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Membership Applications 2023-24
BGC Dovercourt Clubhouse & Junction Triangle Clubhouse
All personal information provided is held in confidence by the Club in accordance to its Privacy Policy
Membership annual fee : $40.00
* marked fields are compulsory
Last Name
*
First Name
*
Gender:
Male
Female
Other
Date of Birth (MM/DD/YYYY)
Current Address
City
Postal Code
Language Spoken at Home
Select After School
*
P.E.T
Dovercourt
St. Anthony
Sacre-Coeur
French School
Regal
Pauline
St. Sebastian
St. Bruno
KKDC
Carleton Village Junior and Senior and Wellness Academy
Other School
Grade
*
School Name
*
Select Program
*
Select Program
Afterschool Program Dovercourt
Safe Walk Dovercourt
Afterschool Program Junction
Select Location
*
Select Location
Programs
Locations
PA DAY
Dovercourt Clubhouse
Junction Clubhouse
Swimming Program
Dovercourt Clubhouse
Summer Camp
Dovercourt Clubhouse
Junction Clubhouse
March Break
Dovercourt Clubhouse
Junction Clubhouse
Winter Camp
Dovercourt Clubhouse
Junction Clubhouse
Parent / Guardian info
Last Name
*
First Name
*
Phone
*
Relationship to the member
*
Gender
Male
Female
Current Address
City
Postal Code
Email
*
Parent / Guardian info 2
Last Name
First Name
Phone
Relationship to the member
Gender
Male
Female
Current Address
City
Postal Code
Email
Does your child have your permission to be released on their own at the end of the day?
Yes
No
Guardian Signature
Clear
Date
Emergency Contact information
This is a person who is authorized to pick up your child and can be contacted by Dovercourt Sta when the parent/guardian cannot be reached.
Last Name
First Name
Cell Phone
Relationship to the member
Emergency Gender:
Male
Female
Emergency Work Phone
Emergency Home Phone
Medical Information
Health Card Number
Family Doctor Name
Health and Personal information
Does your child have any allergies?
Yes
No
Please list all allergies:
Does your child take any medications?
Yes
No
Please list all medicines:
Does your child have any medical or behavioural conditions that we should be aware of?
Yes
No
Please take a moment to explain:
Does your child have any deitary needs or restrictions?
Yes
No
Please list them:
Does your child take any prescribed medications (e.g., EPIPEN, puffer, insulin, etc.)?
Yes
No
Confidential Information
The following voluntary information is for statistical purposes in order to provide our members with improved services. Responses will be kept confidential and not connected to identifying information.
Number of brothers
Number of sisters
Lone-Parent Families (Y/N)
Led by
Do you self-identify as a visible minority?
Do you self-identify as Aboriginal?
Member Accommodation Request
The purpose of asking this question is to know if your child needs any accessibility accommodations. Does your child need any adaptable programming accommodations. If yes please see front desk for a copy of the accessibility accommodations request form.
Yes
No
Media Consent
I hereby give Boys and Girls Clubs of Canada and/or it's member Clubs consent to use and reproduce my child's/youth's first name/image for promotion purposes related to Boys and Girls Clubs of Canada; its member Boys and Girls Clubs and/or external partners. My child's/youth's first name (unless otherwise authorized)/image may be published or used in newspapers, promotional videos, television commercials, program brochures, posters, on World Wide Web or otherwise displayed to the public or used for other educational/fundraising purposes, either in whole or in part by Boys and Girls Clubs of Canada, its member Clubs, and/or external partners I release Boys and Girls Clubs of Canada and its agents from any and all claims, of any nature, based on any uses of the above.
Accept
Decline
Code of Conduct
The safety of each individual in the program is the utmost importance to the BGC Dovercourt Club. Each registrant must recognize a personal responsibility to learn and follow at all times the safety and other rules established by the Club staf. I hereby agree that any behaviour of the registrant that places him/ herself or others at risk may result in the registrant's immediate dismissal from the program. Further, if dismissed from the program, I agree to cover any expense(s) arising from such dismissal. I hereby acknowledge and agree that no refund will be granted for dismissal or removal of the registrant at his/her request before the end of a program session. In order to ensure the safety and well-being of all individuals participating in the program, the Dovercourt Boys and Girls Club reserves the right to alter the program at anytime without notice or compensation to the registrant.
I have read and understand the Code of Conduct:
Signature
Clear
Date
Waiver
I/we agree that I/we will hold harmless and indemnify the Corporation of the City of Toronto and the BGC Dover- court Club, including all staf, volunteers and board members from and against all action, suits, claims and demands which may be brought against or upon the Corporation of the City of Toronto and the BGC Dovercourt Club, as a result of any injury sustained by myself or my child while I/ we or my/our child is a participant in any program operated by said Club.
Signature
Clear
Date
Alternative pickup 1
Last Name
First Name
Phone
Relationship to the member
Alternative pickup 2
Last Name
First Name
Phone
Relationship to the member
Signature
Clear
Save