Member Registration

Membership Applications

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

Note: * marked fields are compulsory

Choose Session *

Last Name *

First Name *

Gender:

Date of Birth *

Current Address

City

Postal Code

Language Spoken at Home

Select After School *

Grade *

Select Program *

Select Location *

Programs	Locations
Safe Walk Dovercourt	Dovercourt Public School	St. Anthony Catholic School	Pauline Public School	St. Sebastian Catholic School
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
Morning Program	Dovercourt Clubhouse	Holy Rosary Catholic School

Parent / Guardian info

Last Name *

First Name *

Phone *

Relationship to the member *

Gender

Current Address

City

Postal Code

Email *

Parent / Guardian info 2

Last Name

First Name

Phone

Relationship to the member

Gender

Current Address

City

Postal Code

Does your child have your permission to be released on their own at the end of the day?

Yes No

Guardian Signature

Date

Emergency Contact information

This is a person who is authorized to pick up your child and can be contacted by Dovercourt Staff when the parent/guardian cannot be reached.

Last Name

First Name

Cell Phone

Relationship to the member

Gender:

Emergency Work Phone

Emergency Home Phone

Medical Information

Health Card Number

Family Doctor Name

Family Doctor Number

Health and Personal information

Does your child have any allergies?

Yes No

Does your child take any medications?

Yes No

Does your child have any medical or behavioural conditions that we should be aware of?

Yes No

Does your child have any deitary needs or restrictions?

Yes No

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.

I Accept I 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

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.

Parent/Guardian Signature:

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