2018-2019 Tidal Waves Swim Team Registration

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

Participant Information

calendar
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 *
You have checked off that your child receives free or reduced lunch.  In the payment section please check the box that says you would like to apply for a scholarship.  Once you submit the form it will ask you for your credit card information. You do not need to enter your credit card information. The office will contact you to discuss payment.

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

Acknowledgements

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 or its partners. The Boys and Girls Club reserves the right to revoke membership at any time. *

Payment

Payment options *

Visa
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