Skip to main content

Summer Camp 2020

Registration Form

Summer Camp 2020 Registration Form

Complete the form below to apply for Summer Camp at DMBGC. The information you provide must be complete and accurate. The answers you provide will be kept confidential. This information is necessary to maintain funding, state compliance and records for Boys & Girls Club service. 

Please note:  Summer Camp spots are extremely limited. Submitting this application does not guarantee a spot in our program. After submission, DMBGC staff will contact you to complete your registration and notify you of placement in the program. 

Click here for more information about Summer Camp 2020.

Child Information
First Name
Middle Initial/Name
Last Name
Address Line 1
Address Line 2
Postal Code

Please note:  Children entering kindergarten are accepted on a case-by-case basis and they must have successfully completed a full-day preschool program. The Club will require written documentation from the program your child attended. 

Preferred Program(s)
Please select all Summer Camp Programs for which you are applying. All programs are open to all youth in Champaign County.

Parent/Guardian Information
First Name
Last Name
What additional questions do you have for us?

Movie Authorization
Age 6-11
Don Moyer Boys & Girls Club has my permission to allow my child to view children’s movies that are rated PG. These movies will be watched in advance by staff. (Examples: Despicable Me; Up; How to Tame Your Dragon)
Age 12-17
Don Moyer Boys & Girls Club has my permission to allow my child to view children’s movies that are rated PG-13. These movies will be watched in advance by staff. (Examples: Harry Potter, X-men)

Field Trip Permission
Field Trip Permission
Occasionally, members of the Don Moyer Boys & Girls Club are asked to participate in field trips. In order for proper planning, it is necessary for the Club to obtain parental permission. All precautions of safety and every consideration for your child’s welfare will be carefully exercised, although the Don Moyer Boys & Girls Club assumes no liability in connection with these field trips. If you want your child to participate in these trips throughout the membership, please express that desire below. Notification will be sent prior to each scheduled field trip.

Code of Conduct

I understand that I am responsible for reviewing the Code of Conduct with my child and will assist Don Moyer Boys & Girls Club in adhering to the principles of the Code of Conduct. 

The Code of Conduct is as follows: 

  • I will honor the DMBGC member code of conduct when I participate in all Club activities. 
  • I will be a law-abiding citizen. 
  • I will respect myself, fellow members, employees, and the facilities. 
  • I will have my coat, hat and book bag in the designated Club location. 
  • I will remain drug, alcohol and tobacco free at the Club. 
  • I will be responsible for all my personal belongings, including electronic devices. I agree that my electronic devices will not interfere with programming and will be used in a productive and positive way relative to my Club policies. 
  • I will use words that are respectful. 
  • I will report uncomfortable or dangerous behavior or touching. 
  • I will cooperate with all directions and requests by DMBGC employees. 
  • I will eat or drink only in designated areas and dispose of garbage properly. 
  • I will refrain from inappropriately touching other Club members. 
  • I will use only assigned Enter or Exit ways to enter or exit DMBGC. 
  • I will enter the Club and remain free of weapons, including those that resemble real weapons with peaceful intentions. 
  • I will refrain from intimate behavior. 

Exceptions to this Code of Conduct may be allowed based on the type of programming or specific rules of the Club. 

Code of Conduct

Release of Information

As the legal parent/guardian of the child listed above, I authorize the School District and/or educational institution my child attends to release the following information to the Don Moyer Boys & Girls Club: 

  • Grade Point Averages
  • Report Cards
  • Progress Reports
  • School Attendance
  • Behavioral Issues
  • IEP Plans
  • 504 Plans
  • Grade Advancement and Graduation Information
  • Communication between school staff (teacher, principal, social worker, etc) and authorized Don Moyer Boys & Girls Club Staff

This form shall be considered a valid release for all information indicated above. The data collected from the schools is intended for several grant and Boys & Girls Clubs of America requirements to assist in achieving academic success and to ensure that we are working closely with families, school and community. 

