Mayo School Year 2022-23
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Parent's E-Mail Address: *
Child's First, Middle, & Last Name: *
Date of Birth (Month, Day, Year): *
Birthplace (City & State): *
Age: *
Grade: *
Teacher's Name
Gender: *
Ethnicity/Race: *
Does your child receive free or reduced lunch? *
Child's Shirt Size: *
Physical Address (Address, City, State, Zip Code): *
1. Parent Contact (Name): *
Parent Contact (Cellphone Number): *
Parent Contact (Employer & Work Number): *
2. Parent Contact (Name): *
Parent Contact (Cellphone Number): *
Parent Contact (Employer & Work Phone Number): *
3. Emergency Contact (Name, Relationship, & Phone: *
4. Emergency Contact (Name, Relationship, & Phone: *
List ALL Names & Telephone Numbers of those who may pick your child up: *
How many live in the household? *
How many live in the household that are under 18? *
Who does your child live with? *
Required
Please indicate any health problems your child has: *
Required
Please explain other health problems or if none please type NONE: *
I give Boys & Girls Clubs of the Upstate permission to administer prescription medication to your child as directed on prescription label: *
I give my permission to allow my child's name, photo, or video image, essays, artwork and/or projects to be used for the purpose of news, publicity, and publication including images & videos for YouTube: *
I hereby allow my child to join and participate in the Boys & Girls Club and participate in its various activities, field trips, and programs. I understand the Club has a discipline plan to place for its Club members and I agree to support and adhere to that plan along with other Club policies. I commit to support the Club's family PLUS program. I give my permission to allow the Club administration to access my child's report cards, test scores, and other school data to be held confidentially for program evaluation purposes. The undersigned, in my capacity as parent or legal guardian, hereby acknowledge the health risks and dangers associated with the transmission of the COVID-19 virus, and other communicable diseases, and recognize the exposure of the COVID-19 virus, or other communicable diseases, could occur while my child is in the care of the Boys & Girls Club of the Upstate. As such, and in consideration for services to be provided by the Boys & Girls Clubs of the Upstate, the undersigned, for myself and my minor child enrolled in the program fully assume all of the risks associated with participation in the program, including the possibility of COVID-10 (or the novel coronavirus) community spread. I, AS A PARENT AND/OR LEGAL GUARDIAN HAVE READ AND FULLY UNDERSTAND AND VOLUNTARILY WAIVING, RELEASING, INDEMNIFYING AND DISCHARGING BOYS & GIRLS CLUBS OF THE UPSTATE AND ITS OFFICERS, DIRECTORS, EMPLOYEES AND VOLUNTEERS FROM ANY AND ALL LIABILITY, DAMAGES AND EACH AND EVERY ACTION (COLLECTIVELY, "CLAIMS") BY PARTICIPATION IN AND/PR ASSOCIATED WITH THE PROGRAM INCLUDING, BUT NO LIMITED TO EXPOSURE OR TRANSMISSION FO THE COVID-19 VIRUS. I represent that I have full authority to sign on behalf of my child(ren) and that my signature binds each other person having authority to make decisions on behalf of the child(ren). MY SIGNATURE BELOW IS CONFIRMATION THAT I HAVE READ AND FULLY UNDERSTAND AND ACKNOWLEDGE THE CONTENTS OF THE RELEASE AND AGREE THAT I AM VOLUNTARILY WAIVING, RELEASING, INDEMNIFYING AND DISCHARGING BOYS & GIRLS CLUBS OF THE UPSTATE AND ITS OFFICERS, DIRECTORS, EMPLOYEES, AND VOLUNTEERS FROM THE CLAIMS. (By typing your name, you are signing that you agree to all the terms and conditions) Sign below: (Please type your first and last name to sign) *
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