Activity Centers Registration Packet

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Activity Center Emergency Contact

Child's Name(Required)

Activity Center Location(Required)

Grade 2026-27(Required)

Is child attending Camp Ed?(Required)

Yes

Address(Required)

Child's allergies(Required)

(including medications, bug bites and food)

Does your child have an Epipen?(Required)

You must provide the Activity Center site with an epipen if your child has an allergy that requires one.

Yes

What can we do if an allergic reaction occurs?(Required)

Emergency Contact Information

Email(Required)

Mom's Name(Required)

Dad's Name(Required)

Mom's Cell Phone(Required)

Dad's Cell Phone(Required)

Mom's Work Phone

Dad's Work Phone

Alternative Emergency Contact

Someone other than a parent MUST be provided.

Name, Phone, and Relationship to Child(Required)

Child's Doctor and Phone(Required)

What hospital do you prefer for your child?(Required)

Is there any medical information we should know about your child?(Required)

Signature of Parent or Guardian(Required)

Activity Center Authorized/Unauthorized Pick Up List

Child's Name(Required)

Activity Center Location(Required)

Authorized

Name-1

Relationship to Child-1

Cell Phone-1

Work Phone-1

Name-2

Relationship to Child-2

Cell Phone-2

Work Phone-2

Name-3

Relationship to Child-3

Cell Phone-3

Work Phone-3

Name-4

Relationship to Child-4

Cell Phone-4

Work Phone-4

Name-5

Relationship to Child-5

Cell Phone-5

Work Phone-5

Name-6

Relationship to Child-6

Cell Phone-6

Work Phone-6

Name-7

Relationship to Child-7

Cell Phone-7

Work Phone-7

Name-8

Relationship to Child-8

Cell Phone-8

Work Phone-8

Unauthorized

Name-9

Relationship to Child-9

Cell Phone-9

Work Phone-9

Name-10

Relationship to Child-10

Cell Phone-10

Work Phone-10

Name-11

Relationship to Child-11

Cell Phone-11

Work Phone-11

Name-12

Relationship to Child-12

Cell Phone-12

Work Phone-12

Name-13

Relationship to Child-13

Cell Phone-13

Work Phone-13

If there is a separation or divorce custody issue of which we should be aware, please explain: Who has primary physical custody? Who can make changes to this packet information?

Although it is not Activity Center’s responsibility to understand or determine legal documents, nor is it our responsibility to enforce legal documents, all court orders will be reviewed and followed to the best of the program’s ability. A parent/guardian with physical custody will always be considered the decision maker. A written agreement signed by the parent/guardian with physical custody is required to make changes involving program documentation (ex. Permission to pick up a child, etc.) Activity Center reserves the right to terminate care in instances of inappropriate behavior by a parent.

Activity Center Hours

Activity Center Location(Required)

Activity Center hours are 7:45am-5:30pm.(Required)

-Please do not drop your child/ren off earlier than 7:45am. The AC Leaders are not on site to supervise your child/ren before this time. Children must be signed in every morning and out at the end of the day.
-Child/ren must be picked up by 5:30pm. Your child/ren may be left unattended if you arrive after hours. We understand there may be circumstances that cause you to be late. Habitual lateness will result in your child/ren being dismissed from the program without a refund.

The late pick up procedure for AC participants is as follows:
1. First late pick up: a verbal reminder.
2. Second late pick up: a call from the program coordinator.
3. Third late pick up: a letter and a three-day suspension.
4. Fourth late pick up: a five-day suspension.
5. Fifth late pick up: dismissal from the program without a refund.
Suspension days exclude weekends and holidays.

I understand the AC hours and late pick up procedure.

Parent Signature(Required)

Date Signed(Required)

Child/ren's Name(Required)

CampEd Children

If your child/ren attends the Bismarck Public School’s CampEd program, we want to make sure the transition from the CampEd program to the Activity Center is in a safe and timely manner. Please tell your child/ren to
go directly to the Activity Center site after CampEd and report in with the leaders by 1:05 pm each day. They should not wander around in the school or out on the playground. Starting in June 29 when CampEd is done,
someone MUST sign in your child, you can not just drop them off and leave. This is for the safety of your child and to make sure they make it to Activity Center and get checked in.

If your child/ren is going to be absent from Activity Center, contact the coordinator that day by 8:00am or sooner at 222-6771 or email blast@bisparks.org.

I understand the CampEd procedure and have explained to my child.

