the circle. If the parking lot is full, parking is available in the municipal parking lot adjacent to the Club parking lot on Governor Street.

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Payment Procedures for Camp

Making Timely Payments / Credit Card Authorization Payment for camp is due prior to the start of each weekly session. Please make every effort to have your balance paid off by the Thursday prior to the start of your child’s camp session. If your child is a full summer camper, please have the equivalent of a week paid by the Thursday prior to each new week. For instance, if your child is attending camp the week beginning Monday July 10, payment should be made by Thursday July 6. In order to assure camp balances are paid in full; all registrations that are made with a partial payment will require a credit card authorization form. This form is included in this packet. All camp balances not paid in full will be charged on the authorized credit card after September 1st. The form must be completed for your child to attend camp. Payments may be made online, by mail or in person via check or credit card. Parents/Guardians of campers who attend camp and have not paid will be contacted by our Office & Finance Manager for payment.

Registration and Fee Policy 2017 A deposit must be made on every registration in order to hold your child(ren)’s place at camp. All deposits are non-refundable. Camp fees must be paid prior to your child’s first day of camp. Full Summer campers must have the current week paid. All campers should be registered for camp before the Friday prior to the following week’s camp. Late pick up fees for parents who do not arrive to pick up their child on time will be billed weekly. If you have any questions about this policy, please contact the Office & Finance Manager, Gerry Hawaux at ext. 16.

Scholarships Because of the generosity of our donors, camp scholarships are available. Families in need of assistance should request a scholarship prior to attending camp. Contact the Office & Finance Manager at ext. 16 or email ghawaux@bgcridgefield.org for an application.

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Medical Policies and Procedures

The safety of campers is a top priority for the Boys & Girls Club summer camp program. Our camp meets or exceeds all standards set by the Connecticut Licensing requirements. The following medical procedures are in place to assure the appropriate support of summer programs.

Medical Supervision The Boys & Girls Club Summer Camp Physician is Dr. David Pazer. Dr. Pazer is not on-site during summer camp but provides oversight in our preparation for camp and is on-call as needed for consultation.

Medical Training of Staff All Directors and year-round professional staff are trained in CPR /AED (Automatic External Defibrillator) for the Professional Rescuer and First Aid. They are also trained in the administration of oral medications, topical medications, inhalants and epi-pens. All Age Group Leaders, Counselors and Assistant Counselors are trained in CPR/AED and First Aid.

Administration of Medications Any child requiring the administration of medication (either daily or in emergency situations) must have an Authorization for the Administration of Medication form (included in this packet) on file. These forms (and medications) must be filed yearly and must be turned in before your child’s first day of camp. Medications must be in the original container and labeled with the child’s name, name of medication, directions for the medication’s administration, and date of the prescription. All unused medication will be destroyed if not picked up within one week following the camper’s departure at the end of camp. For more information, contact Kristin Goncalves, Director of Operations, ext. 17. Medications will only be administered by Directors or full-time year-round staff members.

Injuries Requiring Medical Attention Adequate and appropriate supervision is provided at all times at the camp, however, accidents and injuries can still occur. In the event that an injury occurs during camp, staff (including volunteers) will attend to the child. If the injury warrants further immediate medical attention, every effort will be made to contact a parent or guardian. If efforts to contact parent/guardian are unsuccessful, the staff will take steps to take the child to a physician, dentist or hospital. Please be sure to provide complete contact information when registering your child for camp. If you are currently in the online registration system please review your contact information and make sure that it is accurate and complete. Please be sure to include appropriate daytime phone numbers. Injuries that require minor treatment will be reported to a parent/guardian at the end of the camp day.

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Behavior Management Policy

Behavior Skill Building Camp provides a great opportunity for all children to develop skills and self-confidence. Our camp behavior policy is intended to help all campers be their best while treating fellow campers, staff and volunteers with respect. Each day campers will be assigned to a camp group and will attend morning meeting to review their schedule and their responsibilities. Campers must remain with their group or in areas designated for their group while at camp and follow the direction of their counselors.

Zero Tolerance We do not tolerate stealing, bullying, foul language, wandering from your group, or causing physical harm to others. We reserve the right to remove your child from our camp program without refund if these behaviors are identified and not corrected by your child.

