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Boys Clubs -Form Fill

Section One
Q1

Student Name

First Name
Q2

Student Name

Middle Name
Q3

Student Name

Last Name
Q4

Birth Date

Month
Q5

Birth Date

Day
Q6

Birth Date

Year
Q7

Gender
Q8

Address

Street Address
Q9

Address

Street Address Line 2
Q10

Address

City
Q11

Address

State / Province
Q12

Address

Postal / Zip Code
Q13

Address

Country
Q14

Parent/Guardian Name

First Name
Q15

Parent/Guardian Name

Last Name
Q16

Parent/Guardian E-mail
Q17

Mobile Number

Phone Number
Q18

Phone Number (Other)

Phone Number
Q19

What grade is your Child in?
Q20

What club(s) will your student be participating in?
Q21

I give my child permission to participate in the BDC after school program. I, individually and on behalf of the minor student, voluntarily enter into this waiver and release of liability agreement and waive any and all claims, rights and causes of action of any kind whatsoever arising out of the students participation in BDC after-school programs.
Q22

Type a question
Q23

I fully understand that my child's photo may be taken by members of press/staff at various events or programs. Also, it may be necessary for program staff or volunteers to photograph or video my student to advertise for BDC programs. I give my permission for program staff to photo or video my child. I understand the BDC will only use my student's first name.
Q24

Any Allergies or Medical Conditions we need to be aware of?
Q25

Additional Comments/Questions
Q26

I, THE PARENT OR GUARDIAN, HAVE READ THE ABOVE INFORMATION AND FULLY UNDERSTAND AND TAKE FULL RESPONSIBILITY, WITH ANY RISKS ASSUMED IN ALLOWING MY STUDENT(S) TO BE A PART OF BINGHAMPTON DEVELOPMENT CORPORATION'S AFTER-SCHOOL PROGRAMING.
Q27

Signature