Boys and Girls Club of Leduc- Leduc Boys & Girls Club

Does your child have any additional needs and challenges that might impact their ability to attend the Club safely and securely? These situations can include (but are not limited to) the presence of significant behavioral issues, complex medical conditions, physical/mental emotional health and wellness concerns). If you child has any of these concerns, please contact the Club directly to discuss next steps PRIOR to completing the registration process.

Primary Parent/Guardian

Personal Info:

First Name *

Last Name *

Address *

City *

Postal Code *

Phone Numbers:

Home *

Cell

Work

Email Addresses:

Home *

Work

Please check the checkbox to acknowledge the following:
The Home e-mail addresses noted will be used to communicate all Boys and Girls Club of Leduc information related to club fund-raising, volunteer and child-focused activities to parents.

Work Info:

Employer *

Job Title *

Second Parent/Guardian

Personal Info:

First Name

Last Name

Address

City

Postal Code

Phone Numbers:

Home

Cell

Work

Email Addresses:

Home

Work

Work Info:

Employer

Job Title

Non-Parent Emergency Contacts 2 People Required (ideally within the City of Leduc, or close proximity)

Contact 1:

First Name *

Last Name *

Home Phone *

Cell Phone

Relationship *

Contact 2:

First Name *

Last Name *

Home Phone *

Cell Phone

Relationship *

Contact 3:

First Name

Last Name

Home Phone

Cell Phone

Relationship

Child Information Child 1

Personal Info:

First Name *

Last Name *

Birth Date *

Gender *

School Info:

School *

Grade *

Bussing Required

Medical Info:

(The Boys and Girls Club of Leduc requires that all medical and behavioural information be accurate to for your child’s safety. All information provided will be protected by law and only available to staff to the Boys and Girls Club of Leduc. Please note that while we will make every effort to work with families to find solutions, we may not have the capacity to accommodate complex medical or behavioural conditions.)

Please list any medical/behavioral concerns for this child *

Family Setting:

Family Setting *

Other

(If there are any court orders in place that impact custody, care and/or access with the children, please provide a copy to us for our files. Otherwise, the assumption will be made that BOTH parents have equal rights, access and decision making in regards to the children, and act accordingly. Verbal instructions will NOT be followed without proper documentation to back up the request.)

2023 - 2024 Summer Programs Registration:

Keep Child as Non-Member

Purchase "After School Care" Membership for Child

(Membership entitles child to attend the 2023 - 2024 After School Program and to reduced Summer Fees.)

Select	Session	Cost
Class is full	Week 1 - July 4th to 7th - Sports Week - Short Week, 2023	$0.00
Class is full	Week 2 - July 10th to 14th - Nature Week, 2023	$0.00
Class is full	Week 3 - July 17th to 21st - Adventure Week, 2023	$0.00
Class is full	Week 4 - July 24th to 28th - Discovery Week , 2023	$0.00
Class is full	Week 5 - July 31 - August 4th - Animal Week , 2023	$0.00
Class is full	Week 6 - August 8th to 11th - Plaines, Trains & Automobiles - Short Week, 2023	$0.00
Class is full	Week 7 - August 14th to 18th - Water Week, 2023	$0.00
Class is full	Week 8 - August 21 to 25th - Dinosaur week, 2023	$0.00
	Child's Subtotal	$0.00

(Summer Programming consists of a variety of activities for children aged 6 to 12 years. You may drop your child off at the club at 8:00 am and you must pick them up by 5:00 pm each day they attend. Programming is sold by the week only.)

Child Information Child 2

Include 2nd child

Personal Info:

First Name

Last Name

Birth Date

Gender

School Info:

School

Grade

Bussing Required

Medical Info:

Please list any medical/behavioral concerns for this child

Family Setting:

Family Setting

Other

2023 - 2024 Summer Programs Registration:

Keep Child as Non-Member

Purchase "After School Care" Membership for Child

(Membership entitles child to attend the 2023 - 2024 After School Program and to reduced Summer Fees.)

