2024-2025 Kids Zone and Teen Zone Registration Package

2024-2025 Kids Zone and Teen Zone Registration Package
ZONE REGISTRATION & CONTACTS
PARENT EMAIL:*
example@example.com
SITE
PARTICIPANT FIRST AND LAST NAME*
PARTICIPANT DATE OF BIRTH*

MonthDayYear
Date
ADDRESS*

Street Address

Street Address Line 2

CityProvince

Postal Code
PHONE NUMBER*
Please enter a valid phone number.
START DATE*

MonthDayYear
Date
1 PARENT/ GUARDIAN FIRST AND LAST NAME*
1. PARENT/GUARDIAN PHONE NUMBER*
1. PARENT/GUARDIAN SECONDARY PHONE NUMBER *
2 PARENT/GUARDIAN FIRST AND LAST NAME*
2. PARENT/GUARDIAN PHONE NUMBER*
2. PARENT/GUARDIAN SECONDARY PHONE NUMBER
PERMISSION & WAIVERS

I GIVE THE PARTICIPANT, AS NAMED ABOVE, PERMISSION TO PARTICIPATE IN THE FOLLOWING (INITIAL):
ANY TRANSPORTATION NECESSARY, WHETHER FOR MEDICAL TREATMENT OR CLUB USE*
INITAL
LEAVE THE CLUB WITH STAFF SUPERVISION*
INITAL
ATTEND ANY FIELD TRIPS PLANNED BY THE CLUB*
INITAL
UTILIZE THE CLUB POOL WHEN SCHEDULING ALLOWS*
INITAL
ANY MEDICAL TREATMENT REQUIRED*
INITAL
1. By selecting 'yes', I consent to the collection, use and disclosure of my personal information during the course of my or my child's membership/services for the purpose set out in the Boys and Girls Club of Niagara privacy policy. By selecting 'no', I consent to the use of my personal information only for the purpose of permitting the Boys and Girls Club of Niagara to communicate with me.*

YESNO
2. I consent to my child's image being published in web or print directories for by the Boys and Girls Club of Niagara and/or its branches.*

YESNO
3. By selecting 'yes', I consent to my child's participation in the Boys and Girls Club of Niagara programs. By selecting 'no', I do not consent to my child participating in the boys and girls club of Niagara programs.*

YESNO
YOUR SIGNATURE BELOW INDICATES YOU HAVE FULLY READ, UNDERSTOOD AND COMPLETED THE REGISTRATION FORM AND AGREE TO ALL PERMISSIONS AND WAIVERS CONTAINED HEREIN.
SIGNATURE*

Clear
DATE*

MonthDayYear
Date
ZONE REGISTRATION & CONTACTS
PROGRAM:

KIDS ZONE (6-12 YEARS OLD)TEEN ZONE (13+ YEARS OLD)
SITE

NIAGARA FALLS CLUBST. CATHARINES CLUBFORT ERIE CLUB - EJ FEELAND CENTRE

ALLOWABLE PICK UPS AND EMERGENCY CONTACTS (other than guardians; will call guardians listed above in the event of an emergency) LIST IN APPROPRIATE CALL ORDER, ID REQUIRED FOR PICK UP

	FIRST AND LAST NAME	RELATION	PHONE
1
2
3
4

SAFE ARRIVAL/SAFE RELASE & PARENT HANDBOOK

PLEASE INITAL ALL THAT APPLY
I AUTHORIZE MY CHILD TO PARTICIPATE IN THE BGCN NIAGARA ZONE PROGRAM*
INTIAL
I ACKNOWLEDGE THAT A GUARDIAN MUST BE PRESENT TO SIGN MY CHILD IN AND OUT OF KIDS ZONE PROGRAMS*
INTIAL
TEEN ZONE ONLY: I AUTHORIZE STAFF TO RELEASE MY CHILD FROM PROGRAM UNSUPERVISED
INTIAL
I AUTHORIZE MY CHILD TO BE RELEASE TO THE NAMES PROVIDED UNDER ALLOWABLE PICK UPS *
INTIAL
AFTER READING THE ZONES PROGRAM PARENT HANDBOOK, PLEASE INTIAL BELOW:
I HAVE PROVIDED THE BGC NIAGARA WITH THE MOST RECENT INFORMATION WITH RESPECTS TO MY CHILD INCLUDING EMERGENCY CONTACTS AND SPECIAL REQUIREMENTS *
INTIAL
I AGREE TO KEEP MY CHILD HOME OR MAKE OTHER ARRANGEMENTS IF THEY ARE NOT WELL ENOUGH TO PARTICIPATE IN DAILY ACTIVITIES AND AM PREPARED TO PICK MY CHILD UP IF ILL WITHIN 45 MINUTES OF CLUB CONTACT*
INTIAL
I WILL CALL THE BGC NIAGARA CLUB UNIT IF MY CHILD WILL BE ABSENT *
INTIAL
I ACKNOWLEDGE CLUB HOURS OF OPERATION AND WILL ADHERE TO PRACTICES IN PLACE AND FEES ATTACHED IN THE EVENT OF LATE PICK UP AFTER PROGRAM ENDS*
INTIAL
I HAVE READ THE PARENT HANDBOOK AND UNDERSTAND THE POLICIES AND PROCEDURES AS IT PERTAINS TO MY CHILD'S CARE AT THE BGC NIAGARA CLUB*
INTIAL
YOUR SIGNATURE BELOW INDICATES YOU HAVE FULLY READ, UNDERSTOOD AND COMPLETED THE REGISTRATION FORM AND AGREE TO ALL PERMISSIONS AND WAIVERS CONTAINED HEREIN.
SIGNATURE*

