<p> 2015-2016 After-School Program</p><p>Enroll in the Boys & Girls Clubs of Monmouth County’s After-School Program and give your child the opportunity to grow and develop in a fun and educational setting. </p><p>We offer a safe environment with professional staff to meet all of your child’s needs. Daily activities include homework help, arts & crafts, sports & recreation, gameroom time, special events, and more. We also offer Boys & Girls Clubs of America programs such S.M.A.R.T. Moves, S.M.A.R.T. Girls, Passport to Manhood, Torch Club, and Triple Play.</p><p>Program hours and fees: 2:00-6:00 P.M. $60 a week Membership fee for the year is $20</p><p>All participants must be members of the Boys & Girls Club upon registration. All fees are due upon registration, with club membership being valid until June 2015. The after-school program payment will cover the first week your child attends the program. Fees are due the week prior to the start of the program. PLEASE NOTE: The after-school program follows the Asbury Park school district calendar with the exception of the final days of school. We will provide transportation on all scheduled early dismissal days. The program does not run if the school is closed or dismissed early due to inclement weather.</p><p>For more information please contact Ebony Holloway at [email protected] or call 732-775-7862</p><p>Developed by Boys & Girls Clubs of Monmouth County Asbury Park, NJ 07712 www.bgcmonmouth.org 2015-2016 After-School Program</p><p>After-School Application Serving both Asbury Park & Neptune Township</p><p>Child’s First Name: Last Name:______</p><p>Date of Birth: ____/____/____ School: Grade: </p><p>Parent or Guardian Name(s): ______</p><p>Address: ______Home Phone #: ______</p><p>Mother’s Work Phone # Father’s Work Phone#: ______</p><p>Mother’s Cell# Father’s Cell Phone#:______</p><p>Person(s) authorized to pick up your child / Emergency Contacts: (Person must show picture I.D.) Name:______Relationship: ______Phone#:______Name:______Relationship: ______Phone#:______Name:______Relationship: ______Phone#:______Name:______Relationship: ______Phone#:______</p><p>Student lives with: ___ Father ____ Mother ___ Step Parents ___ Foster ___ Legal Guardian ___ Other Primary Language: □English □Spanish □Other:______</p><p>Is your child under medical care or taking any medication(s)? □ Yes □ No If yes, please check all of the following conditions that your child has and indicate if medication needs to be dispensed at school? □ Bee Sting Allergy Epi-pen□ Yes □ No □ Other Allergies: ______□ Asthma Inhaler □ Yes □ No □ Special Needs / Disability:______□ Diabetes Insulin □ Yes □ No □ Other:______□ Vision / Hearing Glasses □ Yes □ No</p><p>Family Health Care: Physician’s Name:______Phone #:______Address:______Medi-Cal: □Yes □ No Does the Boys & Girls Clubs After-School Program have permission to use photos of your child in educational or promotional materials? (There is no cost.) Yes:_____ No:______</p><p>Does your child have permission to check out at 6:00 pm and walk home? Yes:_____ No:_____</p><p>Please read and sign below: I understand the Boys & Girls Clubs of Monmouth County After-School Program is a nonprofit organization. Our program’s success depends on state grants and district funding. I give permission for staff to review my child’s files for the purposes of analyzing program effectiveness and reporting to funding sources. </p><p>Parent or Guardian Signature:______Date:______</p><p>For Office Use Only Enroll Date: Initials: Date Disenrolled: Reason: </p><p>Developed by Boys & Girls Clubs of Monmouth County Asbury Park, NJ 07712 www.bgcmonmouth.org 2015-2016 After-School Program</p><p>Programa Después de Escuela</p><p>Primer Nombre de hijo/a:______Apellido:______</p><p>Fecha de Nacimiento: ___/___/___ Esquela: ______Grado:____ </p><p>Nombre de Padre o Guardián: ______</p><p>Dirección: ______# Teléfono de Casa ______</p><p># de trabajo de Madre: ______# de trabajo de Padre ______</p><p># Celular de la Madre # Celular de Padre:______</p><p>Persona(s) autorizadas de recoger a su hijo/a. (Persona debe enseñar identificación de retrato). Nombre:______Relación:______#de Teléfono:______Nombre:______Relación:______#de Teléfono:______Nombre:______Relación:______#de Teléfono:______Nombre:______Relación:______#de Teléfono:______</p><p>El Estudiante vive con: ___ Padre ____Madre ___ Padrastro/a ___ Pariente Adoptivo/a ___ Tutor Legal ___Otro Lengua Primaria: □ Inglés □ Español □ Otro:______</p><p>¿Está su hijo/a bajo el cuidado médico o tomando algún medicamento(s)? □ Sí □ No Si su respuesta fue si, por favor marque todas las condiciones siguientes que su hijo/a tiene e indique si el medicamento debe ser suspendida en la escuela. □ Picadura de abeja “Epi-pen” □ Sí □ No □ Alergias: ______□ Asma Inhalador □ Sí □ No □ Necesidades Especiales / Incapacidad:______□ Diabetes Insulina □ Sí □ No □ Otro:______□ Visión Anteojos □ Sí □ No</p><p>Cuidado Familiar de Salud: Nombre de Médico:______#de Teléfono:______Dirección:______Medi-Cal: □ Si □ No Seguro de Salud # ______</p><p>Da permiso que el programa use retratos de su hijo/a en materiales educativos o promocionales? (No hay costo). Si____ No____</p><p>Le da permiso a su hijo/a que firme a las 6:00 PM y camine a casa? Si______No_____</p><p>Favor de leer y Firmar debajo: Yo entiendo que el programa después de escuela, Estos servicios son posibles por becas del Estado y financias del Distrito. Doy permiso que personaje de revise los archivos de mi hijo/a para los propósitos de analizar la efectividad del programa y reportarlos a los fuentes de fondo.</p><p>Firma de Padre/Guardián:______Fecha:______Para uso de Oficina Solamente Fecha de Inscripción:______Iniciales:______</p><p>Developed by Boys & Girls Clubs of Monmouth County Asbury Park, NJ 07712 www.bgcmonmouth.org 2015-2016 After-School Program Fecha de ultimo día:______Razón:______</p><p>Developed by Boys & Girls Clubs of Monmouth County Asbury Park, NJ 07712 www.bgcmonmouth.org</p>