Release of Information

Participation Agreement

I understand that it is my responsibility to monitor my child’s participation in Club activities based on any physical or medical limitations that my child has that would inhibit his/her participation. I understand that Don Moyer Boys & Girls Club operates under an open door policy, therefore, it is my responsibility to monitor and provide transportation for my child to and from the Club. In the event of injury or should emergency care be required, I authorize Club staff to arrange for emergency medical attention for my child, only if I can’t be reached immediately.

I understand that my child may receive non-invasive physical exams and/or other types of assessments as a benefit of his or her membership. I give permission for my child to participate in surveys, discussion groups or other activities that help determine the success of Don Moyer Boys & Girls Club programs. I authorize Don Moyer Boys & Girls Club to obtain or share data related to my child for the purpose of program assessment. I authorize release of information from school about my child so the Clubs can best serve its members. I grant permission for photographs, audiotapes and records of my child to be used by the Club and its agents for public relations and/or program evaluation purposes on behalf of Don Moyer Boys & Girls Club. Don Moyer Boys & Girls Club has permission to receive and share information (for use of identifying program and opportunity needs) with agencies serving our members such as: United Way, Champaign & Urbana Public Schools.

Participation Agreement

Virtual Programming Consent

In an effort to continuously serve members during the Club closure, Don Moyer Boys & Girls Club is providing distance-based, virtual programming for Club members, through which Club staff will facilitate program activities through online platforms. Don Moyer Boys & Girls Club will use software, tools and applications provided by third parties that members, parents/guardians and/or staff will access via the Internet and use for purposes of communication and programming. These platforms include Zoom, Facebook and Youtube.  

This letter seeks consent for your child to utilize Zoom, Facebook and Youtube for distance-based Club program purposes. Please be aware that each application collects different information about its users and has its own privacy terms and conditions to which members must adhere. Please review these carefully before registering your Club member.

In order to participate in virtual Club programming, you will need to provide the following: 

  • A computer, tablet or smartphone with access to the Internet 
  • You may need to provide some customer data, including but not limited to your email address and first and last name, when registering for online platforms.

We will use online platforms for the following program activities:

  • We will use the Zoom software platform for group video chats, sharing projects, and program discussions.
  • Facebook and YouTube will be used to communicate upcoming live video program chats on Zoom and share activities and previously recorded program videos. 

Our commitment to keeping the young people we serve safe is always our number one priority. Don Moyer Boys & Girls Club will actively monitor member activity on these platforms and will make every effort to protect member information by, among other things, maintaining control of, and access to, the data collected; prohibiting re-disclosure of member information; limiting the purposes for which the online platforms may use member information; ensuring there is no advertising and that no member information is collected for commercial purposes.  

Further, all activities online must comply with Don Moyer Boys & Girls Club’s safety policies, including the Code of Conduct, which are available in the Parent Handbook.

Virtual Programming Consent
I give permission for my child to participate in distance-based online Club experiences at Don Moyer Boys & Girls Club.

Parent/Guardian Signature

I certify that the information provided in this application is correct. I understand that falsifying information is grounds for rejection of my application. 

First Name
Last Name

Our Impact

  • Youth Served Daily


  • Summer Membership


  • Teen Members


  • Volunteers


  • Broeren Russo
    Broeren Russo
  • Hickory Point Bank
    Hickory Point Bank
  • Ramshaw Real Estate
    Ramshaw Real Estate
© 2021 Don Moyer Boys & Girls Club
  • DMBGC Terms & Conditions

