| Child's Full Name: (First, Initial, Last, Nickname) | |
| Date of
Birth: (mm/dd/yy) |
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| Address: |
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| City: |
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| Postal
Code: |
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| School: |
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| Days of Care
(check all that apply): |
Monday
Tuesday
Wednesday
Thursday
Friday
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| Hours of
Care (please specify hours of care needed
between the hours of 2:30 - 5:30
pm): |
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| Mother's
Name: |
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| Mother's
Home Address: |
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| Mother's
Employer & Address: |
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| Mother's
Contact Numbers: |
Home:
Cell:
Business:
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| Father's
Name: |
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| Father's
Home Address: |
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| Father's
Employer & Address: |
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| Father's
Contact Numbers: |
Home:
Cell:
Business:
|
| Guardian's
Name: |
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| Guardian's
Home Address: |
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| Guardian's
Employer & Address: |
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| Guardian's
Contact Numbers: |
Home:
Cell:
Business:
|
| Contact
Person (if parents can't be reached): |
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| Contact
Person's Home Address: |
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| Contact
Person's Employer & Address: |
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| Contact
Person's Contact Numbers: |
Home:
Cell:
Business:
|
| Child's
Physician: |
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| Physician's
Address: | |
| Physician's
Phone #: |
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| Names of
others in household, age if under 18, and
relationship: |
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| Authorized
persons who may pick up child: |
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| Previous
Communicable Diseases & Dates: |
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| Previous
Illnesses or Injuries (You will be asked to
present a copy of child's immunization
record): |
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| Special
Medical Conditions or known
Allergies: |
|
| Please
include any of your children's hobbies,
interests and / or favourite activities as
they may be incorporated into program
planning: |
|
General Waiver:
I, the undersigned, the parent/guardian
of the above named child do hereby consent to
this child's participation in the Boys and
Girls Club of Kingston & Area programs. I
acknowledge the participation in this program
involves light to vigorous activity and
includes the possibility of injury. I grant
program officials the authority to obtain
emergency medical treatment as necessary to
insure that the above named child is safe from
further injury. I am aware of no physical or
other reasons why this child should not
participate in club programs and related club
functions. I will impress upon the child the
importance of following club rules,
regulations and instructors' directions. In
consideration of the Boys and Girls Club of
Kingston & Area allowing this child to
participate in club programs, I agree to waive
and release Boys and Girls Club of Kingston
& Area, its employees, and agents from
all claims for damages that may arise other
than by negligence of the Boys and Girls Club
of Kingston & Area, its employees, and
agents as a result of my child's
participation in programs. I am aware that my
child (children) may have their photograph
taken by local media and may appear in a
variety of media sources on behalf of the
Boys and Girls Club of Kingston &
Area.
Check this box if you would prefer the child's picture not be taken.
Transportation
Waiver:
I
acknowledge that my child (children) will be
participating in an activity, trip or event
organized by the Boys and Girls Club of
Kingston & Area. I am aware that the
participation of my child (children) is
outside the scope of their daily routine. I
give permission for my child (children) to
travel by foot, Boys and Girls Club van, or
bus to the desired destination.
By checking on this box, I hereby agree that
the above waivers are understood.
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