2023 - NEW MEMBER - DISCOVERY CLUB - SUMMER Schedule Request Form

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*

MonthDayYear
Date
Grade Current School year*
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?)*

YesNo
Does your child have an Individual Health Plan for the chronic health condition?*

YesNo
Are there any custody agreements, court or restraining orders pertaining to the child?*

YesNo
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*
I 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
Date (Valid Current School Year)

MonthDayYear
Date

BOYS & GIRLS CLUBS OF METROWEST

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

MonthDayYear
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.*

YesNo
I give permission for my child to participate in field trips by means of bus/van and that I will be notified in advance of any trips*

YesNo
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)*

MonthDayYear
Date

BOYS & GIRLS CLUBS OF METROWEST

DISCOVERY CLUB - TRANSPORTATION PLAN / AUTHORIZATION FORM
Child's Information
Child's Name*
Date of Birth*

MonthDayYear
Date
My child will ARRIVE at the Program by:
*Please take into consideration all the ways that your child arrives to our
program. There should be at least 2 selections here if they attend before &
afterschool and/or summer school.
*

Parent / Authorized Drop OffSchool Bus Drop OffUnsupervised Walk from Discovery Club to Classroom (PM)
My child will DEPART the Program by:
*Please take into consideration all the ways your child leaves our program
and departs to go home each day. There should be at least 2 selections hereif your child attends before & after school and/or summer school.
*

School Bus Pick Up (Summer Only)Unsupervised Walk from Discovery Club to Classroom (AM)Parent/Authorized Pick Up
Transportation Contacts
Transportation Contact #1
Name*
Home Phone
Work Phone
Cell Phone*
Relationship to Child*
Transportation Contact #2
Name*
Home Phone
Work Phone
Cell Phone*
Relationship to Child*
Transportation Contact #3
Name*
Home Phone
Work Phone
Cell Phone*
Relationship to Child*
Transportation Authorization
I give permission for my child to be released from the program at the end of the day as stated above and/or give my permission to the above referenced people to receive my child at the end of the day.

This PERMISSION is valid for the current school year or summer camp.

ANY OTHER TRANSPORTATION REQUESTS MUST BE MADE IN WRITING.

This Form will be maintained in your child's file.

One time permissions will be with the daily attendance record or sent to your child's file.

*** If NO ONE is authorized, please indicate by writing "NO ONE" above.
Parent / Guardian Signature*

Clear
Date (Valid Current School Year)*

MonthDayYear
Date
Completes "Consent for Child to Leave the School Age Child Care Program" form per CMR 7.04(7a)8

PAYMENT
TOTAL ALL WEEKS & DAYS
20% DEPOSIT
plus $75.00 Registration Fee
You are required to pay 20% plus a $75.00 non-refundable registration fee with this Kane Summer Discovery application.
TOTAL DUE TODAY

TOTAL DUE TODAY

USD

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

Should be Empty:

BOYS & GIRLS CLUBS OF METROWEST

DISCOVERY - SUMMER 2023 SCHEDULE REQUEST FORMS

Child's Information

Parent Guardian Information

TOTAL BALANCE

BOYS & GIRLS CLUBS OF METROWEST

Child's Information

Parent / Guardian #1 Information

Parent / Guardian #2 Information

Child's Physical Examination & Immunization Records

BOYS & GIRLS CLUBS OF METROWEST

Child's Information

Child's Physician / Clinic Information

Emergency Contacts

Emergency Contact #1

Emergency Contact #2

Emergency Contact #3

Public Relations & Field Trip Consent

First Aid & Emergency Medical Care Consent

BOYS & GIRLS CLUBS OF METROWEST

Child's Information

My child will ARRIVE at the Program by:

My child will DEPART the Program by:

Transportation Contacts

Transportation Contact #1

Transportation Contact #2

Transportation Contact #3

Transportation Authorization

PAYMENT