Beyond Boundaries Collective Enrollment Form

BBC STUDENT PARTICIPANT PROFILE
Child's Legal Name*

Last NameFirst Name
Child's Preferred Name

Last NameFirst Name
If you are enrolling more than one child, please list the legal and preferred names of each child below. In answering questions, please state which answers apply to which children so we can keep clear records.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Date of Birth*

MonthDayYear
Date
Age*
Sex*
School*
Grade*
Child Lives With:*
Mother's Name*

First NameLast Name
Phone Number (C)*

Area CodePhone Number
Phone Number(H)

Area CodePhone Number
Phone Number(W)

Area CodePhone Number
Father's Name*

First NameLast Name
If you need to list multiple parents for multiple children please do so below in this space with their contact information and who the child resides with:
Phone Number (C)*

Area CodePhone Number
Phone Number(H)

Area CodePhone Number
Phone Number(W)

Area CodePhone Number
PERSONS TO CONTACT IN CASE OF AN EMERGENCY WHEN A PARENT CAN'T BE REACHED
Name*

First NameLast Name
Relationship to Parent*
Relationship to child
Phone Number*

Area CodePhone Number

To the Beyond Boundaries Collective Team,

If during the course of my child’s activities, should he/she become ill or sustain an injury, I hereby authorize you to obtain medical and dental attention.
Primary Parent Signature*

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Date*

MonthDayYear
Date
Family Doctor*
Phone Number*

Area CodePhone Number
Does your child need any reasonable modification, because of a different kind of learning ability, to enjoy this program?*
Will your child be taking medication during the program hours?*
A special medication form must be completed prior to giving a child any medication.
Do you give our permission to give your child children’s tylenol if his/her physical condition necessitates it? *
Does your child have any incontinence problems that we need to be aware of? *
Are there any custody issues we need to be aware of to ensure your child’s safety? if yes, please explain. *
Child's Insurance Information
Insurance Company:
Group Policy Number:
Name of Insured:
BEYOND BOUNDARIES COLLECTIVE DROP OFF & PICK-UP AUTHORIZATION FORM

LIST PEOPLE AUTHORIZED TO DROP OFF AND PICK UP CHILD FROM BBC
Parent:*

First NameLast Name
Children*
List any other person(s) please note: Must Show Picture ID
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Primary Parent Signature*

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BEYOND BOUNDARIES COLLECTIVE'S

PROCEDURES FOR ADMINISTRATION OF PRESCRIPTION MEDICATION

The following is our written procedure for the administration of prescription medication by our staff during operating hours.

ADMINISTRATION OF MEDICATION FORM:

The parent must obtain a letter from the child’s physician or health provider indicating the need to administer the prescribed medication to the child during their time at school.

ALL MEDICATIONS MUST BE IN ORIGINAL CONTAINER AND CURRENT.

Our staff must have each parent complete and sign the Authorization for Medication form prior to administration of any medication to a child.

Responsibilities of the Physician/Health Care Provider:

The physician or health care provider must indicate the following in writing:
- Name of the medication, dosage, frequency and method of administration.
- Description of anticipated adverse reactions of the child to the medications.
- Physicians/Health Care Provider signature.
- Parent’s signature approving the administration of the medication (noted on the Authorization of Medication Form).
STORAGE OF MEDICATIONS:

All medications will be stored and secured.

The authorized staff will be the only individuals with access to the medications that are stored.

RESPONSIBILITY FOR ADMINISTERING MEDICATIONS:

The authorized staff will administer all prescribed medication to those children whose parent(s) have signed the Authorization for Medication Form, according to the physician’s orders.

BBC AUTHORIZATION FOR MEDICATION FORM

ONLY PRESCRIPTION MEDICATION WILL BE GIVEN

No medication shall be given by the staff except in special circumstances arranged by authorized staff, at which time a signed note from the parent/guardian giving permission must be on file with our team.
CHILD'S NAME

First NameLast Name
MEDICATION AND PRESCRIPTION NUMBER
NOTE: MEDICATION MUST BE IN ORIGINAL CONTAINER
TIME MEDICATION IS TO BE GIVEN
AMOUNT OF MEDICATION TO BE GIVEN
PARENT/GUARDIAN SIGNATURE

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Date

MonthDayYear
Date

FOR STAFF USE ONLY:

DATE / TIME MEDICATION GIVEN	ADMINISTERED BY
____________________________________	_____________________
____________________________________	_____________________
____________________________________	_____________________

COMMENTS:

_______________________________________________________________

Acknowledgment of the BBC Parent Handbook
Please download and save the BBC Parent Handbook by clicking here.

You are held accountable to the policies stated in the handbook. By signing below you acknowledge receipt and understanding with the policies in the handbook.
Yes I have received, saved, and read the Parent Handbook. By signing below I agree to abide by the policies stated within it.

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Understanding Your Family Vision

Acknowledgment of the BBC Parent Handbook