✿ FROM TWEEN TO TEEN GIRLS’ GROUP ✿

THE BELCHERTOWN KIDZ CLUB

- 2018 SUMMER PROGRAM -

Today’s Date:_______________
Girl’s Full Name: ______________________________________________________________
Girl’s Date of Birth: ____________________________________________________________
Girl’s Home/ Mailing Address: ____________________________________________________

Parent’s / Guardian’s Name: ______________________________________________________

Parent’s / Guardian’s Reachable Phone Number: ______________________________________
Parent’s / Guardian’s Email Address ________________________________________________

ALLERGIES:
The girls will be given snacks every session throughout the summer. Is there any known food
allergies that the Belchertown Kidz Club should be aware of? If so, please let us know on the line
provided: _____________________________________________________________________

PERMISSION:

I, _____________________, give the Belchertown Kidz Club’s all girls program permission to
PHOTOGRAPH my child for publicity and documentation purposes only. By signing this, I
understand that my child’s photo may/may not be used on our current Facebook group page,
local newspapers, flyers, etc.

I, ______________________, give the Belchertown Kidz Club’s all girls group program
permission to VIDEOTAPE my child for publicity and documentation purposes only. The group
leaders would like to use such footage in the slideshow/movie presented to friends and family
during our closing celebration week. By signing this, I understand that my child’s image may/
may not be used on our current Facebook group page.
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I, _____________________, DO NOT give the Belchertown Kidz Club’s all girls program
permission to PHOTOGRAPH my child for publicity and documentation purposes. By signing
this, I understand that my child’s photo will NOT be used on our current Facebook group page,
local newspapers, flyers, etc.

I, ______________________, DO NOT give the Belchertown Kidz Club’s all girls group
program permission to VIDEOTAPE my child for publicity and documentation purposes only.
The group leaders would like to use such footage in the slideshow/movie presented to friends
and family during our closing celebration week. By signing this, I understand that my child’s
image will NOT be used on our current Facebook group page.

PLEASE NOTE: While attending group for the duration of all weeks is not required, please inform
leaders when your child will not be attending group. This will help volunteers plan curriculum
accordingly. We appreciate your cooperation. Thank you!

PARENT/ GUARDIAN’S SIGNATURE ____________________________________