Buzz Club Registration
Please complete this registration for each student. If you would like a printed registration form, one can be found at: www.hornetparkcommunitycenter.com/buzz-club
Buzz Club 2020/21
Student Name *
Was this student enrolled in Buzz Club last school year? *
Grade *
What school with they be attending? *
Your Street Address *
City *
Zip Code *
Date of Birth *
MM
/
DD
/
YYYY
Parent/Guardian Email *
Parent/Guardian Name *
Parent/Guardian Phone Number *
Parent/Guardian Name (2)
Parent/Guardian Phone Number (2)
Emergency Contact Name *
Emergency Contact Phone Number *
Emergency Contact Relationship to Student *
In addition to those already listed, please list up to 5 people over the age of 18 that will have permission to pick up your student. ONLY people on this list will be allowed to pick up your student. Only Name and phone number *
Please list any allergies that our Buzz Club staff should be aware of. *
I give permission to the Buzz Club staff to access my student’s information on Skyward, if needed. *
I give permission to the Buzz Club staff to take and post pictures of my student participating in various activities during program on social media or any other informational flyers/websites. *
I give permission to the Buzz Club staff to administer any minor medical attention to my student if needed. (band aids, triple antibiotic ointment, ice pack, etc.) *
I understand that medications will not be administered during Buzz Club or by Buzz Club staff. *
Required
What is your preferred method of payment? *
Required
I understand it is my responsibility to make sure all payments are made in full and on time. The weekly fee for one student is $35. The weekly fee for each additional student in the same household is $20. *
Required
I understand that ALL payments are due by 6pm on the Monday of the week student(s) will attend Buzz Club. If payments are more than 14 days late, a late fee of $15 per child will be added on per week. If your account becomes 30 days late, a payment arrangement will be required or your student(s) will be removed from the program. *
Required
Disciplinary Policy: It is top priority that Buzz Club provides a safe environment for all students and staff. All school rules apply while your student is attending the program. A zero-tolerance policy for bullying will be enforced at the program. The following disciplinary action will be taken: 1. Verbal warning: Staff will discuss and help redirect the child to positive behavior. 2. Written warning home to person picking up child. 3. After three written warnings your child will be suspended from program. A phone call to parent will be made. Child will not be allowed back into program until behavior issue has been formally addressed by phone conference or face to face meeting. 4. After child returns to program, if problem continues, Buzz Club staff has the right to ask the child not to return to the program permanently. Suspension from the program can be effectively immediately if the offense is warranted which is at the discretion of the Buzz Club staff. *
Required
I understand that my student(s) must be picked up by 6pm. There is a minimum late fee of $15 per student if the pick up person arrives after 6:15. *
Required
I have read and agree to all rules and procedures of Buzz Club *
Required
Name of Parent/Guardian submitting application.
Submit
Never submit passwords through Google Forms.
This form was created inside of City of Beech Grove, IN. Report Abuse