Boys & Girls Clubs Summer 2021 Childcare Registration

Boys & Girls Club of East Providence

115 Williams Ave

East Providence, RI 02914

www.epbgc.org

Camp hours 8:30AM-4:15PM

Before and After Camp available for an additional fee 6:30AM-8:30 AM and 4:15 PM - 6:00PM

Please read parent handbook for updated emergency childcare policies. This can be downloaded here.

Please be sure to send your child with water. We are unable to provide communal water per the Department of Health.

In order to comply with Covid regulations, our capacity will be limited. Once capacity has been reached we will be starting a waiting list. If no spots are available for the session you would like to register for and would like to be added to the waiting list, please check the box for the waiting list you would like to be added to. *

Session 1 July 12 - July 23 (0 remaining)

Session 2 July 26-August 6 (0 remaining)

Session 3 August 10-August 20 (Closed Aug 9) (0 remaining)

Waiting list Session 1 July 12 - July 23

Waiting list Session 2 July 26-August 6

Waiting listSession 3 August 10-August 20 (Closed Aug 9)

Before camp care is available beginning at 6:30 AM and After camp care is available until 6:00PM. Price for before and after camp care is $50 per two week session and space is limited. Please check here if you need before and after camp care. If you receive state assistance, this fee will be covered if you qualify for full time care.

Before and After Camp Care (0 remaining)

Waiting List - Before and After Camp Care

At the Boys & Girls Club of East Providence, we are committed to keeping our members safe. Please review our Covid-19 operations policies here to see what steps we will be taking to do so this summer.

Participant Information

Please note that you must fill this form out for each child you are registering.

First Name *

Middle Name

Last Name *

Nickname

Birth Date * +

Gender *

Home Address *

City *

State *

Zip *

Phone *

Email *

Ethnicity *

School Name *

Grade in September 2021 *

Household / Contact Information

Primary Emergency Contact Name *

Emergency Phone Number *

Mother/Guardian First Name *

Mother/Guardian Last Name *

Mother's Occupation

Mother's Employer *

Mother's Work Phone *

Mother's Cell Phone *

Mother's Email *

Father/Guardian First Name

Father/Guardian Last Name

Father's Occupation

Father's Employer

Father's Work Phone

Father's Cell Phone

Father's Email

Individuals other than parents/guardians who are authorized to pick up child. Please include their phone number. Reminder anyone picking up should have their photo ID for staff to confirm their identity.

	First Name	Last Name	Phone Number	Emergency contact(Y/N)
Contact	First Name	Last Name	Phone Number	Emergency contact(Y/N)
Contact	First Name	Last Name	Phone Number	Emergency contact(Y/N)
Contact	First Name	Last Name	Phone Number	Emergency contact(Y/N)
Contact	First Name	Last Name	Phone Number	Emergency contact(Y/N)

Member Lives With *

Does your child receive free or reduced lunch at school *

Yes

No

Is anyone in the household a member of the military or National Guard *

Yes

No

Health Information

Medical Problems/Allergies *

List ALL medications the child is taking *

Any restrictions of activity due to medical activity, if yes explain *

No

Yes Yes

Physician

Physician's Phone Number

Health Insurance Provider

Subscriber#

I would prefer that my child be taken to ________________Hospital. (Choice may be limited by local rescue service.) *

This health information is correct to the best of my knowledge and the person herein described has permission to engage in all prescribed activities, except as noted by me and the physician. I authorize the Boys & Girls Club of East Providence to arrange for medical examination and/or treatment of my child should an emergency arise in any Boys & Girls Club program. It is understood that every effort will be made to contact the emergency numbers provided before any medical action is taken. *

I agree

Acknowledgements

Childcare Handbook Acknowledgement I hereby acknowledge that I received and have reviewed the Boys & Girls Club of East Providence’s Childcare Parent Handbook. Childcare Handbook can be downloaded here *

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I understand that I am responsible for payment of all sessions that I have registered my child for and that no refunds are given except when disenrolling my child(ren) by giving advanced written notice by the Tuesday prior to the session they are registered for as outlined in the Camp Crosby Parent Handbook. *

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I understand that I must provide the Boys & GIrls Club of East Providence with a valid credit card or debit card number that will be charged as outlined in the parent handbook and that if the card is declined, my child's registration will be forfeited and filled with another child from the camp waiting list. *

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