REGISTRATION SPRING 2016

To complete registration, you must return your completed form with payment to your child’s homeroom or leave it in the JQS office in the JQS After School mailbox by January 29, 2016. Enrollment will take place on a first come first served basis. Confirmation will be sent prior to the start of classes, the week of Feb. 1-5. Classes begin on February 8 and continue until April 11. THERE WILL BE NO CLASSES WINTER BREAK WEEK, February 15-18.

Student’s Name JQS Teacher





Grade Room

Date of Birth





☐ Male ☐ Female







Address





Phone







Zip



Email We try to staff to the needs of our students, please let us know if your child has any emotional, behavioral or mental health issues that will affect their participation in a class.



Emergency Contact:



Phone: Please register only for classes that are the grade level of your child. This is an opportunity for your child to explore a new hobby or interest; classes are priced accordingly for high quality instruction.

SPRING SESSION (February 8-April 11) After School Class or Club Section/Day √ Kung Fu (K2-2) Tuesday Gaming Club (Gr 2-5) Tuesday Art with Ms. Wattles (K2-2) Wednesday Sports & Scholars, Soccer (Gr 3-5) Wednesday Sports & Scholars, Soccer (K2-2) Thursday Mr. Gao’s Art Studio (Gr 3-5) Thursday Total Tuition





Allergies/Medical Issues:

Amount $150 $150 $150 $80 $80 $150 $



Payment is due at the time of registration (cash or check). Please make checks payable to BCNC. If a class is full, cancelled, or re-scheduled, we will contact you about alternatives including a refund or alternate class. If you withdraw a student two weeks or less prior to the start of class you will not receive a refund or a credit.



LIABILITY DISCHARGE AND COVENANT NOT TO SUE FOR THE AFTER SCHOOL ENRICHMENT CLASSES

The application is factual and complete to the best of my ability. I hereby waive and release any and all rights, causes of action, and claims for damages I may have against the City of Boston, Boston Centers for Youth & Families, Boston Chinatown Neighborhood Center and any and all other associated individuals or organizations, for any and all personal injuries or property damage resulting from my participation in BCYF/BCNC/JQS Programs.



Parent/Guardian





Registration cannot be processed without the signature of the waivers below, thank you.



I, the undersigned parent or guardian of [____________________], a minor, hereby consent to his/her Boston Centers for Youth and Families membership and waive and release any and all rights, causes of action and claims for damages I may have against the City of Boston, Boston Centers for Youth & Families, and any and all other associated individuals or organizations, arising out of any and all personal injuries or property damage which I may now or hereafter have as the parent or guardian of said minor, and also all rights, causes of action, and claims which said minor has or may acquire resulting from his/her participation in the program.

I give consent for me/my child to be administered first aid and to be treated by an emergency medical technician-paramedic, nurse or physician. Any follow up medical attention may be given at a local hospital and transportation to a Boston hospital is authorized.

I understand that transportation is not provided and it is my responsibility to arrange transportation to and from Boston Centers for Youth & Families Community Centers. Failure to comply with these rules and expectations can lead to termination of membership.

Parent/Guardian Signature ______________________________________________/ ______/ 2016 MEDIA PERMISSION Josiah Quincy After School Enrichment Program requests permission to use your child(ren)’s image in their materials. By granting your permission, you understand that your child’s likeness could be used in various print, video, or online media. Please be assured that student’s names will not be released, and by signing this form, you/I/we do not waive your right to privacy and confidentiality. • that use of these images is exclusively intended for promotion of the Josiah Quincy After School Enrichment Program; • that images of my child(ren) may appear on the internet for an extended period of time; • that there will be no financial or other remuneration for use of my child(ren)’s image; • that Josiah Quincy After School Enrichment Program is not responsible for any expense or liability incurred as a result of our participation; • that I/we may withdraw our consent at any time through written request to [email protected]. Parent/Guardian Signature ______________________________________________/ ______/ 2016