Sit-out and Redirection Techniques for handling disciplinary problems will be addressed by the Youth Development Professional staff with the guidance of the Camp Director. A camper will sit out of an activity and could have a loss of privileges as the first steps to manage behavior. They will then be redirected to an activity that will positively channel the child’s energy. An apology by the camper is expected immediately when problem behaviors occur.

Contacting Parents The decision to contact a parent will be made once a determination has been made whether or not the camper exhibited an effort to correct his/her behavior. Parents will be notified when a camper has been warned about repeated offenses, and will be given a final opportunity to remain in camp. Continued inappropriate behavior will result in the dismissal from camp without a refund.

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Camp Schedule and Hours

Daily Activities The regular camp day begins at 8:00 am and runs through 5:00 pm. Extended day registration is available from 5:00 pm – 6:00 pm daily. Campers remain in low-structured, supervised activities until their morning meeting at 9:30 am. This allows for the arrival of campers prior to the commencement of structured activities. At 4:00 pm campers will transition to low structured activities in order to prepare them for pick-up by parents by 5:00 pm. Extended day campers will remain in low-structured supervised activities and/or swim time until pick-up by 6:00 pm.

2017 Summer Camp Sample Schedule

8:00 am – 9:30 am Camp Arrival - low structured activities

9:30 am – 9:45 am Group Meeting, Camp Assembly & announcements

9:45 am – 10:30 am Swim Team/group activities

10:30 am – 11:15 am AM Swim Time/group activities

11:45 am – 12:15 pm Lunch (Minis, 1, 2)/Swim Time Group 3 and 4

12:15 pm – 12:45 pm Lunch (group 3 and 4)/group activity (Minis, 1, 2)

12:45 pm – 1:45 pm Afternoon ½ day campers arrive/group activities

1:45 pm – 2:45 pm PM swim time/ group activities

2:45 pm – 3:45 pm PM swim time/ group activities

4:00 pm – 5:00 pm Camp Departures

5:00 pm – 6:00 pm Extended Day Activity Period & Departures

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Aquatics

Safety is the number one priority of the staff on the pool deck at all times. All of our head counselors, and many of our directors, are certified lifeguards. Coverage on the Pool Deck Lifeguards and a director are on the pool deck at all times during camp. The Age Group Leaders and Counselors accompany their groups to their swim time. Many of our counselors are cross-trained as lifeguards. Swimming during the camp day On regularly scheduled camp days, all groups have designated swim times in the morning (approximately an hour) and the afternoon (approximately an hour and 15 minutes). Minis, Group 1, and Group 2 swim together, and Groups 3 and 4 swim together. As an extra precaution, our Mini and Group 1 members are only permitted to swim in the shallow end of the pool, and are accompanied in the water by our Leaders-In-Training, as well as our junior counselors. Group 2, 3 and 4 members can swim in the deep end of the pool after successfully passing our Swim Test. Our swim test consists of being able to swim one length of the pool without stopping, and being able tread water in the middle of the pool for 30 seconds and then successfully swimming back to the edge of the pool unassisted. The swim test is administered by the Group Director, with the assistance of our Head Lifeguard. Personal Flotation Devices We understand that many of our young members use Personal Flotation Devices (PFDs) as an extra precaution, however, we only allow PFDs that are Coast Guard Approved. For more information on PFDs please visit the United States Coast Guard website at http://www.uscg.mil/hq/cg5/cg5214/pfdselection.asp#selection. Personal items We do not permit our members to bring their own water toys, including noodles, water guns, diving rings or sticks, balls, and water baseball bats, as they are a distraction in the pool, and often end up lost. Our staff works hard to come up with new activities and events on the pool deck every day, ranging from Marco Polo to Cannonball contests. Please remember to label your child’s swimming gear, particularly their goggles and towels. Our lost and found pile at the pool deck grows larger and larger by the day!

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Camp Groups, Activities & Program Areas The Boys & Girls Club summer camp program is a fun-filled extension of our year-round programming. Campers participate in a wide range of activities both indoors and out. Campers will have the opportunity to participate in swimming programs, arts & crafts, sports and recreation all summer. Youth are encouraged to have fun while acquiring skills in physical, personal and social development.

Camp Groupings Campers are placed in groups by grade. We will make every attempt possible to place your child with peers and friends as long as appropriate.

Minis – entering 1st grade Group 1 – entering 2nd grade Group 2 – entering 3rd & 4th grade Group 3 – entering 5th & 6th grade Group 4 – entering 7th & 8th grade

Program Areas

The facilities at the Boys & Girls Club of Ridgefield include a full size gymnasium, a heated outdoor swimming pool, art room, indoor games room, soccer field, gaga pit, tetherball area, asphalt wiffle ball court and a raised bed garden.

