Registration 2014-2015 - St. Patrick
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Child's last name *
Child's First Name *
text
Gender and Age *
Ethnicity *
Race *
How many years has your child attended Boys & Girls Club *
Parent 1/Guardian's Name *
Parent/Guardian's Cell Number *
(000)000-0000
Parents/Guardian's Work Number *
(000)000-0000
Parent 2/Guardian's Name *
Parent's/Guardian's Cell Number *
(000)000-0000
Parent's/Guardian's Work Number *
(000)000-0000
What grade will your child be going into in the Fall of 2014? *
Child's Birthdate *
00/00/0000
Home Address *
Number & Street Name
City & State *
Zip Code *
Child lives with: *
Home Phone Number *
Parent contact email address *
Additional Emergency Contacts and Pick Up List, Relation to Child, Contact Numbers
Does your child have any allergies? If so, please list what they are allergic to. *
Does your child have any medical conditions?  If so, please list below. *
Child's Doctor, Doctor's phone number, Insurance Company, and Policy Number *
Does your family qualify for the free/reduced-price lunch program? *
Are you a Military family not living on a base? *
Parent Agreement - PLEASE READ *
Please note that your child's registration is not complete until registration is paid and the Parent Information Guide is read and form is turned in.  Please Read NO REFUND/NO EXCEPTIONS POLICY The Boys & Girls Club of Burbank and Greater East Valley: My signature attached to the following statements signifies my understanding and acceptance of the terms stated herein.   Boys & Girls Club of Burbank and Greater East Valley can share information with Boys & Girls Clubs of America in an effort to best measure Club impact. Permission is herewith granted for my child to participate in all sponsored Boys & Girls Club activities or special events during the time he/she maintains a current membership in the organization. Release is also given for medical, hospital, or surgical care in the case of an accident or emergency, when administered by a licensed physician, provided neither parent can be reached. Further, I agree that the Club may personally transport my child to the nearest known hospital and will hold the Club harmless of any consequences related to such transportation. I grant permission for the Club to take and use photos and video footage of my child in the news and press releases included but not limited to, promotional materials. Further, I herewith acknowledge a WAIVER OF CLAIMS, which releases and forever discharges the Boys & Girls Club of Burbank and Greater East Valley, its staff, and Board of Directors, from any claim or demand what so ever arising out of the participation of my child or ward in the Boys & Girls Club of Burbank and Greater East Valley planned programming conducted in or outside a Boys & Girls Club facility or in the handling of an emergency involving the aforementioned Boy/Girl member. I am also aware that the Boys & Girls Club has an open door policy which means members are free to come and go as they please, unless a parent states otherwise in writing. Our satellite locations all adhere to a sign in and sign out policy and no one is allowed to pick up or walk home with a child unless they are listed on the emergency contact form. If you need to update your emergency contacts, this must be done in writing at your home sites. Once they leave the Club premises, they are no longer under its control or supervision. LATE PICK UP FEE The Club charges a $1 per minute late pick-up fee after the stated closing time and must be paid when child is picked up. Fees are DUE the FIRST of the month. LATE PAYMENT FEE The Club charges a $15 late fee if the monthly fee is paid after the 5th of the month.  Your child may not return until correct payment is made.  Each family is responsible for 5 Hours of Commitment @ $26.34 an hour.  If hours/donations are not completed by the end of the school year you will be charged the remaining balance. Replacement Policy  The Boys and Girls Club of Burbank does not provide refunds in any case. Please note that the Boys and Girls Club of Burbank is not liable for any lost or stolen items. If your child loses or breaks Boys and Girls Club of Burbank property or equipment, it is expected for the member to replace it. By Signing below you are agreeing to all the terms above:
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