2017-2018 Childcare Registration

Boys & Girls Club of East Providence
115 Williams Ave 
East Providence, RI 02914
www.epbgc.org
 

Participant Information

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Ethnicity *
 
Does you child know how to swim? *

Household / Contact Information

Is anyone in the household a member of the military or National Guard *
Does you child receive free or reduced lunch at school *

Health Information

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


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. *
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 NameLast NamePhone NumberEmergency contact(Y/N)
Contact
Contact
Contact
Contact
Contact
Contact
Contact
Contact

Additional Forms


Transportation
 
Most transportation is provided by the East Providence School Department.  All children, except those attending Oldham Elementary School and Hennessey Elementary School must fill out a transportation appeal form and have it approved by the East Providence School Department in order to attend the Childcare program.  
 
The appeal form can be found here.

Acknowledgements

Field Trip Permission 

I hereby grant permission for my child to walk to Central Avenue Playground with Boys & Girls Club of East Providence Staff. *
Childcare Handbook Acknowledgement

I hereby acknowledge that I received and have reviewed the Boys & Girls Club of East Providence’s Childcare Parent Handbook.

Handbook can be downloaded here *
I have read the completed application, understand the rules of the Boys & Girls Clubs and request that my son/daughter be admitted into membership. I have explained the rules to my son/daughter and agree that the Boys & Girls Club will not be responsible for any accident to the boy/girl while on the Club premises or while engaged in any of its activities away from the Club. I give my consent for photographs, in which my son/daughter may appear, to be used in any way by the Boys & Girls Club. The Boys and Girls Club reserves the right to revoke membership at any time. *