Select	Session	Cost
Class is full	Week 1 - July 4th to 7th - Sports Week - Short Week, 2023	$0.00
Class is full	Week 2 - July 10th to 14th - Nature Week, 2023	$0.00
Class is full	Week 3 - July 17th to 21st - Adventure Week, 2023	$0.00
Class is full	Week 4 - July 24th to 28th - Discovery Week , 2023	$0.00
Class is full	Week 5 - July 31 - August 4th - Animal Week , 2023	$0.00
Class is full	Week 6 - August 8th to 11th - Plaines, Trains & Automobiles - Short Week, 2023	$0.00
Class is full	Week 7 - August 14th to 18th - Water Week, 2023	$0.00
Class is full	Week 8 - August 21 to 25th - Dinosaur week, 2023	$0.00
	Child's Subtotal	$0.00

Child Information Child 3

Include 3rd child

Personal Info:

First Name

Last Name

Birth Date

Gender

School Info:

School

Grade

Bussing Required

Medical Info:

Please list any medical/behavioral concerns for this child

Family Setting:

Family Setting

Other

2023 - 2024 Summer Programs Registration:

Keep Child as Non-Member

Purchase "After School Care" Membership for Child

(Membership entitles child to attend the 2023 - 2024 After School Program and to reduced Summer Fees.)

Select	Session	Cost
Class is full	Week 1 - July 4th to 7th - Sports Week - Short Week, 2023	$0.00
Class is full	Week 2 - July 10th to 14th - Nature Week, 2023	$0.00
Class is full	Week 3 - July 17th to 21st - Adventure Week, 2023	$0.00
Class is full	Week 4 - July 24th to 28th - Discovery Week , 2023	$0.00
Class is full	Week 5 - July 31 - August 4th - Animal Week , 2023	$0.00
Class is full	Week 6 - August 8th to 11th - Plaines, Trains & Automobiles - Short Week, 2023	$0.00
Class is full	Week 7 - August 14th to 18th - Water Week, 2023	$0.00
Class is full	Week 8 - August 21 to 25th - Dinosaur week, 2023	$0.00
	Child's Subtotal	$0.00

(Tickets will be distributed to parents for resale on the first day of raffle ticket sales – parents will be notified of the ticket availability via e-mail, the club’s Facebook page and the club’s web site. Ticket sales commence in mid-September and the draw will be held in November. If you elect NOT to purchase the 1 book of 10 tickets you must complete a total of 25 hours of volunteer time by December 31 of the membership year. For each ADDITIONAL book of tickets you purchase you will be credited with 2 volunteer hours in the First Semester of the membership year.)

Number of Books	Number of Months	Fee/Book	Amount
No Westjet Raffle Tickets left	10	$100.00	$0.00

Parents will be notified of the ticket availability via e-mail, the club’s Facebook page and the club’s web site. Ticket sales commence in mid-February and the event will be held in March. If you elect NOT to purchase the 1 ticket you must complete a total of 25 hours of volunteer time by June 28th of the membership year. For each ADDITIONAL book of tickets you purchase you will be credited with 1 volunteer hour in the Second Semester of the membership year.)

Number of Tickets	Fee/Ticket	Amount
No Poker Tickets left	$65.00	$0.00

Monthly PAD Bussing Form

Name of Bank *:

Address of Bank *:

Phone of Bank *:

Payment for:

Bussing Fees: # Children x $40.00/month = $ - Check the Monthly option in the Frequency section and enter the total monthly amount in the Amount Field below and specify Start and End Dates for monthly bussing payments.

In the event of a returned payment for NSF or other reasons, we will attempt to pull the payment again fifteen (15) days after the first attempt date, along with a $25.00 fee for the returned payment. If the second attempt to pull the fees is unsuccessful, payment arrangements will need to be made within two (2) weeks or access to bussing or the club may be suspended until payment is made in full. Signature *:

Bank Information

Branch/Transit # *:

Bank/Inst # *:

Account # *:

Amount:

Start Date *:

End Date *:

I/We understand and agree to the terms and conditions of this Agreement.

Date:

Signature *:

Volunteer Deposits PAD Agreement

Province *:

Payor Postal Code *:

Payor Phone *:

Name of Bank *:

Address of Bank *:

Phone of Bank *:

I/We understand that the bank account provided below (and on the attached voided cheque or CAFT document provided by the bank) will be the bank account from which all deposits will be deducted if it is necessary for the BGC Leduc to redeem the following deposits. If all volunteer commitments are met and my child/children are never picked after BGC closure times I understand that these deposits will not be redeemed. The club will provide me with an electronic version of the Sales Receipt for each deposit redemption that occurs.

