BJNCP Participant Information Form

BJNCP Participant Information Form

Participant's First Name:*

(Child's Name)

Participant's Last Name:*

Age:*

Date of Birth:*

Add another child?

Participant 2 First Name:*

Participant 2 Last Name:*

Participant 2 Date of Birth:*

3. Add Another Child?

Participant 3 First Name:*

Participant 3 Last Name:*

Participant 3 Date of Birth:*

Address:*

Parent Information-

Please list all parent information in case of emergencies.

Parent(s) First and Last Name:*

Parent Email:*

Parent Phone Number:*

Phone

Secondary Phone Number:

Phone

Emergency Contact Information-

Please list an emergency contact other than parents.

Emergency Contact First and Last Name:*

Emergency Contact Phone Number:*

Phone

Relationship to Participant:*

Authorized Pick-Up Information-

Please list all people (including parents) who are authorized to pick-up your child. Your child will only be released to those listed below.

Must be 16 years of age and photo ID is required by parents and any additional listed to pick-up your child.

Up to four Authorized Pick-Ups can be added.

If you would like to add more, please contact Hannah Nyquist at hnyquist@cityofsouthlake.com.

1. Authorized Pick-Up First and Last Name:*

1. Phone Number:*

Phone

2. Authorized Pick-Up First and Last Name:*

2. Phone Number:*

Phone

3. Click below to add another Authorized Pick-Up.

3. Authorized Pick-Up First and Last Name:*

3. Phone Number:*

Phone

4. Click Below to add another Authorized Pick-Up.

4. Authorized Pick-Up First and Last Name:*

4. Phone Number:*

Phone

Medical Information-

Will your child need to take any medications during the program hours?*

If answer is yes, the program supervisor will contact you to fill out an additional form.

Yes

Does your child have allergies, chronic illnesses, or dietary needs?*

Yes

Please list your child's allergies, chronic illnesses, and/or dietary needs.*

Please make sure to specify which child if you are creating this form for more than one child.

Are there any special needs or accommodations that staff should be aware of?*

Yes

Please list any special needs or accommodations.*

Fair Play and Behavior Policy

Our goal is to provide personal growth in a safe environment. Please assist us in maintaining a safe and enjoyable environment by following the Fair Play and Behavior Policy.

Individuals participating in Southlake Community Services programs are expected to:

1. Wear appropriate attire.

2. Refrain from using profane language.

3. Refrain from placing themselves and/or others at risk (i.e. hitting, fighting, biting, kicking, spitting, etc.).

4. Respect other participants, staff, and things belonging to others.

5. Participate in activities, remain with staff, refrain from disrupting program activities, and follow directions to the best of their ability.

*Persons endangering the safety of themselves or others will be removed from the facility or program. Other infractions of rules will be handles as deemed necessary by Community Services staff.*

1st Offense: Verbal Warning

2nd Offense: Disciplinary write up for parent/guardian to sign.

3rd Offense: Conference with child, parent/guardian, and program director.

4th Offense: 2 days suspension - NO REFUND.

5th Offense: Dismissed from program - NO REFUND.

I have read and agree to the Fair Play and Behavior Policy and will review the expectations with my child.*

Send me a copy of my responses

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