Zone Registration Form 2020/2021

ZONE REGISTRATION

If you have more than one child you will be required to complete a registration package for each child. We are excited to offer our Kids Zone program starting October 14 every Monday, Wednesday and Friday from 6:00 to 8:30 pm. Our Teen Zone program will be offered Tuesday and Thursday starting October 13 from 6:00 to 8:30pm. Transportation is not available at this time.
PARTICIPANT NAME: *

First Name Last Name
DATE OF BIRTH: *

Month Day Year
Date
SELECT PROGRAM: *

Kids Zone Teen Zone
SELECT SITE: *

Niagara Falls Club St. Catharines Club Fort Erie Club- EJ Freeland Community Centre
HIDDEN- first page site.
START DATE: *

Month Day Year
Date
ADDRESS: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
EMAIL:
BY ENTERING YOUR EMAIL ADDRESS YOU ARE AUTHORIZING THE BOYS AND GIRLS CLUB OF NIAGARA TO CONTACT YOU VIA EMAIL REGARDING THE REGISTRATION PROCESS.
PRIMARY PHONE NUMBER:

Area Code Phone Number
1. PARENT/GUARDIAN: *

First Name Last Name
PRIMARY PHONE NUMBER: *

Area Code Phone Number
SECONDARY PHONE:

Area Code Phone Number
2. PARENT/GUARDIAN: *

First Name Last Name
PRIMARY PHONE NUMBER: *

Area Code Phone Number
SECONDARY PHONE:

Area Code Phone Number
I GIVE THE PARTICIPANT, AS NAMED ABOVE, PERMISSION TO PARTICIPATE IN THE FOLLOWING (INITIAL):
ANY TRANSPORT NECESSARY, WHETHER FOR MEDICAL TREATMENT OR CLUB USE
LEAVE THE CLUB WITH STAFF SUPERVISION
ATTEND ANY FIELD TRIPS PLANNED BY THE CLUB
UTILIZE THE CLUB POOL WHEN SCHEDULING ALLOWS
ANY MEDICAL TREATMENT REQUIRED
1. By selecting 'yes', I consent to the collection, use and disclosure of my personal information during the course of my or my child's membership/services for the purpose set out in the Boys and Girls Club of Niagara privacy policy. By selecting 'no', I consent to the use of my personal information only for the purpose of permitting the Boys and Girls Club of Niagara to communicate with me. *

YES NO
2. I consent to my child's image being published in web or print directories for by the Boys and Girls Club of Niagara and/or its partners. *

YES NO
3. By selecting 'yes', I consent to my child's participation in the Boys and Girls Club of Niagara programs. By selecting 'no', I do not consent to my child participating in the Boys and Girls Club of Niagara programs. *

YES NO
YOUR SIGNATURE BELOW INDICATES YOU HAVE FULLY READ, UNDERSTOOD AND COMPLETED THE REGISTRATION FORM AND AGREE TO ALL PERMISSIONS AND WAIVERS CONTAINED HEREIN.
SIGNATURE: *

Clear
DATE: *

Month Day Year
Date
PARENT HANDBOOK ACKNOWLEDGEMENT (INITIAL)

After reading the Zone Programs Parent Handbook, please sign below. Your signature indicates that you have fully read and understood the Parent Handbook and agree to all terms and conditions herein.
I have provided the Boys & Girls Club with the most recent information with respect to my child including emergency contacts and special requirements. *
I agree to keep my child home or make other arrangements if s/he is not well enough to full participate in daily activities and am prepared to pick up my child if ill within 45 minutes of Club contact. *
I will call the appropriate Boys and Girls Club Unit if my child will be absent for any reason understanding that I will still be charged the daily fee (IF APPLICABLE).
I acknowledge Club hours of operation and will adhere to practices in place and fees attached in the event of late pick ups after program ends. *
I have read the parent handbook and understand the policies and procedures as it pertains to my child's care at the Boys and Girls Club. *
SIGNATURE: *

Clear
DATE: *

Month Day Year
Date
SPECIAL REQUIREMENTS
PARTICIPANT NAME *

First Name Last Name
DATE OF BIRTH: *

Month Day Year
GENDER:
AGE: *
HEALTH CARD NUMBER: *
THIS SECTION WILL INFORM THE BOYS AND GIRLS CLUB STAFF OF ANY SPECIAL NEEDS THE PARTICIPANT HAS TO ENSURE A FULLY INTEGRATED SETTING AND OPPORTUNITIES FOR THE PARTICIPANT. IF THE PARTICIPANT HAS A DISABILITY OR REQUIRES MEDICATION FOR A SPECIAL NEED, PLEASE INDICATE BELOW. IF THE NEEDS OF THE PARTICIPANT REQUIRES ONE ON ONE SUPPORTS THE PARENT/GUARDIAN MUST MEET WITH THE SUPERVISOR TO DISCUSS REQUIREMENTS OF THE PARENT IN OUT SOURCING SUPPORTS PRIOR TO COMMENCING SERVICES.
1. DOES THE PARTICIPANT HAVE ANY SPECIAL REQUIREMENTS? *

Yes (must specify below) No
If YES please specify:
2. IS THE PARTICIPANT ON ANY MEDICATION NOW OR HAVE THEY BEEN ON MEDICATION IN THE PAST? *

Presently (must specify below) Previously n/a
If PRESENTLY, what is the medication?
If PRESENTLY, what is the reason for taking the medication?
If PRESENTLY, how often?
If PRESENTLY, what is the dosage?
IF YOU HAVE INDICATED YOUR CHILD IS CURRENTLY TAKING MEDICATION, PLEASE CHECK BELOW TO GIVE A DESCRIPTION OF THE MEDICATION.

