Guardian Handbook & Forms

Guardian Handbook

Please fully review the manual linked below. Contact the Club with any questions.

2022 Guardian Handbook

Pick Up Authorization

Please update the Club if have changes to who is authorized to pick up your child(ren).

Pick Up Authorization

Prescription Medication

Please complete the form below for any medication that your member requires. If he or she requires multiple medications, please submit a separate Prescription Medication Distribution Form for each medication.

Prescription Medication Distribution Form

Guardian Information

Guardian Name

First Name

Last Name

Phone Number

Child Information

Child Name

First Name

Last Name

Medication Information

Name of Medication

Reason for Medication

Dosage

Frequency & Times to be Given

Medication Start Date

MM

DD

YYYY

Medication End Date

MM

DD

YYYY

Does the medication require refrigeration?

Yes

No

Is self-medication permitted and recommended for this member?

Yes

Yes AND I recommend the medication be kept "on-person" by the member.

No

Member has been instructed in the proper self-administration of the prescribed medication(s).

Yes

No

Potential Side-Effects/Contradictions/Adverse Reactions

Treatment in the event of an adverse reaction

Agreement & Signature

Signature

I hereby authorize the Boys & Girls Club of Livingston County to administer and assist my child in taking the above medication. I understand that additional parent/prescriber signed statements will be necessary if the dosage or frequency of the medication is changed. Medication must be in the original, unopened, sealed container and be properly labeled with the member’s name, prescriber’s name, date of prescription, name of medication, dosage, strength, time interval, route of administration and the date of drug expiration when appropriate.

Confirm Handbook Agreement

Guardian Name

First Name

Last Name

Child Name

First Name

Last Name

Your Involvement (Optional)

We need parents to help Livingston County Boys and Girls Club in several ways. Please select any of the following that you're interested in.

Donate snacks

Monetary donations

Volunteer for special events or activities

Share your skills and talents with the members

Sponsor another Club member for an After-School Membership or Summer Camp

Become a part of the Parent Advisory Council

Signature

By typing your name here, you affirm that all information provided is accurate and that you agree to the following: The Parent/Guardian Handbook describes important information about Boys & Girls Club of Livingston County, and I understand I should consult the Director of Operations regarding any questions not answered in the document. I have received this document and understand it is my responsibility to read, know, understand, and comply with the policies contained therein and any additions made to it.