Studentís Name ________________________________________††† Sex _______
Name _______________________________________††††††† Daytime Telephone _______________________
Name _______________________________________††††††† Daytime Telephone________________________
Evening Telephone ____________________________†††††††††† E-mail __________________________________
2004 Summer Arts Program
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.
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.
Parents/Guardian Name (Please Print) __________________________________________
††††††††††† Signature _____________________________________________ Date _______________
a fun, safe environment for the students in
the BCCA Summer Arts Program!
BCCA Summer Program Coordinator
BCCA • 14 Green Street (Coolidge Corner), Brookline MA 02150 • (t): 617.738.2800 • (f): 617.738.2801