Clear
DATE*

MonthDayYear
Date
SPECIAL REQUIREMENTS
PARTICIPANT HEALTH CARD NUMBER*
PARTICIPANT GENDER*
PARTICIPANT AGE*
SPECIAL REQUIREMENTS
THIS SECTION WILL INFORM THE BGC NIAGARA STAFF OF ANY SPECIAL NEEDS THE PARTICIPANT HAS TO ENSURE A FULLY INTEGRATED SETTING AND OPPORTUNITIES FOR THE PARTICIPANT. IF THE PARTICIPANT HAS A DISABILITY OR REQUIRES MEDICATION FOR A SPECIAL NEED, PLEASE INDICATE BELOW. IF THE NEEDS OF THE PARTICIPANT REQUIRES ONE ON ONE SUPPORTS THE PARENT/GUARDIAN MUST MEET WITH THE SUPERVISOR TO DISCUSS
1. DOES THE PARTICIPANT HAVE ANY SPECIAL REQUIREMENTS?*

YESNO
IF YES, PLEASE SPECIFY*
IF NO, PLEASE ENTER NA
2. DOES THE PARTICIPANT NOW OR HAVE THEY EVER TAKEN ANY MEDICATIONS?*

PRESENTLYPREVIOUSLYNO
IF PRESENTLY WHAT MEDICATIONS?*
IF NO, PLEASE ENTER NA
WHEN?*
IF NO, PLEASE ENTER NA
HOW MUCH?*
IF NO, PLEASE ENTER NA
REASON?*
IF NO, PLEASE ENTER NA
3. ARE YOU RECEIVING SUPPORT SERVICES FOR THE PARTICIPANT AT THIS TIME?

YESNO
IF SO FROM WHAT AGENCY?*
IF NO, PLEASE ENTER NA
4. HAVE YOU RECEIVED SUPPORT FOR THE PARTICIPANT IN THE PAST?*

YESNO
IF SO FROM WHAT AGENCY?*
IF NO, PLEASE ENTER NA
5. DOES THE PARTICIPANT HAVE ANY ALLERGIES?*

YESNO
IS THE REACTION ANAPHYLACTIC?*

YESNO
IF SO WHAT ARE THEY AND WHAT IS THE LEVEL OF SEVERITY*
IF NO, PLEASE ENTER NA
ADDITIONAL SUPPORT - PLEASE INDICATE THE LEVEL OF SUPPRT NEEDED IN THE FOLLOWING AREAS:
DRESSING*
TOILETING*
MOBILITY*
COMMUNICATION*
FEEDING*
BEHAVIOUR*
MEDICATION DESCRIPTION

ANY MEDICATION DISTRIBUTED TO A PARTICIPANT BY A CLUB STAFF MUST BE CONTAINED IN THE ORIGINAL PRESCRIPTION BOTTLE FROM THE PHARMACY. ANY CHANGES TO THE ORIGINAL PRESCRIPTION MUST BE AUTHORIZED BY THE PHYSICIAN AND CHANGED AT THE PHARMACY.

MEDICATION DESCRIPTION

	NAME OF MEDICATION	DOSAGE (NOTE MG)	TIME TAKEN	DURATION
1
2
3

PARENT HANDBOOK
FINANCIAL AGREEMENT AND ACKNOWLEDGEMENT OF RULES AND REGULATIONS

After reading the 2023-2024 Zone Parent Handbook, please sign below. Your signature below indicates that you have fully read and understood the 2023-2024 Zone Parent Handbook and agree to all terms and conditions contained herein. Initial:
I have provided the BGC Niagara with the most recent information with respect to my child including emergency contacts and special requirements.
INITAL
I agree to keep my child home or make other arrangements if s/he is not well enough to fully participate in daily activities and am prepared to pick up my child if ill within 45 minutes of Club contact.
INITAL
I will call the appropriate BGC Niagara Unit if my child will be absent for any reason understanding that I will be charged the daily fee.
INITAL
| understand a guaranteed spot in care must be paid for in advance. 2-week written notice must be given to the Club reception for any child being withdrawn. I understand that parents not giving 2 weeks' notice are financially responsible for those 2 weeks of fees where applicable.
INITAL
I have read the Zone Parent Handbook and understand the policies and procedures as it pertains to my child's care at the BGC Niagara.
INITAL
I have read, understand and authorize the administration of over-the-counter products I may send with my child, if my child is unable to self administer.
INITAL
SIGNATURE*

Clear
DATE*

MonthDayYear
Date
Should be Empty:

2024-2025 Kids Zone and Teen Zone Registration Package

ZONE REGISTRATION & CONTACTS

PERMISSION & WAIVERS

ZONE REGISTRATION & CONTACTS

SAFE ARRIVAL/SAFE RELASE & PARENT HANDBOOK

AFTER READING THE ZONES PROGRAM PARENT HANDBOOK, PLEASE INTIAL BELOW:

SPECIAL REQUIREMENTS

SPECIAL REQUIREMENTS

ADDITIONAL SUPPORT - PLEASE INDICATE THE LEVEL OF SUPPRT NEEDED IN THE FOLLOWING AREAS:

MEDICATION DESCRIPTION

PARENT HANDBOOK