Miramichi Boys and Girls Club Request for Program - Fall 2008 Shipwrecked (Gr K-1-2-3) Amazing Race (Gr 4-5-6) Cartooning (Gr 4-5-6) Survivor (Gr 3-4-5) Babysitters (October 25th, 2008) Catch Kids (Gr K-1-2-3) Cool Art (Gr K-1-2-3) Drama 101 (Gr 4-5-6) Date of Intake:  Received By:  Last Name:  First Name:  Mailing Address:  Community:  Postal   Code:  Telephone (h):  Telephone (w):  Email:  Date of Birth:  Age:  Parent / Guardian:  Marital Status:  School:  Grade:  Place of Employment:  Medicare #:  Emergency Contact:  Allergies: Permission for photo release Office Use Only Please Ask: Has your child recently/currently been involved in a Boys and Girls Club Program: yes no IF YES, ask child’s name, parent and phone #...we will confirm rest of details from database.                                                                                                                                       Added / Updated Database:  Initial: