2011 / 2012 Evening Programs Application

** Form must be completely filled out in order for your child to attend program **

Member's Name:
Date of Birth: (mm/dd/yy)   Age:  
Address:
City:
Postal Code:
Parent / Guardian Name:
Home Phone #:
Cell Phone #:
Other Phone #:
Email:
Alternative / Emergency Contact Person:
Relationship to your child:

Contact Phone #:
Member's Health Card #:
Doctor's Name:   Phone #:  
Please indicate any allergies, medications or special needs your child may have. If mediction needs to be given during program hours, please contact the Program Coordinator.
How will your child be getting to program? (car, walking, etc.):
Is your child allowed to walk home by themselves when program is finished?:
During program hours, is your child allowed to leave the building? (ie. go to the store, go to a friend's house)
Please indicate who is allowed to pick your child up from program (please include relationship to your child).
What school does your child attend?
What program location(s) will your child be attending?
Please indicate below if your child will be participating in any of the commitment programs throughout the week: Rotary Basketball (Mondays)
Karate (Tuesdays & Thursdays)
Glee Club (Mondays)
Drama (Tuesdays)

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.

 
Admin | © Boys & Girls Club of Kingston & Area 2012 | Privacy Policy | Site Map | Website Powered by SiteMajic
Site Meter