The following information is necessary for our records and for the funding our organization receives. The answers you provide are completely confidential. Your cooperation in providing this information is both appreciated and necessary.

Ethnic Background *

Aboriginal Asian African Caribbean Caucasian European Middle Eastern Spanish

Parent(s) Marital Status: *

Married Separated Divorced Widowed Single

Child Lives With: *

Number of Sisters / Step Sisters: *

Number of Brothers / Step Brothers: *

Number of People in Household *

Family Setting: *

One Parent Family Two Parent Family Joint Custody

PARENT / GUARDIAN 1

Name *

First Name Last Name

Occupation *

Employer *

Work Phone

Cell Phone

Email

example@example.com

PARENT / GUARDIAN #2

Name *

First Name Last Name

Occupation *

Employer *

Work Phone

Cell Phone

Email

example@example.com

EMERGENCY CONTACTS

(people who do not live in the home)

Emergency Contact 1:

Name *

First Name Last Name

Relationship *

Home Phone Number *

Work Phone Number

Cell Phone Number

Emergency Contact 2:

Name *

First Name Last Name

Relationship *

Home Phone Number *

Work Phone Number

Cell Phone Number

Please list anyone who is ALLOWED to pick up your child(ren):

Name

First Name Last Name

Relationship to Child

Phone Number

Name

First Name Last Name

Relationship to Child

Phone Number

Name

First Name Last Name

Relationship to Child

Phone Number

Name

First Name Last Name

Relationship to Child

Phone Number

Supper Club School-Year Membership

We are offering Families the opportunity for Full Year Supper Club at $60.00 per child.

Payment is non-refundable and not prorated. Supper club runs from September to June

Supper is served 4:00 pm to 6:00 pm, Monday to Friday.

Single meals are also available for $2 per visit per child.

Supper Club Calculation

Do you wish to sign up for Supper Club Memberships? *

Supper Club Membership cost for all children: {supperClub}

Please acknowledge that you have read, and understand the above statement.

BOYS & GIRLS CLUB OF LONDON - CHILD MEMBERSHIP CONTRACT

RELEASE OF LIABILITY, WAIVER OF CLAIMS

ASSUMPTION OF RISKS AND INDEMNITY AGREEMENT.

BY SIGNING THIS AGREEMENT YOU WILL WAIVE CERTAIN

LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE

PLEASE READ CAREFULLY!

Type your initials here to show that you have read and understand the statement above. *

Child 1's Full Name *

First Name Middle Name Last Name

Child 1's Birth Date *

Month Day Year

Medical Condition which may impact Child 1's ability to take part in activities (see below). If NONE, please type your initials into the box. *

Child 2's Full Name

First Name Middle Name Last Name

Child 2's Birth Date

Month Day Year

Medical Condition which may impact Child 2's ability to take part in activities (see below). If NONE, please type your initials into the box. *

Child 3's Full Name

First Name Middle Name Last Name

Child 3's Birth Date

Month Day Year

Medical Condition which may impact Child 3's ability to take part in activities (see below). If NONE, please type your initials into the box. *

Child 4's Full Name

First Name Middle Name Last Name

Child 4's Birth Date

Month Day Year

Medical Condition which may impact Child 4's ability to take part in activities (see below). If NONE, please type your initials into the box. *

Address *

Street Address

Street Address Line 2

City

Postal / Zip Code

Email *

example@example.com

Name *

First Name Last Name

Phone Number *

Area Code Phone Number

TO: Boys & Girls Club of London and the Boys & Girls Club of London Foundation (together the “BGCL”) and their directors, officers, employees, instructors, agents, representatives, volunteers, independent contractors, subcontractors, sponsors, successors and assigns (hereinafter collectively referred to as the “Releasees”).

COVID – 19 COVID-19 is a contagious disease (“Covid”). We care about you, your family, our employees and the public. We strive to obey the law and follow Covid guidelines and implement all risk mitigation measures. However there are significant health risks and high risk of transmission through physical or shared contact. COVID-19 is novel and, because it can be transmitted through physical or shared contact with another person, the risk of contraction from engaging in sport activities may be foreseeable.

