Student
Registration Form
Student’s Name ________________________________________ Sex _______
Age ____________ Grade (entering Fall ’04) ____________ 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) ________________________________________________________________________________________
Payment:
Amount: _____________
Payment Type:
□ Credit card Type ________ Number __________________________________ Exp. Date _____/_____
□ Check (enclosed & made payable to the BCCA)
□ Cash (Please don’t send cash by mail. To pay in cash, please pay in person at the BCCA)
2004 Summer Arts
Program
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 _______________
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