    DON MOYER BOYS & GIRLS CLUB ("DMBGC") and its services are subject to the following Terms of & Conditions ("T&C"). DMBGC reserves the right to update the T&C at any time without notice. By using this website, you acknowledge and agree to these limitations as set forth.
    DMBGC provides you with access to a variety of resources ("Services") including general information, message and/or communication facilities, downloads, and calendars, etc. and may include a Members Only section that can be accessed only by staff and members. The Services, including any updates, enhancements, new features, and/or the addition of any new web properties, are subject to the T&C.
    Use of this content (documents, whitepapers, graphics, logos, software, forums, polls, etc.) is for informational and non-commercial or personal use only. You may not modify any content, copy, distribute, transmit, display, perform, reproduce, publish, license, create derivative works from, transfer, post on any network, broadcast in any media or sell any information, software, products or services obtained from the Services unless expressly permitted by DMBGC. Elements of our website is protected by trade dress, trademark, unfair competition, and other laws and may not be copied or imitated in whole or in part. All rights in such materials are reserved to the respective owners.
    DMBGC makes no warranties or representations of any kind that the services provided by this website or any linked site will be uninterrupted, error-free, or that the site or the server that hosts the site are free from viruses or other forms of harmful computer code. All such information is provided "as is," and with specific disclaimer of any warranties of merchantability, fitness for a particular purpose, title, or non-infringement. In no event shall DMBGC, its agents, or anyone else who has been involved in the creation, production, or delivery of these pages, be liable for any direct, incidental, or consequential damages resulting from the use of this website or any linked site.
    With respect to goods or services purchased directly from DMBGC through the website, DMBGC's liability, in any case, is expressly limited to replacement of defective goods, or the repayment or crediting to you an amount equal to the purchase price of the goods, if DMBGC so chooses.
    Links to other websites do not imply an endorsement of the materials disseminated at those websites, nor does the existence of a link to another site imply that the organization or person publishing at that site endorses any of the materials at this site. Links to other websites are provided by DMBGC as a convenience to its users. DMBGC is not responsible for the materials contained at any website linked to this site.
    As a condition of your use of the Services, you will not use the Services for any purpose that is unlawful or prohibited by these terms, conditions, and notices. You may not use the Services in any manner that could damage, disable, overburden, or impair any DMBGC website, or interfere with any other party's use and enjoyment of the Services. You may not attempt to gain unauthorized access to any Services, computer systems or networks connected to any DMBGC server or to any of the Services, through hacking, password mining or any other means. You may not obtain or attempt to obtain any materials or information through any means not intentionally made available through the Services.
    The Communication Services may contain forums, calendars, and/or other message or communication facilities designed to communicate with you. You agree to use the communication services only to view and post messages and material that are proper and, when applicable, related to the particular communication service. By way of example, and not as a limitation, you agree that you will not:
    1. Use the Communication Services in connection with surveys, contests, pyramid schemes, chain letters, junk email, spamming or any duplicative or unsolicited messages (commercial or otherwise).
    2. Advertise or offer to sell or buy any goods or services.
    3. Publish, post, distribute or disseminate any inappropriate, profane, defamatory, obscene, indecent or unlawful topic, name, material or information.
    4. Use any material or information, including images or photographs, which are made available through the Services in any manner that infringes any copyright, trademark, patent, trade secret, or other proprietary right of any party.
    5. Provide links to files that contain viruses, Trojan horses, worms, time bombs, cancelbots, corrupted files, or any other similar software or programs that may damage the operation of another's computer or property of another.
    6. Download any file posted by another user of a Service that you know, or reasonably should know, cannot be legally reproduced, displayed, performed, and/or distributed in such manner.
    7. Falsify or delete any copyright management information, such as author attributions, legal or other proper notices or proprietary designations or labels of the origin or source of software or other material contained in a file that is uploaded.
    8. Restrict or inhibit any other user from using and enjoying the Communication Services. Violate any code of conduct or other guidelines which may be applicable for any particular Service.
    9. Harvest or otherwise collect information about others, including e-mail addresses.
    10. Violate any applicable laws or regulations.
    11. Create a false identity for the purpose of misleading others.
    12. Use, download or otherwise copy, or provide (whether or not for a fee) to a person or entity any directory of users of the Communication Services or other user or usage information or any portion thereof.

    DMBGC reserves the right to review materials posted to the Communication Services and to remove any materials at its sole discretion. DMBGC reserves the right to terminate your access to any or all of the Services at any time, without notice, for any reason whatsoever.
    Always use caution when giving out any personally identifiable information in any Services. DMBGC does not control or endorse the content, messages or information found in any Communication Services and, therefore, DMBGC specifically disclaims any liability with regard to the Communication Services and any actions resulting from your participation in any Communication Services.

Powered by Firespring