Camp Activities Weekly themes make every week at camp different and exciting. Core activities like swimming, sports and art are always part of the camp schedule, but additional activities will be added to match the theme of the week. Daily Activities include but are not limited to: Art, Baggo, Basketball, Board Games, Capture the Flag, Card games, Coke-n-Pepsi, Dodge ball, Dominoes, Flag Football, Four Square, Gaga Pit, Kickball, Matt Ball, Nine Square, Soccer, Tug-o-War, Obstacle Course, Wiffle Ball, Relay Races, Tag, Painting, Swimming, Knockout, Shuffle Board, Parachute, Playground Fun, Ultimate Frisbee, and Volleyball.

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Food & Refreshments

Bringing and Purchasing Food Campers must bring lunch and snacks or purchase them from the Club daily. All groups will have a designated morning and afternoon snack time in their daily schedule. Lunch boxes will be stored in chilled coolers during the camp day. Campers’ lunch boxes should include an ice pack and be labeled with their name. Most parents understand their children’s eating habits better than we do. Please provide the appropriate number of snacks, drinks and lunch to get them through a hot summer day.

Lunch Schedule Monday – Grilled Cheese

Includes: Grilled cheese sandwich, a drink, and a snack (Village Pizza & Pasta) Tuesday – Pizza

Includes: One or two slices of pizza, a drink, and a snack (Village Pizza & Pasta) Wednesday – Cookout

Includes: Hotdogs or hamburgers, drink & snack (Ridgefield Prime) Thursday – In-town Lunch (need appropriate money) or bring your own lunch Friday – Pasta

Includes: Macaroni & cheese or pasta with marinara sauce, a drink, and a snack (Ridgefield Prime)

Snack Shack & Ice Cream Café The Snack Shack will be open daily in the afternoon for children to purchase healthy snacks. Snack Shack items range in price from $ .25 to $1.00. You may choose to deposit money in your child’s camp bank account to purchase snacks from the snack shack. The Ice Cream Café is a great addition to camp. The Ice Cream Café will open Monday and Wednesday afternoons. Ice Cream prices range from $1.00 to $3.00. Campers must have money with them for the Ice Cream Café; they cannot use money from their camp bank account. Campers are not permitted to borrow money from counselors or the Club to pay for ice cream.

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In-Town Lunch - Thursdays We use several of the local establishments that are willing to provide a low cost lunch for children. This is extremely popular with the kids and merchants in town. Children must cooperate with staff and behave appropriately at all times when we are in town. Campers who are not able to behave appropriately will lose the privilege of attending in-town lunch. Once a child loses this privilege, they will be required to bring their own lunch and eat at the Club. Children who bring their lunch will remain on campus. Thursday lunch options include Steve’s Bagels, Planet Pizza, Village Deli, Chez Lenard’s Hot Dog Cart, and Subway. The campers will also stop at Deborah Ann’s following lunch. In-Town Lunch on Thursdays is a very popular event with campers. YOUR CHILD MUST BE AT CAMP BY 10:00 AM ON THURSDAYS if they wish to participate. This allows us to prepare our rosters to take everyone safely into town. If your child is not able to be at the Club by 10:00 am, please provide them with lunch. We do not provide lunch on Thursdays. Campers who do not go into town are able to relax at the Club, participate in activities and eat lunch while other campers are in town. Please be sure to provide your child with enough money to purchase lunch and drinks in town. We recommend $10. Campers are not permitted to borrow money from counselors or the Club to pay for food in town.

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2017 Summer Camp Staff

Title Name Age BGCR

years exp Prof. Affiliation / School

Camp Director Mike Flynn 37 16 Boys & Girls Club of Ridgefield, Executive Director

Medical & Aquatics Director Kristin Goncalves 32 9 Boys & Girls Club of Ridgefield, Director of Operations

Asst. Camp Director Jess Murphy 28 6 Boys & Girls Club of Ridgefield, Program Director

Office & Finance Manager Gerry Hawaux 56 10 Boys & Girls Club of Ridgefield, Office & Finance Mgr.

