RSCC 20124821 50Avenue, St. Paul T0A 3A0 Tel:780 645-6769; Fax:780 645-3650; e-mail: bgclubstpaul.ab@hotmail.caSummer Program 2015Child's Name:DOB:Home Address:Mothers Name: Fathers Name:Guardian #1 Name: Guardian #2 Name:Land/Street Location: Land/StreetLocation:Mailing Address: Mailing Address:Town/Province: Town/Province:Postal Code: Postal Code:Phone #: Phone #: Cel #: Cel #: E-mail address: E-mail address: Work/School Phone #: Work/School Phone #:Best Way to reach you (cirlce one): Text, Call, Email, Face Book Message Best Way to reach you (cirlce one): Text, Call, Email, Face BookEmergency Contact #1: Emergency Contact #2: (Must be other than parent/guardian & in the St. Paul County)(Must be other than parent/guardian & in the St. Paul County)Home Address: Home Address:Phone#:Phone#:Cel#:Cel#:Work/School Phone #: Work/School Phone #:Medical Condition: YesNoState Medical Condition:List of Medication:How is medication to administer: Allergies: YesNoList of Allergies: Allergy Reactions: Emergency actions: Immunizations up to date: YesNoExplaination(Optional):Emergency/Medical Waiver: I give permission to the Summer Program Staff to give emergency medical care to the event that I cannot be contacted immediaately. I furtherconsent to pay for all medical expenses deemed necessary in such an emergency.

Parent/Guardian Signature:Date: Health HistoryWhat are your child's reactions to illness:(convulsions to high fever etc.)

Eating HabitsFood likes: Food dislikes:Is your child a fussy eater:

Sleeping HabitsDoes your child nap?:YesNoAny other relevant information:Toileting HabitsIs your child toilet trained?YesNoAny other relevant information?:

Note: Parents are required to supply diapers, pull ups, ad wipes for those children who use them. Also, please supply extra clothing and underwear at all times. Thank you! Photo WaiverI give permission to the Summer Program staff to take pictures of my child whileattending the centre and centre functions. These pictures may be displayed in photo albums, and on facebook and centre dcor etc. Parent/guardian signature:Date:

Field Trip Permission WaiverI hereby give consent for my child to leave the premises of the centre on walking excursions to placesof interest planned and supervised by the staff of the Boys & Girls Club of St.Paul and District. I understandthe children visit businesses in St. Paul as well as neighbourhood parks and landmarks.Parent/guardian signature:Date:

Contracted time agreement: (maximum of 9.5 hours per day) I understand that I must have my child picked up from the Centre no later than my contracted time.I also understand that 9.5 hours per day is the maximum of hours I am entitled to for full time care.If I am late with no notice to the centre, I will be charged $5.00 for every 15 minutes that I am late.Parent/guardian signature:Date:Bingo contractI understand that I am responsible to work one bingo a year per child that is registered. I am responsibleto provide two $200.00 checks as retainers for the bingos I will be scheduled for. I understand that I will be provided with the dates and times of bingos that I am responsible for. Parent/guardian signature:Date:Bingo Schedule Dates (circle the date you would prefer) : July 1st, 4:15 PM or August 10th at 5:00PM

Notice of TerminationI agree to give a one week written notice of termination of my child from the centre. I understand that if I do not give a weeks notice I will be responsible for the full month fee.Parent/guardian signature:Date:Holidays/absencesI understand that I am responsible for notifying the centre of any holidays/absences that my child and I may take. Also, I am aware that I am responsible for fees in my childs holiday/absences.Parent/guardian signature:Date:

Family Handbook AgreementI have received and read the family handbook of policies and guidelines. I agree to abide by these policies and understand that my child's space may be terminated in failure to do so.Parent/guardian signature:Date:

Child's fileChild's files and waivers have to be updated with any changes of infromation ie. New phone numbers.

Getting to know your child:Has your child been cared for by anyone other than a family member: YesNoWhat is your childs first spoken language:Tell us about your family: (siblings, hobbies, culture & traditions, etc)

How well does your child settle in new surroundings?

Does your child have any particular fears or dislikes?

Does your child have any comfort item? (blanket, toy?)

Are there any customs or religious beliefs that would prevent your child fromparticipating in any holiday or seasonal occasions?

Please comment on anything that would be of importance concerning your child.

Your child's daily informationWhat date will your child start coming to the Centre? What time would your child arrive? What time will your child be picked up?Contracted hoursWhat days during the week would your child need the Centres services? (Please enter hours required per day.)MondayTuesdayWednesdayThursdayFriday

Families are entitled to a maximum of 9.5 hours a day for full time fees.There is an extra charge for exceeding the maximum daily hours.I have read and understand: Parent/Guardian InitialsWho is has permission to pick up your child from the centre? (They require photo id when they do so.)

NameRelationship to the child

Parent/Guardian Initials

Is there anyone who is absolutely NOT allowed to pick-up or have access to your child?NameRelationship to the child

Parent/Guardian Initials

I have read and filled out this registration form completely and truthfully to the best of my knowledge.Parent/ Guardian signature: _____________________ Date: ______________Thank you for choosing The Boys and Girls club . We look forward to our days with your child!

&"Comic Sans MS,Bold"&14The Boys & Girls Club of St.Paul and District

&P&8Created by Sylvie ProteauUpdated by the Accreditation Team June 12th, 2015

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