Bank Information

Branch/Transit # *:

Bank/Inst # *:

Account # *:

Volunteer Deposits and volunteering commitments:

If the volunteer commitment is not completed per session the following deposit will be redeemed via automatic withdrawal from the bank account noted above 1 week after the session end date.

Session 1: Sept to Dec	Volunteer Deposit	Session 2: Jan to May	Volunteer Deposit
Session 1: 10 Hours volunteering	$400.00	Session 2: 10 Hours volunteering	$400.00
Session 1: 20 Hours volunteering	$800.00	Session 2: 20 Hours volunteering	$800.00
Session 1: 30 Hours volunteering	$1200.00	Session 2: 30 Hours volunteering	$1200.00

I/We understand and agree to the terms and conditions of the Volunteer Agreement

Date:

Signature *:

Summary of Payments

Memberships

(Membership entitles child to attend the 2023 - 2024 After School Program and to reduced Summer Fees. Membership fees are NOT pro-rated based on usage. * Payment plans available when registering in person at the club.)

Number of Children	Fee/Child	Amount
0	$390.00	$0.00

Bussing

Number of Children	Number of Months	Fee/Child/Year	Amount
0	10	$400.00	$0.00

Westjet Raffle Tickets - 1 book of 10 tickets

(Tickets will be distributed to parents for resale on the first day of raffle ticket sales – parents will be notified of the ticket availability via e-mail, the club’s Facebook page and the club’s web site. Ticket sales commence in mid-September and the draw will be held in November. If you elect NOT to purchase the 1 book of 10 tickets you must complete a total of 25 hours of volunteer time by December 31 of the membership year. For each ADDITIONAL book of tickets you purchase you will be credited with 2 volunteer hours in the First Semester of the membership year.)

Number of Books	Fee/Book	Amount
0	$100.00	$0.00

Poker Night Tickets

Parents will be notified of the ticket availability via e-mail, the club’s Facebook page and the club’s web site. Ticket sales commence in mid-February and the event will be held in March. If you elect NOT to purchase the 1 ticket you must complete a total of 15 hours of volunteer time by June 28th of the membership year. For each ADDITIONAL book of tickets you purchase you will be credited with 1 volunteer hour in the Second Semester of the membership year.)

Number of Tickets	Fee/Ticket	Amount
0	$65.00	$0.00

Summer (Members)

Summer Programs are sold by the week only and are NOT pro-rated based on usage. *Payment plans available.

Number of Children	Number of Weeks	Fee/Child/Week	Amount
0	0	$120.00	$0.00

Summer (Non-Members)

Number of Children	Number of Weeks	Fee/Child/Week	Amount
0	0	$175.00	$0.00

Total

			FinalAmount
			$0.00

Terms & agreements

Parent Handbook

I have read and agree to the Terms and Conditions listed in the Parent Handbook

Confidentiality: Confidential information requested is for club records and for the funding the Boys and Girls Club of Leduc receives. The answers you provide will be kept completely confidential. Your cooperation in providing this information is both appreciated and necessary. The four people you list below are approved as Emergency Contacts for your child/children and as Individuals who may pick up your child/children from the Boys & Girls Club of Leduc at the end of a program session.

Register for the After School Program or Summer Camps

Primary Parent/Guardian

Personal Info:

Phone Numbers:

Email Addresses:

Work Info:

Second Parent/Guardian

Personal Info:

Phone Numbers:

Email Addresses:

Work Info:

Non-Parent Emergency Contacts 2 People Required (ideally within the City of Leduc, or close proximity)

Contact 1:

Contact 2:

Contact 3:

Child Information Child 1

Personal Info:

School Info:

Medical Info:

Family Setting:

2023 - 2024 Summer Programs Registration:

Child Information Child 2

Personal Info:

School Info:

Medical Info:

Family Setting:

2023 - 2024 Summer Programs Registration:

Child Information Child 3

Personal Info:

School Info:

Medical Info:

Family Setting:

2023 - 2024 Summer Programs Registration:

Westjet Raffle Tickets (1 book of 10 tickets)

Poker Night Tickets

Monthly PAD Bussing Form

Volunteer Deposits PAD Agreement

Summary of Payments

Terms & agreements