The Brigade Youth Program Brockton

The Brigade Youth Program Brockton

Registration Form
NewReturning

Child's Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
FemaleMale
Primary Language*
AsianBlackHispanicMixed/OtherNative AmericanWhite
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Relationship To Child*
Primary Language*
YesNo
Cell Phone*
Work Phone*
Email*
example@example.com

Emergency Contacts / Medical Information
Child Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Emergency Contact

who can we contact in an emergency or nonemergency if you can not be reached. Please note that the person listed as "emergency contact" is automatically authorized to pickup your child from the program.
Name*

First NameLast Name
Relationship to child*
YesNo
Cell Phone*
Work Phone*

Child's Medical Information

Please write NONE if there are none

Rows	Allergies	Reaction	Treatment
1
2
3

YesNo
If YES, Please Explain:
YesNo
If YES, Please Explain:
YesNo
If YES, Please Explain:
YesNo
If YES, Please Explain:

Child's Insurance Information
Medical Insurance Company*
Child's Physician*
Policy Number*

Returning Child
Child's Name

First NameLast Name
Child's Name

First NameLast Name
Parent's Name

First NameLast Name
Parent's Name

First NameLast Name
Physician's Phone Number*

Required Parent/Guardian Signature
Parent's Name

First NameLast Name
General Permission

I GIVE MY CHILD PERMISSION TO PARTICIPATE IN THE BBGB PROGRAM. I UNDERSTAND THAT THIS INCLUDES CLOSELY SUPERVISED OUTDOOR ACTIVITIES AND FIELD TRIPS. I HAVE SUBMITTED ALL PERTINENT INFORMATION FOR MY CHILD TO THE DIRECTOR OF THE PROGRAM. I DO NOT HOLD BBGB, GRACE CHAPEL BROCKTON OR ANY OF THEIR AFFILIATES LIABLE FOR ANY PERSONAL INJURIES THAT MAY OCCUR TO MY CHILD DURING THEIR PARTICIPATION IN THE PROGRAM. I GIVE PERMISSION TO THE HEALTH CARE PROFESSIONAL SELECTED BY BBGB TO ORDER ANY TREATMENTS RELATED TO THE HEALTH OF MY CHILD FOR BOTH ROUTINE HEALTH CARE AND IN EMERGENCY SITUATIONS. IF I CANNOT BE REACHED IN AN EMERGENCY, I GIVE MY PERMISSION TO THE HEALTH CARE PROFESSIONAL TO HOSPITALIZE, SECURE PROPER TREATMENT FOR, AND ORDER INJECTION, ANESTHESIA, OR SURGERY FOR THIS CHILD. I UNDERSTAND MY CHILD’S HEALTH INFORMATION WILL BE SHARED ON A “NEED TO KNOW” BASIS WITH BBGB STAFF.
Parent/Guardian Signature

Clear
Parent's Name

First NameLast Name
Photo/Video Release

I GIVE PERMISSION FOR THE IMAGE OF MY CHILD, TO BE USED ON THE BBGB WEBSITE, IN THE PROMOTIONAL MATERIALS OF THE CHURCH OR THE EPISCOPAL DIOCESE OR OTHER PARTNER ORGANIZATIONS.
Parent/Guardian Signature

Clear
Parent's Name

First NameLast Name
Field Trip Permission

I GIVE PERMISSION FOR MY CHILD, TO PARTICIPATE IN ALL BGBB FIELD TRIPS
(INCLUDING BUS TRIPS). IT IS IMPORTANT FOR YOUR CHILD TO FOLLOW ALL
PROGRAMS AND GROUP RULES. OTHERWISE, YOUR CHILD MAY LOSE ALL FIELD
TRIP PRIVILEGES.
Parent/Guardian Signature

Clear
I GIVE PERMISSION FOR MY CHILD TO LEAVE THE BGBBPROGRAM BY HIM/HERSELF AT DISMISSAL TIME. I WILL PROVIDE FOR ANYNECESSARY TRANSPORTATION AND I ACCEPT ALL RESPONSIBILITY FOR MYCHILD ONCE HE/SHE LEAVES THE PROGRAM. I DO NOT HOLD BGBB STAFF ORAFFILIATES RESPONSIBLE IN THE EVENT OF AN EMERGENCY OR ACCIDENT.I DO NOT GIVE PERMISSION FOR MY CHILD TO LEAVE THE BGBB PROGRAM BY HIM/HERSELF AT DISMISSAL TIME. MY CHILD MUST REMAIN AT THE PROGRAM UNTIL I OR ANOTHER PERSON DESIGNATED ON THE APPLICATION FORM ARRIVES TO PICK UP MY CHILD
Parent/Guardian Signature

Clear

Brigade Program Registration Fees*

Registration Fee

Please let us no if you need help with payments.

$50.00

Enter coupon

Total

$0.00

loading smart payment buttons...

Should be Empty:

The Brigade Youth Program Brockton

Child's Information

Parent/Guardian Information

Spiritual Status

Emergency Contacts / Medical Information

Emergency Contact

Child's Medical Information

Child's Insurance Information

Returning Child

Required Parent/Guardian Signature

I GIVE PERMISSION FOR THE IMAGE OF MY CHILD, TO BE USED ON THE BBGB WEBSITE, IN THE PROMOTIONAL MATERIALS OF THE CHURCH OR THE EPISCOPAL DIOCESE OR OTHER PARTNER ORGANIZATIONS.

I GIVE PERMISSION FOR MY CHILD, TO PARTICIPATE IN ALL BGBB FIELD TRIPS(INCLUDING BUS TRIPS). IT IS IMPORTANT FOR YOUR CHILD TO FOLLOW ALLPROGRAMS AND GROUP RULES. OTHERWISE, YOUR CHILD MAY LOSE ALL FIELDTRIP PRIVILEGES.

I GIVE PERMISSION FOR MY CHILD, TO PARTICIPATE IN ALL BGBB FIELD TRIPS
(INCLUDING BUS TRIPS). IT IS IMPORTANT FOR YOUR CHILD TO FOLLOW ALL
PROGRAMS AND GROUP RULES. OTHERWISE, YOUR CHILD MAY LOSE ALL FIELD
TRIP PRIVILEGES.