Facilities Manager Ed Flynn 69 11 Boys & Girls Club of Ridgefield, Facilities Manager

Age Group Director Jeff Goncalves 26 6 Boys & Girls Club of Ridgefield, Program Coordinator

Age Group Director Devon Lawrence 25 3 Boys & Girls Club of Ridgefield, Program Coordinator

Asst. Camp Ops. Becky Rosevalt 28 6 Boys & Girls Club of Ridgefield, Youth Development Staff

Asst. LIT Manager Joe Haskins 24 2 Boys & Girls Club of Ridgefield, Youth Development Staff

Age Group Leader Triston Philip 22 8 Boys & Girls Club of Ridgefield, Youth Development Staff

Age Group Leader Alyssa Alt 23 7 Boys & Girls Club of Ridgefield, Youth Development Staff

Age Group Leader Tim Cozens 22 7 Springfield College, 2017 Graduate

Age Group Leader Dan Liddi 22 7 Southern CT State University, 2017 Graduate

Age Group Leader Christina Gramling 21 6 Bryant University

Age Group Leader Colm Hall 23 7 College of Wooster, 2016 Graduate

Age Group Leader Maria D’Jay 21 5 Villanova University

Age Group Leader Lily Parshenov 21 5 George Mason University

Counselor Rhys Hall 20 5 Johnson & Wales University

Counselor Nina Taubes 19 4 Fordham University

Counselor John Balsamo 19 4 Manhattan College

Counselor Lindsey Melagrano 19 4 Sacred Heart University

Counselor Nick Bryant 20 4 Lehigh University

Counselor Jack Hinds 19 4 Western Connecticut State University

Counselor Liam Greenan 19 4 University of Connecticut, Storrs

Counselor Mikhaela Miller 19 4 Salve Regina

Counselor Cameron Bittick 19 2 University of Alabama

Asst. Counselor Max Meyer 19 3 Northeastern University

Asst. Counselor Nick Laudati 18 2 University of Connecticut, Storrs

Asst. Counselor Grayson Platt 18 2 University of Connecticut, Stamford

Asst. Counselor Connor Bryant 18 2 Virginia Tech

Asst. Counselor Brianna Patricio 20 4 Boys & Girls Club of Ridgefield, Youth Development Staff

Art Teacher Molly Williams 20 2 American University

Camp Facilities Joe Coyle 20 4 University of Delaware

Asst. Camp Facilities Erick Villalta 20 3 Western Connecticut State University

Asst. Camp Facilities Shawnell Francois 19 3 Texas Southern University

Aquatics Manager Madison Damron 23 5 UCLA, 2016 Graduate

Head Swim Coach/Lifeguard Alex Damron 20 4 John Hopkins University

Lifeguard/Swim Instructor Steve Creedon 28 6 Town of Greenburgh Police Department

Lifeguard/Swim Instructor Erin Murphy 19 3 Sacred Heart University

Lifeguard/ Asst. Swim Coach Colin Hughes 18 2 Western Connecticut State University

Lifeguard/Swim Instructor Catalina Carmona 16 2 RHS

Alternate Director Tom DiMarzo 47 11 Scotland School 5th Grade Teacher, RHS Basketball Coach

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Summer Camp Activities 2017

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Authorization for the Administration of Medication

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Sunscreen Application and Off-Site Permission Form

Parent / Camper Agreement The______________________ family has reviewed the information stated throughout the Summer Camp Packet. By signing this agreement, we understand the policies and procedures that are in place at the Boys & Girls Club of Ridgefield Summer Camp. I have discussed and reviewed the packet with my child(ren) and our family is excited to attend the Boys & Girls Club Summer Camp.

Scheduled Field Trip, Off-site locations and Transportation I, the parent/guardian of the child(ren) listed below, understand that the scheduled field trips or off-campus activities occur during summer camp at locations specified in field trip announcements. Scheduled field trips will leave the Club at approximately 9:00 am and will arrive back at the Club at approximately 4:00 pm. I understand that on Thursdays campers will walk to town with camp staff for lunch. I also understand that campers will use the Veteran Park Fields which are not part of the Boys & Girls Club campus. Occasionally, there may be opportunities to participate in activities within walking distance of the Club without making plans ahead of time.

I understand transportation to the field trip location will be by walking, or via transportation in the Boys & Girls Club bus, school bus, or coach bus.

