After School Registration-2024

Member Information
Student's Name*

First NameMiddle NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Date

MonthDayYear
Does your child have an IEP or 405 Plan? (Please be honest it is for your child's benefit)

YesNo
Current Age*
Child's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child currently lives with:*
Relationship to child*
Current School*
Dismissal Time (Regular Day)*
HH:MM
Grade*
School Address

Street Address

Street Address Line 2

CityState

Zip Code
School Phone Number

Area CodePhone Number
Identifying Marks
Height*
Weight*
Skin Color
Hair Color
Eye Color

Emergency Contacts and Authorized Pick-Ups

In case of emergency, Parents/Guardians are always contacted first.
Name (1)*

First NameLast Name
Cell Phone Number (1)*

Area CodePhone Number
Alternate Phone (1)

Area CodeNumber
Choose one: (1)*

Emergency Contact and Authorized Pick upAuthorized Pick up only
Name (2)*

First NameLast Name
Cell Phone Number (2)*

Area CodePhone Number
Alternate Phone Number (2)

Area CodeNumber
Choose one: (2)*

Emergency Contact and Authorized Pick upAuthorized Pick up only
Name (3):*

First NameLast Name
Cell Phone Number (3)*
Alternate Phone (3)

Area CodeNumber
Choose one: (3)*

Emergency Contact and Authorized Pick upAuthorized Pick up only
Name (4):

First NameLast Name
Cell Phone (4)

Area CodeNumber
Alternate Phone (4)

Area CodePhone Number
Choose one: (4)

Emergency Contact and Authorized Pick upAuthorized Pick up only

Verification Form - Arrival and Departure
Child's Name

First NameLast Name
Arrival Time*
My Child will arrive at BBTMusic by:*

Parent authorized releaseSupervised walk into the programUnsupervised walk into the programPublic TransportationBBTMusic Transportation
Arrival - Let us know excepted arrival time*
My Child will leave BBTMusic by:*

Parent authorized releaseSupervised walk into the programUnsupervised walk into the programPublic Transportation
Departure - Let us know excepted departure time*
Parent Signature ( Type Name)*

ALLERGY INFORMATION

PLEASE COMPLETE THIS FORM EVEN IF YOUR CHILD HAS NO KNOWN ALLERGIES
Food Allergies*

YesNo
List your child's food allergies, the severity and treatment needed to administer.
Medication Allergies*

YesNo
List any medication your child is allergic too.
Does your child use any form of medication in an emergency exposure?*

YesNoOther
List any medication form of medication in and emergency exposure. (Ventolyn Benadryl, Bee sting kit etc...)
If your child does use a medication in the event of an emergency exposure, please bring the LABELED medication with FULL WRITTEN INSTRUCTIONS FOR USE AND UNDER WHAT SPECIFIC CONDITIONS IT SHOULD BE ADMINISTRATED.

Medical Permission Form:
By signing this registration form, I give permission for my child named below to receive emergency treatment and to be hospitalized at my expense, if necessary. I understand
Child's Name
Parent/Guardian Initials*
Policy Number*
Medical Insurance*
Child's Physician*
Physician's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician's Phone Number

Area CodePhone Number

Medical Records and Custody
Do you have any custody agreement, court orders, and restraining orders pertaining to the child named above.

YesNo
Special limitations or concerns.
I certify the documentation of physical examination and immunization in accordance with public school health requirements and lead paint poisoning screening in accordance with public health requirements are on file at my child's school
Parent Guardian
Parent Guardian

MEDICAL CONSENT (Please complete and sign by Doctor)

Please sign and return to BBTMusic fax 781-780-3827
Child Name

First NameLast Name
Name of Medication
Is the medication

PrescriptionNon Prescription
Dosage
Date Medication to be given
Times Medication to be given
Reason for medication
Possible side effects
Directions for storage
I parent/guardian named below, give permission to BBTMusic authorized staff members to administer medication to my child as indicated above.
Parent/Guardian Name
Doctor's Signature

Transportation Authorization One Way
Start Date

MonthDayYear
Date
School
Student's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Parent's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name

First NameLast Name
Home Phone

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Emergency Contact Cell

Area CodePhone Number
SCHOOL PICK-UP/PROGRAM DROP-OFF
School
Pick up Time

:HourMinutesAM/PM Option
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Phone Number

Area CodePhone Number
School Contact Name

First NameLast Name
I First Name Last Name , Parent of First Name Last Name . Give my authorization to Building Bridges through Music to transport my child as specified above
Date*

MonthDayYear
Date

Registration Form Checklist

Forms can be emailed back to admin@bbtmusic.org or faxed to 781-780-3827.
- Site Visit and/or enrollment meeting (New families)
- Medication Consent form 606 CMR signed by Doctor
- Health Care Plan Form signed by Doctor
- Physical
- Immunization Chart
- Copy of insurance card
- Copy of child immunization
- Photo id of adults picking up non-parents
- Signed authorization form
- Picture of the child (office)
- Lead paint screening for all children under the age of six.
Should be Empty:

Medical Records and Custody