School Age Child Care Registration

H.H. Garnet Monthly Early Dismissal Enrollment 2024

Boys & Girls Clubs of Harford & Cecil Counties
Early Dismissal Program- January 24, 2025

If you have more than one child you wish to enroll, please complete a separate form for each child.

Youth Medical Information
Youth Medical Information
Insurance Company*
Insurance Policy/Group Number:*
Health Problems/Allergies:
Please list any medications and note any that will be needed during hours of care:
Disabilities/Psychological Conditions:
Does your child have an IEP or 504 plan that you are willing to share with us?

YesNo
Physician:*
Physician Phone Number*

Area CodePhone Number
Dentist or Dental Group
Dentist Phone Number

Area CodePhone Number

Emergency Contacts / Pick-up Information
Pick Up and/or Emergency Contact Information:

Please list two people who are authorized to serve as emergency contact or are approved to pick up child in addition to the parent.
Name*

First NameLast Name
Cell Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Check all that apply to emergency contact #1*

Primary Emergency ContactEmergency ContactLives with memberApproved Pick Up Person
Name*

First NameLast Name
Cell Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Check all that apply to emergency contact #2*

Primary Emergency ContactEmergency ContactLives with memberApproved Pick up Person

Informed Consent and Acknowledgement

I understand and agree that my child (or ward) must be picked up by closing time or a fee will be charged which must be paid before my child (or ward) can return to the Club.

I understand and agree that BGCHC does not refund membership fees and that my child (or ward) must obey all rules (Code of Conduct). I further understand that behavioral problems that cannot be solved can result in my child (or ward) being suspended from BGCHC without a monetary refund.

It is expressly understood and agreed that BGCHC shall not be responsible or legally liable for any losses of personal property, for any bodily injuries, or the results thereof, incurred and suffered by the applicant on any property of the BGCHC or in connection with any activities of any of its Units, or while engaged in any of the BGCHC’s activities away from the Club.

Internet Usage Agreement: The opportunity to use Club’s computers is based upon clear guidelines and agreements: (1) always be respectful of others, (2) never give out personal information over the computer, (3) always remember you are responsible for what you do online, (4) always follow the computer lab supervisor’s instructions, (5) never agree to meet in person with anyone you meet online and (6) never visit ‘off-limits’ web sites. Failure to uphold these agreements will result in revocation of the member’s online privileges.
Code of Conduct
Play Fairly and Be Honest Be Respectful of Boys & Girls Club Staff
Say Only Good Things About Others
Resolve Disagreements in a Positive Way
Be Respectful Of Other Members and Their Property
Take Care of Your Boys & Girls Club Facility and Equipment
Avoid Use of Improper Language
Remove Hats Before Entering Building
Applaud The Efforts of Others
Run Outside Only
Participate Only In Program Areas Open To Your Age Group
Listen During Assemblies
Dress Appropriately At All Times
Smoking, Drugs, Alcohol and Other Drugs and Weapons Are Strictly Prohibited
Stealing will not be Tolerated!
I have read and explained the rules to my son/daughter/ward and agree that the Boys & Girls Clubs will not be responsible for any accident to the boy/girl while on the Boys & Girls Clubs premises or while engaged in any of its activities away from the Boys & Girls Clubs.*

YesNo
I give my consent for photographs or video taping in which my son/daughter/ward may appear, to be used in any way the Boys & Girls Clubs may care to use them as long as it is consistent with the BGCHC mission.*

YesNo
I acknowledge that I have received and therefore am responsible for the information present in the Parent Handbook for Boys & Girls Clubs School Based Programing. I have completed the Enrollment form, Emergency Card (OCC 1214), Health Inventory/Health Assessment (OCC 1215), Medication Administration Form (OCC 1216) (if necessary), Seizure Medication Administration Form (if necessary), Asthma Action Plan (if necessary), Emergency Form Information Form for Children with Special Needs ( if necessary) for enrollment into the Boys & Girls Clubs School-Based Program.*

YesNo
I have reviewed, read and explained the internet/computer policy with my student; and therefore my student is responsible for following the policy. My student understands the discipline consequences of not adhering to the policy.*

YesNo
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature of Parent/Guardian's*

First NameLast Name
Should be Empty:

H.H. Garnet Monthly Early Dismissal Enrollment 2024

Early Dismissal Program- January 24, 2025