2017-2018 February Vacation Camp Registration

Boys & Girls Club of East Providence

115 Williams Ave

East Providence, RI 02914

www.epbgc.org

2017 Holiday Camp Hours: Feb. 19-23, 2018 from 6:30am - 6:00 pm

Vacation Camp Registration Includes: Club membership for one year, one free field trip of your choice (schedule to be released early February),

and lunch and dinner daily.

Participant Information

First Name *

Middle Name

Last Name *

Nickname

Birth Date *

Gender *

Home Address *

City *

State *

Zip *

Phone *

Email *

Ethnicity *

Current School *

School if choosing other above

Grade in September 2017 *

Does you child know how to swim? *

Yes

No

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

Member Lives With *

Household Size - Please include all adults and children living in the household *

Annual Household Income: This information is kept confidential and is used to help us secure funding through Boys & Girls Clubs of America and other funders *

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

Yes

No

Does you child receive free or reduced lunch at school *

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#

Child's Immunization Record - Please upload a copy of your child's immunization record. You may use a photo or scan of the record. Your registration will not be complete until we receive this record.

Child's most recent physical (must be dated within last year) - Please upload a copy of your child's most recent physical. You may use a photo of the physical. Your registration will not be complete until we receive this physical.

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

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)
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)

Additional Forms

Meal Benefit Form - This form must be returned to the Club in order for us to receive CACFP reimbursement for meals. You will not be charged for any meals covered by CACFP funds.

The meal benefit form can be found here.

Acknowledgements

Field Trip Permission

I hereby grant permission for my child to attend field trips during the vacation camp, including walking to Central Avenue playground if weather permits. *

I agree

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 agree

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. *

I agree

Payment

One Week Vacation Camp Registration *

$90.00