ASSUMPTION OF RISKS

I am aware that the activities at the BGCL programs involve risks and dangers that may cause serious injury and even death, and loss or damage to personal property. These risks are inherent in the activities and cannot be eliminated without altering their character and value. The risks include, among others, the following: contracting Covid; moving about the BGCL premises; negligence on the part of myself and/or other participants; negligence of the BGCL and its staff, including the improper use of equipment; the breakage and failure of equipment and structures; over exertion, together with other risks which may be encountered and NEGLIGENCE ON THE PART OF THE RELEASEES, INCLUDING THE FAILURE ON THE PART OF THE RELEASEES TO SAFEGUARD OR PROTECT ME FROM THE RISKS, DANGERS AND HAZARDS REFERRED TO ABOVE.

The BGCL programs are designed for use by participants of average strength, mobility and fitness who are in good health. Several medical
conditions, including but not limited to obesity, high blood pressure, cardiac and coronary artery disease, pulmonary problems, arthritis, tendonitis, or joint and muscular-skeletal problems may impair the safety and well being of participants as may other medical, physical, psychological or psychiatric problems. All such medical conditions may increase the risk of participating in the programs and cause the participant to be a danger to themselves or others. Participants with underlying medical, physical, psychological or psychiatric conditions must evaluate their condition and their ability before choosing to participate in the programs. All participants must inform BGCL in writing of any such medical, physical, psychological or psychiatric conditions before participating in any programs. The Releasees reserve the right to prevent any person, for medical or safety reasons, from participating in the programs at any time.

I AM AWARE OF THE RISKS, DANGERS AND HAZARDS ASSOCIATED WITH MY USE OF THE BGCL PROGRAMS AND I FREELY ACCEPT AND FULLY ASSUME ALL SUCH RISKS, DANGERS AND HAZARDS AND THE POSSIBILITY OF PERSONAL INJURY, DEATH, PROPERTY DAMAGE AND LOSS RESULTING THEREFROM.

RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT

In consideration of the Releasees permitting my use of the BGCL PROGRAMS and other facilities at the BGCL (hereinafter referred to as “the BGCL Facilities”), I hereby agree as follows:

TO WAIVE ANY AND ALL CLAIMS that I have or may in the future have against the RELEASEES , and TO RELEASE THE RELEASEES from any and all liability for any loss, damage, expense or injury including death that I may suffer, or that my next of kin may suffer resulting from either my use of or my presence at or on the BGCL Facilities DUE TO ANY CAUSE WHATSOEVER, INCLUDING NEGLIGENCE, BREACH OF CONTRACT, OR BREACH OF ANY STATUTORY OR OTHER DUTY OF CARE, INCLUDING ANY DUTY OF CARE UNDER THE OCCUPIERS LIABILITY ACT, RSO 1990, c.02 ON THE PART OF THE RELEASEES, AND ALSO INCLUDING THE FAILURE ON THE PART OF THE RELEASEES TO SAFEGUARD OR PROTECT ME FROM THE RISKS, DANGERS AND HAZARDS REFERRED TO ABOVE;

TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability for any damage to property of or personal injury to any third party, resulting from my use of or presence on the BGCL facilities.

I HAVE READ AND UNDERSTAND THIS AGREEMENT AND I AM AWARE THAT BY SIGNING THIS AGREEMENT I AM WAIVING CERTAIN LEGAL RIGHTS WHICH I OR MY HEIRS, NEXT OF KIN, EXECUTORS, ADMINISTRATORS, ASSIGNS AND REPRESENTATIVES MAY HAVE AGAINST THE RELEASEES.

Signed {dateIn}

Signature

Clear

Name

First Name Last Name

Today's Date

Month Day Year

Date in Text

MEMBERSHIPS ARE VALID FOR ONE YEAR FROM THE TIME OF PURCHASE

Submitting this form gives the Boys and Girls Club of London authority to charge the sum detailed below to your credit card or Paypal account.

Total Cost

Total

CAD Child Membership Fee

Date

Day Month Year

Child Membership Registration

Child 1

Child 2

Child 3

Child 4

PARENT / GUARDIAN 1

PARENT / GUARDIAN #2

EMERGENCY CONTACTS

(people who do not live in the home)

Emergency Contact 1:

Emergency Contact 2:

Please list anyone who is ALLOWED to pick up your child(ren):

Supper Club School-Year Membership

ASSUMPTION OF RISKS