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

  • YOUR SIGNATURE BELOW INDICATES YOU HAVE FULLY READ, UNDERSTOOD AND COMPLETED THE REGISTRATION FORM AND AGREE TO ALL PERMISSIONS AND WAIVERS CONTAINED HEREIN.

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  • 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.
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  • SPECIAL REQUIREMENTS

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  • 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.

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  • ADDITIONAL SUPPORT

    PLEASE INDICATE THE LEVEL OF SUPPORT NEEDED IN THE FOLLOWING AREAS. IF NO ADDITIONAL SUPPORT IS REQUIRED PLEASE IDICATE 'N/A'.
  • 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.

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  • ALLOWABLE PICK UPS AND EMERGENCY CONTACTS

    OTHER THAN GUARDIANS. IN APPROPRIATE CALL ORDER. ID REQUIRED FOR PICK UP.
  • SAFE ARRIVAL & SAFE RELEASE

    PLEASE INITIAL ALL THAT APPLY.
  • YOUR SIGNATURE BELOW INDICATES YOU HAVE FULLY READ, UNDERSTOOD AND COMPLETED THE CONTACTS FORM AND AGREE TO ALL PERMISSIONS AND WAIVERS CONTAINED HEREIN.

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