Release Statement I hereby grant permission for my son/daughter to participate in field trips and off-site activities. I understand that adequate and appropriate supervision will be provided. I recognize, however, that unanticipated situations and problems can arise on any trip. I further agree to release and hold harmless the Boys & Girls Club of Ridgefield, its agents, officers, and volunteers, from any and all liability, claims, suits, demands, judgments, costs, interests, and expenses (including attorneys’ fees) arising from such activities including any accident or injury to the child and the medical costs.

In the event of an injury requiring medical attention, I hereby grant permission to the supervising staff (including volunteers) to attend to my child. If the injury warrants further medical attention, I expect every effort will be made to contact me to receive authorization before action is taken. If efforts to contact me are unsuccessful, I grant permission for necessary medical treatment to be given to my child. In addition, I hereby give permission to the staff (including volunteers) to take my child to the physician, dentist, or to the hospital if an accident or serious illness occurs on the trip and I cannot be located. In the event that a student must return to the Club independently for reasons of health, accident, failure to conform to rules established by the staff member in charge, etc., I agree to accept full responsibility for and pay for the cost of medical care, transportation and other incidental expenses.

Application of Sunscreen I am completing the Sunscreen Opt-out form.

I give permission for the Camp Group Leader or other designated Boys & Girls Club staff member to assist my child with his/her application of sunscreen to exposed skin, including but not limited to the face, tops of ears, neck, shoulders, arms, legs and feet. I understand that the application of sunscreen will take place twice daily. Sunscreen will not be applied to any broken or irritated skin. I will be notified if my child develops a skin reaction. If I do not want sunscreen applied to my child I must submit the Sunscreen Opt-out form on page 20 of the Summer Camp Packet. It is my responsibility to provide sunscreen with a SPF of 15 or higher. In the event that my child does not have sunscreen with him/her, the camp may apply Rocky Mountain SPF 30 Broad Spectrum Sunscreen. I have reviewed the active ingredients listed on the Opt-out form and am not aware that my child is allergic to these ingredients.

Child’s #1 Name: (Print) __________________________________________________

Child’s #2 Name: (Print) __________________________________________________

Child’s #3 Name: (Print) __________________________________________________

Parent/Guardian: (Print) __________________________________________________

Parent/Guardian Signature ________________________________________________

Home Ph: ___________________ Cell Ph: ___________________ Work Ph: __________________

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Sunscreen Opt-out Form I do not give permission for the Camp Group Leader or other designated Boys & Girls Club staff member to assist my child with his/her application of sunscreen to exposed skin, including but not limited to the face, tops of ears, neck, shoulders, arms, legs and feet. It is my responsibility to provide sunscreen with a SPF of 15 or higher. I have reviewed the active ingredients listed below and my child may NOT use any sunscreen other than the one that he/she brings to camp. (Sunscreen bottle must be labeled with child’s first and last name in permanent ink). Date signed: _______________ (Good from June 26 to August 18, 2017 only) Name of camper(s): _____________________________________ Parent/Guardian Signature: _____________________________________ Rocky Mountain Sunscreen SPF 30 Broad Spectrum Hypoallergenic and Fragrance Free Ingredient Listing Active Ingredients: Avobenzone 3.0% Homosalate 10.0% Octisalate 5.0% Octinoxate 7.5% Oxybenzone 4.0% Inactive Ingredients: Acrylates/C10-30 Alkyl Acrylate Crosspolymer, Aloe Barbadensis Leaf Juice, Benzyl Alcohol, Carbomer, Cetyl Alcohol, DEA-Cetyl Phosphate, Disodium EDTA, Hydrogenated Polyisobutene, Stearic Acid, Triethanolamine, Water

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Credit Card Authorization Form

All information will remain confidential.

Cardholder Name (as printed on card):

___________________________________________

Billing Address (for credit card below):

___________________________________________

___________________________________________

Credit Card Type: _____ Visa _____ MasterCard _____ Amex

Credit Card Number: ___________________________________________

Expiration Date: ___________________________________________

Card Identification Number (4 digits located on front of Amex; 3 digits located on back of Visa and MasterCard): ________

I authorize the Boys & Girls Club of Ridgefield to charge any unpaid balance for Summer Camp 2017 to my credit card provided above (on or after September 1, 2017). Cardholder – Print Name, Sign and Date Below:

Signed: ___________________________________________

Dated: ___________________________________________

Printed Name: ___________________________________________

Child’s Last name ___________________________________________

41 Governor Street, Ridgefield, CT 06877 Tel (203) 438-8821 Fax (203) 438-0676 Web www.bgcridgefield.org