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The Boys Girls Club of St.

Paul and District


4821 50Avenue, St. Paul T0A 3A0

Tel:780 645-6769; Fax:780 645-3650; e-mail: bgclubstpaul.ab@hotmail.ca

Summer Program 2015


DOB:

Child's Name:
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 Bo

Emergency 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:

Yes

No

Yes

No

Yes

No

State Medical Condition:


List of Medication:
How is medication to administer:
Allergies:
List of Allergies:
Allergy Reactions:
Emergency actions:
Immunizations up to date:

Explaination(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 further
consent to pay for all medical expenses deemed necessary in such an emergency.

Created by Sylvie Proteau


Updated by the Accreditation Team June 12th, 2015

The Boys Girls Club of St.Paul and District

Date:

Parent/Guardian Signature:

Health History
What are your child's reactions to illness:(convulsions to high fever etc.)

Eating Habits
Food likes:
Food dislikes:
Is your child a fussy eater:
Sleeping Habits
Any other relevant information:

Does your child nap?:

Yes

No

Toileting Habits
Is your child toilet trained?

Yes

No

Any 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 Waiver
I give permission to the Summer Program staff to take pictures of my child while
attending 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 Waiver
I hereby give consent for my child to leave the premises of the centre on walking excursions to places
of interest planned and supervised by the staff of the Boys & Girls Club of St.Paul and District. I understand
the 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 contract
I understand that I am responsible to work one bingo a year per child that is registered. I am responsible

Created by Sylvie Proteau


Updated by the Accreditation Team June 12th, 2015

The Boys Girls Club of St.Paul and District


to 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

Notice of Termination
I 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/absences
I 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 Agreement
I 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 file
Child'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:
What 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?)

Created by Sylvie Proteau


Updated by the Accreditation Team June 12th, 2015

The Boys Girls Club of St.Paul and District


Are there any customs or religious beliefs that would prevent your child from
participating in any holiday or seasonal occasions?
Please comment on anything that would be of importance concerning your child.

Your child's daily information


What date will your child start coming to the Centre?

What time would your child arrive?


What time will your child be picked up?
Contracted hours
What days during the week would your child need the Centres services?
(Please enter hours required per day.)
Monday Tuesday

Wednesday

Thursday

Friday

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

Who is has permission to pick up your child from the centre?


(They require photo id when they do so.)
Name

Relationship to the child

Parent/Guardian Initials

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

Relationship to the child

Parent/Guardian Initials

I have read and filled out this registration form completely and truthfully to the best of my
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Created by Sylvie Proteau


Updated by the Accreditation Team June 12th, 2015

The Boys Girls Club of St.Paul and District


knowledge.
Parent/ Guardian signature: _____________________

Date: ______________

Thank you for choosing The Boys and Girls club . We look forward to our days with your child!

Created by Sylvie Proteau


Updated by the Accreditation Team June 12th, 2015

The Boys Girls Club of St.Paul and District

l.ca

Call, Email, Face Book

County)

Created by Sylvie Proteau


Updated by the Accreditation Team June 12th, 2015

The Boys Girls Club of St.Paul and District

facebook and

derstand

nsible

Created by Sylvie Proteau


Updated by the Accreditation Team June 12th, 2015

The Boys Girls Club of St.Paul and District

t I will be

ugust 10th at 5:00PM

Yes

No

Created by Sylvie Proteau


Updated by the Accreditation Team June 12th, 2015

The Boys Girls Club of St.Paul and District

m daily hours.

rent/Guardian Initials

Created by Sylvie Proteau


Updated by the Accreditation Team June 12th, 2015

The Boys Girls Club of St.Paul and District

___

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Created by Sylvie Proteau


Updated by the Accreditation Team June 12th, 2015