Boys & Girls Club of East Aurora School Age Program

FALL 2023 REGISTRATION FORM

Child’s name: ________________________________________Birthdate: ____________ Gender: _______

Parent(s)/Guardian: ________________________________________ home phone: _______________

Address: _____________________________________________________ grade entering: ___________

Email address: _________________________________ School attending: ________________________

Please enroll my child in the module indicated below:

[ ] Before School Module- This module operates at the Parkdale site only for Parkdale students. Children are divided by grade between two classrooms. This module is for children in grades K -4, and operates from 7 am to 9 am on school days only, following the East Aurora Union Free School District calendar.

[ ] Five days per week

[ ] Four days per week: (circle days): M T W R F

[ ] Three days per week: M T W R F

[ ] Two days per week: M T W R F

[ ] After School Module- Two locations are offered for After School; a room at Parkdale, and two rooms at the Boys & Girls club site, divided by age. Please indicate a site preference for your child.

This module is for children in grades K-and up and operates immediately following school dismissal to 6:00 pm on regular school days only, following the East Aurora Union Free School District calendar.

SITE PREFERENCE: [ ] Boys & Girls Club of East Aurora site [ ] Parkdale site

[ ] Five days per week

[ ] Four days per week (circle days): M T W R F

[ ] Three days per week: M T W R F

[ ] Two days per week: M T W R F

Non School Day Module- You are automatically registered for this module. This module is for children in grades K and up and operates from 7 am to 6:00 pm on days that the E. A. Union Free School District is closed, and half days. You will be notified of these days and requested to sign your child up for care as needed. ALL NON SCHOOL DAYS INCLUDING SUMMER ARE PROVIDED FOR AT THE BOYS & GIRLS CLUB SITE. Summer registration is separate.

_____________________________________________________________________________________________

** You are responsible for monthly payments for each day your child is registered whether your child attends or not. Fees are based on the number of school days throughout the year, divided into ten equal payments for each month of service. One month withdraw notice required.

I, the parent/guardian of_________________________________, authorize the Boys & Girls Club of East Aurora to release confidential educational and/or medical information to use in pursuing their duties. This contract specifically includes permission for my child to have his/her picture taken as part of the publicity and to attend and participate in field trips that are part of the program. I release the Boys & Girls Club of East Aurora and any of its staff from any responsibility or liability in connection with these activities. I AGREE TO ALL POLICIES STATED ON THIS CONTRACT.

Parent /Guardian signature:____________________________________________ date:______________

Daytime phone number: ______________________________________________

Registration is on a first come/first served basis. Spots are limited. If available, a space will be reserved for your child upon receipt of this form and $40.00 family Registration fee, applicable for new enrollees.

Please use one form per child.