HUDSON- 2021 - 2022 Membership Registration

Membership Registration Form

Hudson Clubhouse
If you would like to register your child for transportation from the schools to the Club, please call 978-562-9924.
Type of Membership Registration: *

New Renewal
How many children are you registering for membership? *
Are you interested in signing up and paying a deposit for transportation?
Member Information
Child #1 Name *

First Name Last Name
Child #1 Sex *
Child #1 Birth Date *

Month Day Year
Date
Child #1 Age *
Child #1 School Name *
Child #1 Address *

Street Address

Street Address Line 2

City

Postal / Zip Code
Child #1 Grade *
Child #1 School Phone Number *

Area Code Phone Number
Child Number 2 Information
Child #2 Name

First Name Last Name
Child #2 Sex
Child #2 Birth Date

Month Day Year
Date
Child #2 Age
Child #2 School Name
Child #2 Grade
Child #2 School Phone Number

Area Code Phone Number
Child Number 3 Information
Child #3 Name

First Name Last Name
Child #3 Sex
Child #3 Birth Date

Month Day Year
Date
Child # Age
Child #3 School
Child #3 Grade
Child #3 School Phone Number

Area Code Phone Number
Parent/Guardian Information

You must enter information for at least one parent/guardian.
Mother/Guardian #1 Name

First Name Last Name
Mother/Guardian #1 Cell Phone Number

Area Code Phone Number
Mother/Guardian #1 Home Phone Number

Area Code Phone Number
Mother/Guardian #1 Email Address
example@example.com
Mother/Guardian #1 Address

Street Address

Street Address Line 2

City

Postal / Zip Code
Mother/Guardian #1 Occupation
Mother/Guardian #1 Employer
Mother/Guardian #1 Work Phone Number

Area Code Phone Number
Father/Guardian #2 Name

First Name Last Name
Father/Guardian #2 Cell Phone

Area Code Phone Number
Father/Guardian #2 Home Phone

Area Code Phone Number
Father/Guardian #2 Email Address
example@example.com
Father/Guardian #2 Address

Street Address

Street Address Line 2

City

Postal / Zip Code
Father/Guardian #2 Occupation
Father/Guardian #2 Employer
Father/Guardian #2 Work Phone Number

Area Code Phone Number

Emergency Contact

In case of an Emergency, if a Parent/Guardian cannot be reached:
Emergency Contact #1 Name *

First Name Last Name
Emergency Contact #1 Relationship *
Emergency Contact #1 Relationship *

Street Address

Street Address Line 2

City

Postal / Zip Code
Emergency Contact #1 Phone Number *

Area Code Phone Number
Emergency Contact #2 Name

First Name Last Name
Emergency Contact #2 Relationship
Emergency Contact #3 Address

Street Address

Street Address Line 2

City

Postal / Zip Code
Emergency Contact #2 Phone Number

Area Code Phone Number
Emergency Contact #3 Name

First Name Last Name
Emergency Contact #3 Relationship
Emergency Contact #3 Address

Street Address

Street Address Line 2

City

Postal / Zip Code
Emergency Contact #3 Phone Number

Area Code Phone Number
List any medical, physical, or emotional conditions that we should be aware of to better serve your child: (allergies, medication, etc.)

Authorization and Consent
1. 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 cannot be reached, I hereby authorize the qualified staff at the Boys & Girls Club to transport my child to the nearest hospital.
2. Child's Doctor & Insurance *
Doctor's Phone Number & Address *
3. I understand the Club is not, nor claims to be, a licensed day care center. (Unless your child is registered in the licensed SACC Program).

4. I authorize Boys & Girls Club staff/volunteers who are trained in the basics of first aid to treat my child when appropriate.

5. I give permission for my child to participate in field trips by means of bus/van. I understand that I will be notified in advance of any trips.
6. I give consent to have my child photographed or videotaped for public relations purposes. *

Yes No
Parent/Guardian Signature *

Clear
Today's Date *

Month Day Year
Date

Transportation Information
Member Name
The above member will follow the following BUS RULES as long as he/she is a member of the Boys & Girls Clubs of MetroWest:
- Respect and Listen to the bus driver
- Respect and Listen to the monitors on the bus
- Stay seated at all times
- Keep all body parts to yourself and inside the bus
- Throwing objects is not allowed on the bus or out the windows
- Inside voices and use of appropriate language.
PLEASE NOTE: These rules are to insure that all members are safe while on the bus. Failure to obey the rules will result to suspension off the bus for entire school year.

CONSEQUENCES FOR NOT FOLLOWING THE RULES

1ST Offense Warning

2ND Offense 2-Day Suspension off the bus

3RD Offense Suspension off the bus for the entire school year
By signing this contract, you are agreeing to the rules and consequences if the rules are not fulfilled.
Member Name
Date

Month Day Year
Date
Parent Name
Parent Signature

Clear
Date

Month Day Year
Date
Transportation from School

If your child attends the After School Program at the Boys & Girls Clubs of MetroWest, Argeo R. Cellucci, Jr. Clubhouse, the School Department requires that you notify your child's school in writing. Please complete the following release fields.
I give permission for my child (name below) to attend the Boys & Girls Clubs of MetroWest and to be picked up by the Club's bus immediately after my child's dismissal. The child is being dismissed from the school listed below.
Child's Name
Child's School
Parent/Guardian Signature

Clear
Date

Month Day Year
Date

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.

Boys & Girls Clubs of MetroWest has put in place preventative measures to reduce the spread of COVID-19; however, the Club cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending the Club could increase your risk and your child(ren)’s risk of contracting

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending the Club and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Club may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Club employees, volunteers, and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the Club or participation in Club programming (“Claims” On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless the Club, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Club, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Club program.
Signature of Parent/Guardian *

Clear
Date *

Month Day Year
Date
Name of Parent/Guardian *
Name of Club Participant(s) *

Payment Page

If you are not going to make a credit card payment today, please click the "Preview PDF" button below, save and print a copy of your filled forms. Forms can be mailed or dropped off at the Club with cash or check.

My Products

HUDSON Clubhouse Membership Annual membership for one member to the Hudson Clubhouse. Payment amount must match the number of registered members answered previously.

$ 25.00 Annual Membership

Total

$ 0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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Membership Registration Form

Member Information

Parent/Guardian Information

Emergency Contact

Registration Questions

Authorization and Consent

Transportation Information

By signing this contract, you are agreeing to the rules and consequences if the rules are not fulfilled.

Transportation from School

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19

Payment Page