Summer Camp Participant Agreements 2020

Dear Parent/Guardian,

Completion of all sections of this form is required for participation in 2025-26 After School Program or Before School Program through Wakeman Boys & Girls Club. Please complete one form for each child. By completing this form, you acknowledge this information may be transferred to your Daxko family account by WBGC staff.

Location attending for After School Program and/or Before School Program:

Southport ClubhouseSmilow-Burroughs ClubhouseMadison Avenue Community ClubhouseMcKinley School Site

Child's Name*

First NameLast Name

Date Of Birth*

MonthDayYear

Address*

Street Address

Street Address Line 2

City/TownState

Zip Code

1st Parent/Guardian Name*

First NameLast Name

Relationship to Child*

1st Parent/Guardian Date Of Birth*

MonthDayYear

Home Phone*

Cell Phone*

Email*

example@example.com

2nd Parent/Guardian Name

First NameLast Name

Relationship to Child

2nd Parent/Guardian Date Of Birth

MonthDayYear

Home Phone

Cell Phone

Email

example@example.com

Insurance Carrier for Child*

Insurance Policy Number*

Does your child have:

Individual Education Program (IEP)504 Plan

If you would like Wakeman Boys & Girls Club to review your child’s IEP or 504 Plan, please provide a copy to the Program Director.

Special health care needs:

Other relevant information about your child helpful for our staff to support a great program experience:

Note: Section 19a-79-5a(a)(2)(E) of Connecticut State Statutes requires a child’s Health Record to include information regarding disabilities or special health care needs such as allergies, special dietary needs, dental problems, hearing or visual impairments, chronic illness, developmental variations or history of contagious disease, and an individual plan of care for the child with special health care needs or disabilities. The plan shall be developed with the child’s parent(s) and health care provider and updated, as necessary. Section 19a-79-4a(h)(2)(H)(viii) requires that the health consultant shall assist in the review of individual care plans
as needed.

I grant Wakeman Boys & Girls Club permission to arrange transportation for my child by ambulance to the hospital deemed appropriate by Club staff and emergency personnel. I give the hospital permission to treat my child in case of injury or accident sustained at Wakeman Boys & Girls Club.

Electronic Signature of Parent/Guardian - Permission to Treat*

Full Name of Parent/Guardian Completing this Form*

First NameLast Name

Date*

MonthDayYear

Insurance Form