2024-2025 Holy Family After School Program Membership Form

2024-2025 holy family after school program membership form

2024-2025 Holy Family After School Program Membership Form

MEMBER INFORMATION

Child's Full Name: *

First

Middle

Last

Child's Birthday: *

Mailing Address: *

Address Line 1

City

State / Province / Region

Postal Code

Physical Address (if different):

Address Line 1

City

State / Province / Region

School: *

Grade: *

Siblings who are members:

Is this child in Foster Care? *

Background Information (voluntary): To support BGC Battlefords in tracking progress, statistics, and applying for funding, please check if any of the below categories apply to your child.

PARENT/GUARDIAN INFORMATION

Parent/Guardian #1

Parent/Guardian #1 Name: *

First

Last

Relation to Member: *

Primary Phone Number: *

Alternate Phone Number:

Email Address: *

Employer:

Parent/Guardian #2 Name:

First

Last

Relation to Member:

Primary Phone Number:

Alternate Phone Number:

Email Address:

Employer:

EMERGENCY CONTACT INFORMATION

*Will only be contacted if we're NOT able to reach the parents/guardians listed above*

Emergency Contact #1

*OTHER THAN the parents/guardians listed above (e.g. Grandparent, Family Friend, Co-worker, Neighbour etc.)*

Emergency Contact #1 Name: *

First

Last

Relation to Member: *

Primary Phone Number: *

City of Residence: *

Emergency Contact #2

*OTHER THAN the parents/guardians listed above (e.g. Grandparent, Family Friend, Co-worker, Neighbour etc.)*

Emergency Contact #2 Name: *

First

Last

Relation to Member: *

Primary Phone Number: *

City of Residence: *

MEDICAL INFORMATION

Does your child have any needs/requirements in the following areas? If yes, please explain further. If applicable, please indicate any diagnoses and medications that they are taking. If no, please note 'not applicable' on the boxes below.

Allergies: *

Medical Condition(s): *

Learning/Behavioral Needs: *

Does your child have a disability? (ex. Physical Disability or Cognitive Disability such as: ADHD, FASD, etc.) *

Other Considerations (Any additional information which may assist your child in positively participating in our programs.): *

If your child requires the use of any medications (for allergies, medical conditions, etc.) while participating in our programs, separate medical/permission forms will be required. Forms are available online (www.bgcbattlefords.ca) or in person (by visiting the office).

CUSTODY AND/OR COURT ORDER

Custody and/or Court Order *

Not Applicable
See Below

If a custody or court order exists, a copy of the order must be given to BGC Battlefords. The parent/guardian is responsible for providing accurate and up to date information concerning the legal guardianship of the child. Without a custody or court order on file, BGC Battlefords cannot deny access to the non-enrolling parent.

Please attach a copy of the court order to this form or submit via email to ac.bcgb@ofni.

Click or drag a file to this area to upload.

Please list anyone who is NOT ALLOWED to pick up your child:

Custody and/or Court Order

I will provide BGC Battlefords with legal documentation (custody or court order).

Signature of Parent/Guardian

RELEASE PASSWORD

The safety of your child is of utmost importance to us. Therefore, until BGC Battlefords staff become familiar with the child’s parents/guardians, you will be asked for a release password OR government issued photo ID. Anyone picking up the child other than the parents/guardians will be asked for the same release password and/or their government issued photo ID.

Release Password: *

MEDIA CONSENT & RELEASE

BGC Battlefords has the right to use any artwork, photographs, video, and/or audio of my child while participating in Club activities for the purpose of advertisement and promotional campaigns in the future. My child’s image may be published or used in newspapers, promotional videos, television commercials, television news items, program brochures, posters, social media sites, etc. or otherwise displayed to the public or used for other educational/fundraising purposes, either in whole or in part by BGC Battlefords, BGC Canada and/or external partners. No names will ever be used in association with a child’s image without written permission of the parent/guardian. *

Yes, I agree
No, I don't agree

Signature of Parent/Guardian: *

CONTRACT AGREEMENT

Please choose the service agreement required for your child: By agreeing to this contract, you are committed to the contract and the contract fees regardless of attendance.

AFTER SCHOOL CARE (Class dismissal to 5:30pm, open early on Early Dismissal Days): *

Full-time – child can attend the program on all school days (approximately 20 days per month) - $250/month
Part-time – child can attend the program a max of 12 days/month - $160/month
Casual – child can attend the program a max of 5 days/month - $70/month
I do not require after school care

*If you require extra visits (beyond the 5 or 12 max days per month), additional care will be provided at a rate of $15/visit.

When do you intend to start the program? *

What is the timeframe that you are committed to this contract level? *

School Year
Specific Months

Do you have approval from another organization to cover the fees? If so, please provide us with their information:

Organization:

Contact Name:

Email Address:

Phone Number:

*Written approval from the organization is required prior to your child(ren) attending the programs.

CHANGES TO CONTRACT AND CANCELLATION POLICY

By signing this agreement, you are committing to this service agreement for the 2024-2025 School Year. Please note, changes/cancellations to this agreement require written notice BEFORE the 1st day of the month affected. For example, if you would like to change/cancel for October, you must submit the Satellite Site Contract Amendment Form by September 30th (or earlier). Please contact the office to request a Contract Amendment Form or visit our website (www.bgcbattlefords.ca). If we do not receive notice before the 1st of the month, you will owe the full amount invoiced to you. BGC Battlefords also reserves the right to terminate this program by providing one month’s notice to families. *

I have read and agree to abide by the Changes & Cancellation Policy.

Signature of Parent/Guardian: *

CONSENT TO RELEASE INFORMATION

Since BGC Battlefords is partnered with Holy Family School to provide this program, I acknowledge that the administration teams from BGC Battlefords and Holy Family School at times may communicate regarding my child (e.g. regarding attendance/support strategies, etc.) in order to provide the best services possible.

Signature of Parent/Guardian: *

PARENT/GUARDIAN HANDBOOK

I acknowledge that I will/have read and adhere to the information provided in the Parent/Guardian Handbook.

Please view our Parent/Guardian Handbook here. Paper copies will also be available at our office.

Signature of Parent/Guardian: *

MEMBERSHIP CONTRACT

Parents/Guardians: Please read and initial beside the following statements agreeing to:

• I understand that any violations of the Parent/Guardian and/or Participant Codes of Conduct may result in services being terminated. *

• I agree that under no circumstances are BGCB staff members, volunteers or board members responsible for lost or stolen belongings. *

• With full knowledge of the existence and nature of my legal right and in consideration for the opportunities provided to my child by BGCB, I waive my legal right against BGCB, its staff, volunteers, or Board of Directors for any injury or damage suffered during or by reason of practicing, participating or assisting in a BGCB service, program, or experience. *

• I further authorize the application of emergency medical attention and undertake to be responsible for any hospitalization, medical, ambulance or other expenses. *

Date / Time (am/pm):

Date

Time

Signature of Parent/Guardian: *

*If you would like a copy of this membership form, please contact the office at (306) 445-0002 or ac.bcgb@ofni.

BGC Battlefords is committed to protecting the confidentiality of personal information. The information collected will assist BGC Battlefords in service delivery and is kept confidential.