The Brigade Youth Program Brockton
Registration Form
Child's Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Gender
*
Female
Male
Primary Language
*
Race
*
Asian
Black
Hispanic
Mixed/Other
Native American
White
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Parent/Guardian Information
Parent/Guardian Name
*
First Name
Last Name
Relationship To Child
*
Primary Language
*
Does the Child live with you?
*
Yes
No
Cell Phone
*
Work Phone
*
Email
*
example@example.com
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Spiritual Status
While church membership is NOT required, we are interested in knowing if your family is a member of a worshipping congregation.
My child has participated in the Boys' & Girls' Brigade Brockton in the past:
*
Yes
No
What Year?
My family is a member of an Episcopal/Anglican congregation:
*
Yes
No
Which Church?
How did you find out about us?
*
Returning
Family Member
Flier
School
Website
Other
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Emergency Contacts / Medical Information
Child Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
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 Name
Last Name
Relationship to child
*
Does this person live with your child?
*
Yes
No
Cell Phone
*
Work Phone
*
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Child's Medical Information
Please write NONE if there are none
Allergies
Reaction
Treatment
1
2
3
Does your child have any special disabilities/needs or chronic health conditions?
*
Yes
No
If YES, Please Explain:
Does your child take medication?
*
Yes
No
If YES, Please Explain:
Does your child have any dietary restrictions?
*
Yes
No
If YES, Please Explain:
Does your child have an IEP or any learning or reading disabilities?
*
Yes
No
If YES, Please Explain:
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Child's Insurance Information
Medical Insurance Company
*
Child's Physician
*
Policy Number
*
Physician's Phone Number
*
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Required Parent/Guardian Signature
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
Photo/Video Release
I GIVE PERMISSION FOR THE IMAGE OF MY CHILD, TO B USED ON THE BBGB WEBSITE, IN OTHER PROMOTIONAL MATERIALS OF THE CHURCH OR THE EPISCOPAL DIOCESE OR OTHER PARTNER ORGANIZATIONS.
Parent/Guardian Signature
Clear
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
Transportation Waiver
*
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
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Registration Fee
Please let us no if you need help with payments.
$
50.00
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