Clapp Club – Tuesday 
3:30 – 5:00 PM
October 18th – December 6th

Child’s name: __________________________________ Grade ___ 

School ________  Teacher _______________________ Bus # _____

Parent/guardian name: __________________________________________

Name of anyone else to be allowed to pick up child: 

Home phone: ___________________________  Cell phone: ______________________

Emergency contact person and cell phone #: ________________________________

Food allergies: ___________________________________________________________
Other allergies or medical information: ____________________________________

___  I would like my child to ride a bus from the SRE or CHCS to the Clapp Memorial 
	Library on these Tuesdays.
___ I will transport my child to the Clapp Memorial Library.

I, ___________________________________, understand that I must inform the staff at 
	(print name)
the Clapp Memorial Library if my child will not attend on a scheduled day.  Children 

that are unable to follow the rules of the program may lose the privilege of attending.  

There is not a certified nurse on location.  All children will be picked up in the 

Children’s Activity Room downstairs in the Library by 5:00 PM.  There will be an 

attendance sheet that must be signed at pick up.

_____________________________	(signature)

Snacks:  A simple snack and water will be provided at the Library.  

Children may not bring food unless it has been arranged with Jennifer 

Whitehead, Head of Children’s Services.  Families are asked to make a 

$4 donation when returning paper work or at the first pick up to help 

with the cost of snack.  If there is a parent that would like to 

volunteer to help with snack, please let Jennifer know.