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2020 Project Backpack Registration Form

2020-2021 Project Backpack Registration Form

Pick-Up: WEDNESDAYS from 3:00pm-7:00pm at the Club (1301-104 St. North Battleford)

Project Backpack will run from October 21, 2020 - June 16, 2020. Pick up will be located through the back gym doors (near the playground).

MEMBER INFORMATION

Member's Name *

First

Last

Birthdate (month/date/year) *

Physical Address *

Address Line 1

City

State / Province / Region

Postal Code

Mailing Address

Address Line 1

City

State / Province / Region

Postal Code

Gender *

Male
Female
Non-binary

School

Siblings Who are Members

Background Information (Voluntary): To support BGCB in tracking progress, statistics, and applying for funding, please check if any of the below categories apply to you.

First Nations
Metis
Francophone
ESL (English Second Language)
New Canadian
Immigrant

Country of Origin

PARENT/GUARDIAN INFORMATION

Parent/Guardian #1 Name *

First

Last

Relation to Member *

Employer *

Phone Number *

Cell Number *

Email Address

Parent/Guardian #2 Name

First

Last

Relation to Member

Employer

Phone Number

Cell Number

Email Address

HOUSEHOLD INFORMATION

How many adults are in the household? *

How many children are in the household? *

What are the names and ages of everyone in the household? *

Does anyone in the household have any food allergies? *

Yes
No

If yes, what are the food allergies?

MEDIA CONSENT & RELEASE

Boys & Girls Clubs of The Battlefords has the right to use any artwork, photographs, video and/or audio of myself, my child and any other members of my household while participating in club activities for the purpose of advertisement and promotional campaigns in the future. *

Yes, I agree.
No, I do not agree.

Media Consent & Release -NAME *

First

Last

Media Consent & Release -DATE (month/date/year) *

PROJECT BACKPACK RULES AND ACKNOWLEDGEMENT

Parents/Guardians please read and agree to, by initialing beside, the following statements:

I understand that if I miss TWO pick-up dates within the school year I may be removed from the program. *

I understand that I must inform Boys & Girls Clubs of The Battlefords if my phone number, address, or household information changes. *

I understand that if I will be unable and/or away on a pick-up day I must contact BGCB. *

I understand that there will be no delivery under any circumstances. *

I understand that pick-up day is Wednesdays between 3:00pm-7:00pm. *

Rules & Acknowledgement - NAME *

First

Last

Rules & Acknowledgement -DATE *

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