Parent Signature(Required)

Date Signed(Required)

Child(ren)'s Name(Required)

Enter NA if your child is NOT attending CampEd.

Activity Center Discipline Procedure

Activity Center Location(Required)

Disciplinary Procedure(Required)

Single day disciplinary procedure.
1. First offense in a single day: The child receives a verbal warning. Leaders explain what the child has done wrong, why it shouldn’t be done, and that it shouldn’t happen again.
2. Second offense in the same day: The child receives a second verbal warning and a time-out. Explain again what the child has done wrong and why it shouldn’t be done. The child will then sit out of activities for a short time.
3. Third offense in the same day: The child receives a final warning, and the parent will be called. The child is to be picked up immediately; and will sit in time out until parent arrives. The child will be suspended the following day.

Disciplinary procedure for multiple suspensions.
• Second suspension: one day
• Third suspension: three days
• Fourth suspension: five days
• Fifth suspension: dismissed from the program with no refund.
*Suspension days exclude weekends and holidays.

• Fighting, hitting, or inappropriate physical contact of any kind will result in a three-day suspension. Fighting is defined as: actual or attempt to bully, intimidate, or harass another person that results in a physical altercation (ex. hitting, kicking, and shoving) between any AC participant(s) or staff.
• Second fighting offense: sent home immediately and a five-day suspension.
• Third fighting offense: sent home immediately and dismissed from the program with no refund.
In instances that include extreme verbal abuse, destructive or violent behavior, where someone may be injured, the child will be sent home immediately and dismissed from the program with no refund.

I understand the disciplinary procedure and have explained it to my child.

Parent Signature(Required)

Date(Required)

Child(ren)'s Name(Required)

Permission Slip to Leave Grounds

Permission Slip(Required)

Throughout the summer, there are times that the AC group leaves the school for walks to other playgrounds, to go on scavenger hunts, or to take a short hike. These walks may not be decided until the day of the session. Please sign the permission slip below to allow your child to attend these walks.

I agree to let my child leave the AC grounds with leaders and the AC group.

Parent Signature(Required)

Date(Required)

Child(ren)'s Name(Required)

Activity Center Bookmobile Permission Form

Child's Name: Last Name(Required)

First Name(Required)

Middle Initial(Required)

Activity Center Location(Required)

1. Would you like your child to check out library books from Burleigh County Library's Bookmobile?(Required)

Yes! Please proceed to question 2.

No, thank you. Please sign and date the bottom of the page.

2. Does your child already have a library card?

(Bismarck Public Library, Burleigh County Library-Bookmobile, or Morton Mandan Public Library)

Yes, enter their library card number in A below.

No, but will be using a parent, guardian, brother, or sister's library card. Complete B1 and B2 below.

Yes, but I don't know it. Complete C1 and C2 below.

No. Please fill out registration below in section D.

A. Enter child's library card number if known.

B1. Enter name on borrowed card's account.

B2. Number of borrowed card's account.

C1. Parent call 701-355-1491, library staff will give it to you over the phone to enter here.

C2. Do you want a replacement card?

Yes

D. Library Card Registration

Child's Name (Last, First, Middle Initial)

Address

Address City State Zip

Phone

Notices via text?

Yes

4-digit PIN

(Required to access your account and electronic resources online)

Child's Date of Birth

(month/day/year)

Age Group

12 and under

13-17

School

Parent/Guardian Name

Please read the statement below.

Bismarck Parks and Recreation is not responsible for any items check out from the Bookmobile. It is the responsibility of the family to see that all items are returned to the bookmobile or Bismarck Library and/or pay any fines for lost or damaged books. Any questions may be directed to the Burleigh County Library at 355-1491 or kmcdonald@bismarcklibrary.org.

Initial this statement.

I understand that items checked out on the Bookmobile's last visit in July must be returned to the Bookmobile or the Bismarck Library (DO NOT LEAVE BOOKS AT THE ACTIVITY CENTER).

Initial this statement.

I agree that I am responsible for all materials checked out with this card.

Initial this statement.

If materials are lost, damaged, or not returned to the correct location, I am responsible for any fines that have accrued.

Parent/Guardian Signature(Required)

Date(Required)

Activity Center Contact Information

Activity Center Emergency Contact

Emergency Contact Information

Alternative Emergency Contact

Activity Center Authorized/Unauthorized Pick Up List

Authorized

Unauthorized

Activity Center Hours

Activity Center Discipline Procedure

Permission Slip to Leave Grounds

Activity Center Bookmobile Permission Form

D. Library Card Registration

Please read the statement below.

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