TEEN REGISTRATION

TEEN REGISTRATION
OPENING DAY

BCNY’s Fall 2021 afterschool program starts on Tuesday, October 12th.

SCHOOL HOLIDAY CLOSURES

BCNY is closed when NYC public schools are closed. Please view the BCNY calendar included with this form. For closures due to inclement weather, please be on the lookout for messages from BCNY.

ELIGIBLE AGES

Boys and young men currently enrolled in 9th, 10th, 11th and 12th grade are eligible for program and member registration at Abbe Clubhouse and Gerry Clubhouse.

REQUIRED REGISTRATION DOCUMENTS
- Birth Certificate/Passport (a photocopy is acceptable)
- Updated Immunization Records OR New York Dept. of Education “Medical Request for Immunization Exemption” Form
- Proof of COVID Vaccination for Members age 12 or over
- CACFP Food Form
- Physical Examination Form (signed, dated in 2021 or later, and stamped)
ATTENDANCE POLICY

Registered members are expected to attend and abide by the attendance policy determined by the member’s specific program. Members who cannot meet these expectations may have their membership reviewed or suspended.

WAITLIST

Please note that space is limited. Registration is on a first-come, first- served basis. If registration is full, your child will be placed on a waitlist.

ABBE CLUBHOUSE: 133-01 41st Road, Flushing, New York 11355 718.886.5454

GERRYCLUBHOUSE: 321 East 111th Street New York, NY 10029 212.534.2661
CLUBHOUSE AFFILIATION *

Gerry Clubhouse (321 E 111th Street, New York, NY 10029, 212.534.2923) Abbe Clubhouse (133-01 41st Road, Flushing, NY 11355, 718.886.7803)

	Type in Value
# of Children
# of Adults
TOTAL Family Size

	Response
Operations of Serious Injuries (Dates)
Hospitalization (Dates)
Chronic or Recurring Illness
Any specific activities to be encouraged?
Conditions that require activity to be restricted?
Permission for all program activities unless otherwise noted by Dr.
Appliance worn (glasses, contacts, etc.)
Medication taken (including medication for mental health conditions)
Suggestion from Parent/Guardian

FOR MEMBERS AGES 13 & UP
Dear Parent/Guardian:

BCNY teen members are permitted to leave the Clubhouse unaccompanied at the end of the day by scanning out in the lobby.

If you require your teen member be picked up by an authorized adult, please sign and submit the form below to the clubhouse registrar. If your teen member’s traveling arrangements change, please notify Clubhouse staff immediately.

If you have questions or concerns, please contact the Clubhouse Director.
(Gerry: terrence.taylor@bcny.org Abby: ron.britt@bcny.org)
I,parent/guardian's name require that my son, member's name be picked up by an authorized adult. He is not permitted to travel home alone.
Signature

Clear
Date

Month Day Year
Date

VACCINATION REQUIREMENTS
Dear BCNY community,

This school year, BCNY staff is fully vaccinated to serve your children and do our utmost to keep our communities safe. As you know, the Delta variant has been spreading across New York City. As part of our mission, we want to make sure we continue to serve our community of boys and young men with a vaccination requirement for eligible BCNY members.

BCNY requires all members eligible for a Covid 19 vaccine, currently 12 years old and up, be vaccinated with at least their first dose by October 12th, 2021 and fully vaccinated by November 16th, 2021.

Please upload the member’s Covid 19 vaccination proof (a photograph of member Covid 19 vaccination card) October 12th and, if applicable, proof of second dose by November 16th. Don’t hesitate to call your local clubhouse with questions or if you cannot upload member vaccination proof, please hand it in directly to the clubhouse registrar.

We are aware there are named conditions which would preclude a child from being vaccinated. If this is the case, we need you to submit documentation by your child's physician exempting them from the Covid 19 vaccine in lieu of vaccination proof by October 12th, 2021 using the link https://bit.ly/3hETNs9

Legal guardians and members 18 and over, please sign and date this form to acknowledge you have read and understood BCNY’s vaccination requirement.
Member's Full Name *

First Name Last Name
Parent/Guardian's Full Name *

First Name Last Name
Signature *

Clear
Date *

Month Day Year
Date
Vaccination Proof *

Cancel of
Should be Empty:

	Name	Relationship	Address	Number
Primary
Secondary

	Name	Cell Number
Contact #1
Contact #2

	Full Name	Cell Number
Option #1
Option #2
Option #3

	Illnesses/Conditions	Dates
Ear Infections
Rheumatic Fever
Seizures
Diabetes
Asthma
Other

	Allergies	Dates
Hay Fever
Ivy Poisoning, etc.
Insect Stings
Penicillin
Food
Other

TEEN REGISTRATION

MEMBER INFORMATION

MEMBER'S EDUCATION

Primary Parent/Guardian Information

SECONDARY PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACTS

MEMBER'S HEALTH INFORMATION

HOUSEHOLD INFORMATION

HEALTH RECORD FOR CHILDREN IN DAY CAMPS AFTERSCHOOL & YOUTH CENTERS

FOR MEMBERS AGES 13 & UP

VACCINATION REQUIREMENTS

	Allergies	Dates
Chicken Pox
Measles
German Measles
Mumps
Other Contagious Illnesses