| Child's Name: | |
| Date of Birth: (mm/dd/yy)
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Age:
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| Address: |
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| City: |
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| Postal Code: |
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| Parent / Guardian Name: |
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| Home Phone #: | |
| Work Phone #: |
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| Parent / Guardian Name: |
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| Home Phone #: | |
| Work Phone #: |
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| Emergency Contact Person: |
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| Phone #: |
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| Relationship to your child: |
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| Child's Health Card #: | |
| Doctor's Name:
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Phone #:
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| Please indicate any allergies, medications or special needs your child may have. If mediction needs to be given during program hours, please contact the Program Coordinator to fill out the "Permission to Administer Medication Form". (Please be specific) |
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| What camp are you registering your child for? |
Week #1: July 3rd - July 6th
Week #2: July 9th - July 13th
Week #3: July 16th - July 20th
Week #4: July 23rd - July 27th
Week #5: July 30th - August 3rd
Week #6: August 6th - August 10th
Week #7: August 13th - August 17th
Week #8: August 20th - August 24th |
| How will your child be getting home each day?: |
Walking Home Alone
Being Picked Up |
| If your child is being picked up, please indicate name of person who will be doing the pick-up. (Please list all authorized persons who are able to pick up your child(ren). Any persons whose name is not on this list will not be permitted to pick up your child) |
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| Please indicate your child's swimming level: |
Beginner
Intermediate
Advanced |
Does your child require a life Jacket?:
*Note- if your child does require a life jacket, they will not be permitted to take it off, even if remaining in the shallow end unless otherwise stated by parent/guardian. |
Yes
No |
| Please indicate your child's t-shirt size: |
Youth XS
Youth S
Youth M
Youth L
Youth XL
Adult XS
Adult S
Adult M
Adult L
Adult XL |
| If you would like to be added to our mailing list and receive program updates and program information, please provide your email address: |
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It is mandatory that any person signing this document read it first in its entirety.
General Waiver:
I, the undersigned, the parent/guardian of the above named child do hereby consent to this child's participation in the Boys and Girls Club of Kingston & Area programs. I acknowledge the participation in this program involves light to vigorous activity and includes the possibility of injury. I grant program officials the authority to obtain emergency medical treatment as necessary to insure that the above named child is safe from further injury. I am aware of no physical or other reasons why this child should not participate in club programs and related club functions. I will impress upon the child the importance of following club rules, regulations and instructors directions. In consideration of the Boys and Girls Club of Kingston & Area allowing this child to participate in club programs, I agree to waive and release Boys and Girls Club of Kingston & Area, it's employees, and agents from all claims for damages that may arise other than by negligence of the Boys and Girls Club of Kingston & Area, it's employees, and agents as a result of my child's participation in programs. I am aware that my child (children) may have their photograph taken by local media and may appear in a variety of media sources on behalf of the Boys and Girls Club of Kingston & Area.
Transportation Waiver:
I acknowledge that my child (children) will be participating in an activity, trip or event organized by the Boys and Girls Club of Kingston & Area. I am aware that the participation of my child (children) is outside the scope of their daily routine. I give permission for my child (children) to travel by foot, Boys and Girls Club Van, or Bus to the desired destination.
By checking on this box, I hereby acknowledge and confirm that I have read this entire document and agree that the above waivers are understood.
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