VOUCHER - DISCOVERY CLUB - Schedule Request Form Summer 2021_PACKET

BOYS & GIRLS CLUBS OF METROWEST

DISCOVERY CLUB - ENROLLMENT FORM
Child's Information
Child's Name *
Home Address *
Home Phone Number *
Age at Admission *
Date of Admission *

Month Day Year
Date
Grade Current Schoolyear *
Primary Language *
Child's Additional Information
Identifying Marks *
Allergies *
Special Diet *
Physician/Clinic Name *
Physician/Clinic Phone *
Physician/Clinic Address *
Eye Color *
Hair Color *
Skin Color *
Sex *
Height *
Weight *
If you answer yes to any of the following questions, please provide the Boys & Girls Clubs offices a copy of the proper documentation.

Thank you
Does your child have a chronic health condition? (medical, ADHD, ASD, dietary, auditory?) *

Yes No
Does your child have an Individual Health Plan for the chronic health condition? *

Yes No
Are there any custody agreements, court or restraining orders pertaining to the child? *

Yes No
Limitations/Concerns
Parent / Guardian #1 Information
Name *
Relationship to Child *
Home Address *
Home Phone *
Cell Phone Number
Please enter a valid phone number.
Email *
example@example.com
Business/Work Name *
Business/Work Address *
Business/Work Phone *
Hours at Work *
Parent / Guardian #2 Information
Name
Relationship to Child
Home Address
Home Phone
Cell #
Please enter a valid phone number.
Email
example@example.com
Business/Work Name
Business/Work Address
Business/Work Phone
Hours at Work
Child's Physical Examination & Immunization Records
School *
School Address *
/ certify that documentation of physical examination and immunizations in accordance with public school health requirements, and lead poisoning

screening in accordance with public health requirements are on file at my child's school.
Initial Here *
Sign Here *

Clear

BOYS & GIRLS CLUBS OF METROWEST

DISCOVERY CLUB - FIRST AID & EMERGENCY CONSENT FORM
Child's Information
Child's Name *
Date of Birth *

Month Day Year
Date
Allergies
Chronic Health Conditions
Child's Physician / Clinic Information
Physician / Clinic Name *
Address *
Phone *
Emergency Contacts

I give permission for my Child to be released to these contacts. (In order to be contacted)
Emergency Contact #1
Name *
Home Phone *
Work Phone *
Cell Phone *
Relationship to Child *
Emergency Contact #2
Name
Home Phone
Work Phone
Cell Phone
Relationship to Child
Emergency Contact #3
Name
Home Phone
Work Phone
Cell Phone
Relationship to Child
Public Relations & Field Trip Consent
I give consent to have my child photographed or videotaped for public relations purposes. *

Yes No
I give permission for my child to participate in field trips by means of bus/van and that I will be notified in *

Yes No
First Aid & Emergency Medical Care Consent
I authorize Discovery Club/BGCMW Staff who are trained in the basics of First Aid / CPR to give my child First Aid / CPR when appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I can not be reached, I hereby authorize the program to transport my child to the nearest medical care facility, and to secure necessary medical treatment for my child.
Health Insurance Carrier *
Policy # *
Subscriber of Policy *
Parent / Guardian #1 *
Cell Phone Number
Please enter a valid phone number.
Parent / Guardian #2
Cell Phone Number
Please enter a valid phone number.
Parent / Guardian Signature *

Clear
Date (Valid Current School Year) *

Month Day Year
Date