2004 Summer Arts Program


Student Registration Form


Studentís Name ________________________________________††† Sex _______

Age ____________ ††† †††††††††Grade (entering Fall í04) ____________†† Date of Birth _______/____/________

T-shirt size:†††††† Youth S††††††††††† Youth M††††††††† Youth L††††††††††† Adult S Adult M†††††††††† Adult L


Emergency contacts:

Name _______________________________________††††††† Daytime Telephone _______________________

Name _______________________________________††††††† Daytime Telephone________________________

Evening Telephone ____________________________†††††††††† E-mail __________________________________

Mailing Address __________________________________________________________________________


Program Sessions: (Please specify theme, dates, and half-day or extended-day option) ________________________________________________________________________________________



Amount: _____________

Payment Type:

Credit card†† Type ________Number __________________________________ Exp. Date _____/_____

Check (enclosed & made payable to the BCCA)†††††

Cash (Please donít send cash by mail. To pay in cash, please pay in person at the BCCA)




2004 Summer Arts Program

Brookline Community Center for the Arts

Health & Safety Agreement


Health Agreement

Allergies/Health Concerns __________________________________________________________________ __________________________________________≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠≠______________________________________________


I agree that I have disclosed all allergies and health conditions that will help the BCCA guarantee a safe summer program for my child.

I understand that the BCCA Summer Arts Program will be a peanut-free environment. For the safety of all students, I will refrain from sending snacks with my child that may contain peanuts.I also agree to abide by additional safety precautions that may be implemented to accommodate other specific needs.


Pick-up Authorization Agreement

I agree to send a signed note to the BCCA providing authorization if someone other than the two guardian/emergency contacts will be picking up my child.Also, students will not be allowed to leave by themselves without the appropriate parent/guardian authorization.


Program Licensure

I acknowledge that the BCCA Summer Arts Program is not a licensed day-camp, and I may inquire about program supervision and safety specifications to the Summer Program Coordinator at the contact info below.



Behavior Policy

I understand that repeated, disruptive and/or disrespectful behavior by my child will be grounds for dismissal from the BCCA Summer Arts Program. In this event, the program fee will not be refunded.


Any other helpful information (health-related, behavioral, etc.) about my child: ________________________________________________________________________________________ ________________________________________________________________________________________


Parents/Guardian Name (Please Print) __________________________________________


††††††††††† Signature _____________________________________________ Date _______________


Thank you for your cooperation in making this

a fun, safe environment for the students in

the BCCA Summer Arts Program!


Emily Gold,

BCCA Summer Program Coordinator

BCCA • 14 Green Street (Coolidge Corner), Brookline MA 02150 • (t): 617.738.2800 • (f): 617.738.2801