Boys and Girls Club Services of Greater Victoria
ABL Registration Form 2010
Boys & Girls Club Services of Greater Victoria and the Boys & Girls Clubs of Greater Victoria Foundation are committed to protecting the privacy of the personal information of our employees, volunteers, members, participants and their families, donors and other stake holders and we have developed appropriate policies to safeguard that personal information. Please review these policies on our website, www.bgcvic.org. If at anytime you feel that your privacy rights have been violated, please contact our Agency Privacy Officer – see website for contact information, or call (250) 384-9133.
Section 1 – PARTICIPANT INFORMATION
Name:______________________________ Home Phone:__________________
Age:__________ Date of Birth:__________________
Address:__________________________________________ Male Female Trans
City:________________ Postal Code:____________
E-mail:____________________________School:________________ Grade:______
Cultural Background: Caucasian New Canadian
First Nations: Band:__________________________________
Other:__________________________________________________
Have you attended ABL programming before? Yes No
If yes, When and Where? ________________________________________________
Section 2 – PARENT/GUARDIAN INFORMATION (IF UNDER 18)
Mother/Guardian’s Name:________________________________
Day Phone:______________________________
Father’s/Guardian’s Name:_______________________________
Day Phone:______________________________
Youth currently lives with:(Please check only one)
Mother Two Parents In Care Father Shared Custody Other________________
Custody Arrangement / Order: Yes No IF YES PLEASE ATTACH
Section 3 – EMERGENCY INFORMATION
Care Card Number:________________________ Family Doctor:_______________________ Phone:____________
If I am not available, I authorize Boys and Girls Club Services to secure the medical services deemed necessary for the well being of my son/daughter/youth. Parent/Guardian Initials:________
Emergency Contact #1
Name:__________________________________ Phone:________________________ Relationship:_____________
Emergency Contact #2
Name:__________________________________ Phone:________________________ Relationship:_____________
_
Section 4 – SWIMMING ABILITY _
Please indicate your youth’s swimming ability:
Strong Swimmer Capable Swimmer Weak Swimmer Non Swimmer
(deep water/ (up to shoulder/ (waist deep/ (shallow water/
Deep pool) shallow end of shallow end of small pool only)
big pool) big pool)
Section 5 – HEALTH & SPECIAL CONSIDERATIONS _
Has your child experienced, or are they currently experiencing any of the following? Please check:
Hepatitis, HIV, Tuberculosis, Other infectious conditions, Diabetes, Epilepsy,
Thyroid condition, Liver or kidney conditions, Vision impairment or requires glasses,
Hearing impairment, Motion sickness
Dizzy spells, Fainting, Convulsions, Persistent headaches,
Asthma – allergy/exercise induced Chest pains on exertion,
Frequent infections of throat, tonsils, sinuses, or ears, Chronic skin problems – rashes, hives
Chronic cough bronchitis, bloody sputum Poor circulation - gets cold easily,
Heat palpitations, irregular heartbeat, heart murmurs, Poor circulation - gets cold easily,
Nausea, Vomiting, Food intolerances, Heartburn, Diarrhea or blood in the stool,
Pain in neck, back, shoulders, arms or legs, Hernia,
Joint pains, swelling, or stiffness, injury, Urination difficulty: enuresis ,
Broken bones, Joint dislocations, Serious sprains Injury to head, chest, internal organs,
Fear of heights,Claustrophobia, Agoraphobia, Dietary restrictions or food allergies, Continuing use of alcohol or drugs Episodes of depression or anxiety
Any other health concerns_______________________________________________________
Section 6 – CHILD PICK UP INFORMATION
I, the parent/guardian or the designate(s) listed below, will pick up my youth at the program completion time. Person(s) I designate to pick up my youth are: _______________________________________________________
_______________________________________________________
Signature of parent/guardian:_____________________________Date:______________________
Section 7 – ADDITIONALS
May we send you our annual appeal letter? Yes No
Would you like to receive a copy of our quarterly agency newsletter? Yes No
Photography Waiver:
I also give permission for photographs of my child to be used for publicity purposes connected with the promotion of Boys & Girls Club Services. Yes No Parent/Guardian Initials:_________
Section 8 – OFFICE USE ONLY
Start Date:_____________________________ End Date:_____________________________
Program Payment Information:
Registration form complete: Yes No
Paid: Yes No
Method of Payment: Cash Cheque Credit other
Card type:_____________________________________
Name of Cardholder:___________________________________
Card Number:____________________________Expiry Date:________________
Security Code (when applicable):____________________