Yes my child is currently taking medication.

3. ARE YOU RECEIVING SUPPORT SERVICES FOR THE PARTICIPANT AT THIS TIME? *

Yes (must specify below) No
If YES, from what agency or agencies?
4. HAVE YOU RECEIVED SUPPORT SERVICES FOR THE PARTICIPANT IN THE PAST? *

Yes (must specify below) No
If YES, from what agency or agencies?
5. DOES THE PARTICIPANT HAVE ANY KNOWN ALLERGIES? *

Yes (must specify below) No
Is the reaction anaphylactic? *

Yes (must specify below) No n/a
Please describe the allergy and level of severity:
ADDITIONAL SUPPORT

PLEASE INDICATE THE LEVEL OF SUPPORT NEEDED IN THE FOLLOWING AREAS. IF NO ADDITIONAL SUPPORT IS REQUIRED PLEASE IDICATE 'N/A'.
DRESSING: *
TOILETING: *
MOBILITY: *
COMMUNICATION: *
FEEDING: *
BEHAVIOUR: *
YOUR SIGNATURE BELOW INDICATES YOU HAVE FULLY READ, UNDERSTOOD AND COMPLETED THE REQUIREMENTS FORM AND AGREE TO ALL TERMS AND CONDITIONS CONTAINED HEREIN. I HEREBY AUTHORIZED THE STAFF OF THE BOYS AND GIRLS CLUB OF NIAGARA TO ADMINISTER THE MEDICATION AS INDICATED ON THIS FORM. I UNDERSTAND THAT ALL MEDICATIONS MUST BE CONTAINED IN THE ORIGINAL PRESCRIPTION BOTTLE AND CAN ONLY BE CHANGED BY THE PARTICIPANT’S PHYSICIAN OR PHARMACY. I AGREE TO NOT HOLD RESPONSIBLE ANY MEMBER OF THE CLUB STAFF FOR ANY ADVERSE EFFECTS THE MEDICATION MAY HAVE ON THE PARTICIPANT. IF THE ABOVE HAS NOT BEEN COMPLETED. I ACKNOWELDGE THAT THE PARTICIPANT IS NOT TAKING ANY MEDICATION FOR THE DURATION OF THEIR TIME WITH THE BOYS AND GIRLS CLUB OF NIAGARA.
SIGNATURE: *

Clear
DATE: *

Month Day Year
Date
ALLOWABLE PICK UPS AND EMERGENCY CONTACTS

OTHER THAN GUARDIANS. IN APPROPRIATE CALL ORDER. ID REQUIRED FOR PICK UP.
1. FULL NAME: *
RELATION: *
PHONE: *
2. FULL NAME:
RELATION:
PHONE:
3. FULL NAME:
RELATION:
PHONE:
4. FULL NAME:
RELATION:
PHONE:
SAFE ARRIVAL & SAFE RELEASE

PLEASE INITIAL ALL THAT APPLY.
I AUTHORIZE MY CHILD TO PARTICIPATE IN THE BOYS AND GIRLS CLUB ZONE PROGRAM.
I ACKNOWLEDGE THAT A GUARDIAN MUST BE PRESENT TO SIGN MY CHILD IN & OUT OF KIDS ZONE PROGRAMS.
TEEN ZONE ONLY: I AUTHORIZE STAFF TO RELEASE MY CHILD FROM THE PROGRAM UNSUPERVISED.
I AUTHORIZE MY CHILD TO BE RELEASED TO THE NAMES PROVIDED UNDER ALLOWABLE PICK UPS.
YOUR SIGNATURE BELOW INDICATES YOU HAVE FULLY READ, UNDERSTOOD AND COMPLETED THE CONTACTS FORM AND AGREE TO ALL PERMISSIONS AND WAIVERS CONTAINED HEREIN.
SIGNATURE: *

Clear
DATE: *

Month Day Year
Date

ZONE REGISTRATION

I GIVE THE PARTICIPANT, AS NAMED ABOVE, PERMISSION TO PARTICIPATE IN THE FOLLOWING (INITIAL):

PARENT HANDBOOK ACKNOWLEDGEMENT (INITIAL)

SPECIAL REQUIREMENTS

ADDITIONAL SUPPORT

ALLOWABLE PICK UPS AND EMERGENCY CONTACTS

SAFE ARRIVAL & SAFE RELEASE