Boys & Girls Club of Hernando County : Find a Club : Before & After School : West Hernando Membership Application

MEMBERSHIP APPLICATION

Unit Name (Required)

Unit Name:

Anticipated Start Date

Membership Type

Membership Type:

Before School Only
After School Only
Before & After School

MEMBER INFORMATION

First Name (Required)

First Name

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Middle Name

Last Name (Required)

Last Name

Date of Birth (Required)

Date of Birth:

Gender (Required)

Gender:

Ethnicity (Required)

Ethnicity:

Address

Address:

City

City:

State

State:

Zip Code

Zip Code:

Home Phone: (Required)

Home Phone:

Cell Phone:

EMail:

SCHOOL INFORMATION

School

School:

Grade (Required)

Grade:

Free or Reduced Lunch? (Required)

Lunch Level:

MEDICAL INFORMATION

Doctor's Name and Telephone Number

Permission for Treatment by Doctor/Hospital? (Required)

Does Member have any Serious Medical Issues?

If yes, please describe...

This list should include all known allergies

Is Member currently on any medications?

If yes, please list

PHYSICAL INFORMATION

Eye Color (Required)

Hair Color (Required)

Skin Color/Features (Required)

Skin Color/Features:

Height (Required)

Height:

Weight (Required)

Weight:

HOUSEHOLD INFORMATION

Member Lives With...

Mom
Step Mom
Dad
Step Dad
Grandparent
Foster Parent(s)

Annual Household Income (Required)

Number in Household

Number in Household:

Is there a Member of the Household 65 years old or older?

Is there a Member of the Household Handicapped?

Current Head of Household

Current Single Parent (Required)

Contact Information (Required)

Primary Contact Name (Required)

*Primary Contact Name:

The primary contact will be the first person contacted with any concerns regarding member, member's account or in an emergency

Relationship to Member (Required)

Relationship to Member:

Information/Permissions

Select all that apply:

This Person is the Parent/Guardian of the Member
This person is an Emergency Contact in the Event Parent/Guardian is unreachable
This person is authorized to Pick Up or Drop Off Member

Home Phone

Home Phone:

Work Phone

Work Phone:

Cell Phone

Cell Phone:

EMail:

Full Name

Relationship to Member (Required)

Information/Permissions

Select all that apply:

This is Member's Parent/Guardian
This person is an Emergency Contact in the Event Parent/Guardian is unreachable
This person is authorized to Pick Up or Drop Off Member

Home Phone

Home Phone:

Work Phone

Work Phone:

Cell Phone

Cell Phone:

EMail:

Full Name

Relationship to Member

Information/Permissions

Select All That Apply:

This is Member's Parent/Guardian
This person is an Emergency Contact in the Event Parent/Guardian is unreachable
This person is authorized to Pick Up or Drop Off Member

Home Phone

Home Phone:

Work Phone:

Cell Phone:

EMail:

Full Name

Relationship to Member

Information/Permissions

Select All That Apply:

This is Member's Parent/Guardian
This person is an Emergency Contact in the Event Parent/Guardian is unreachable
This person is authorized to Pick Up or Drop Off Member

Home Phone:

Work Phone

Work Phone:

Cell Phone

Cell Phone:

EMail:

Disclaimer: (Required)

PARENT RELEASE I, the parent/guardian of the minor child listed on this application, for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever discharge the Boys & Girls Club of Hernando County, and Boys & Girls Clubs of America, their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organizations such as staff, directors or volunteers, from all liability, claims, demands, or causes of action for any and all loss, damage, injury or death and any claim of damages resulting from use of facilities owned or controlled by the above organizations, or participation in activities of said organizations either at or away from the Club.

KNOW YOUR CHILD’S CHILD CARE CENTER   The parents or legal guardian’s signature verifies receipt of the child care brochure and agree to review with my child/children.

PARENT HANDBOOK   I have received a copy of the Boys & Girls Club Program Handbook.   I agree to become familiar with the contents of this handbook.

CLUB RULES/CODE OF CONDUCT   I agree to review the Clubs rules & consequences along with the Code of Conduct with my child/children.  I understand that membership can be suspended or revoked should behavior warrant such action.

CAMPS   I understand that accounts must be paid to date in order to register for any camp.

LATE FEES   I will adhere to the program hours.  I understand that I will be charged $1 per minute/per child according to the clock on site.  I understand that membership may be suspended until payment is made or discharge, in the event my child/children are picked up late three times.

MOVIE RELEASE FORM   I give my child/children permission to watch PG rated movies in the event of rain, early release days or as an optional activity.

PICTURE RELEASE FORM   I release the right to all photographic material that The Boys & Girls Clubs of Hernando County might use for promotional activities without obligations to me or my child/children.

MEDICAL TREATMENT   I give permission to the Boys & Girls Club of Hernando County to seek emergency medical treatment for my minor child if I cannot be reached. I will be responsible for any/all costs of medical attention and treatment.

PROGRAMS.  I understand that my child may participate in the SMART programs which include SMARTGirls, Passport to Manhood, SMARTMoves, and StreetSMARTS.  These programs will aid my child in attaining the skills, confidence and knowledge to make positive choices throughout life.  Topics cover, broken into age-appropriate modules, may include: diversity, anger and conflict, peer pressure, bullying, gangs, drug and alcohol abuse, premature sexual activity, physical and emotional change and growth, self-esteem and body image, healthy eating and eating disorders, sexual and reproductive health, personal values and social interaction.

DATA COLLECTION   I give my permission to the Boys & Girls Club of Hernando County to collect information via online or written surveys, questionnaires, interviews, and focus groups from the minor child listed on this application. Any and all information received will be kept strictly confidential. Data gathered through these means will be summarized in the aggregate and will exclude all references to any individual responses. The aggregated results of these analyses may be shared with Club staff, Boys & Girls Clubs of America (BGCA), funders, and other community stakeholders to evidence program effectiveness and/or Club impact on our members.

SCHOOL INFORMATION   I give my permission to the Boys & Girls Club of Hernando County and Hernando County School District to exchange information regarding the minor child listed on this application. The purpose of the exchange is to help both organizations do a better job of helping the student be successful in school, in the Boys & Girls Club and in life. This release is valid for one year and may be revoked at any time by contacting the Boys & Girls Club in writing.

DATA SHARING   I understand that the Boys & Girls Club of Hernando County may share information about the minor child listed on this application with Boys & Girls Clubs of America (BGCA) for research purposes and/or to evaluate the program’s effectiveness. Information that will be disclosed to BGCA may include the information provided on this membership application form, information provided by the minor child’s school or school district, and other information collected by Boys & Girls Club of Hernando County, including data collected via surveys or questionnaires. All information provided to BGCA will be kept confidential.

TECHNOLOGY   As a member of the Boys & Girls Club, your child will have access to the Internet. While precautions are being taken, it is possible that s/he may access inappropriate sites. The Boys & Girls Club will have rules and consequences at the Club for such behavior; however we will not be responsible for the consequences of such access.

MISCELLANEOUS   I understand that the Boys & Girls Club is not responsible for lost or stolen items. Parents and Club members are responsible for their own transportation to and from the Club. I give permission for my child’s picture, moving pictures, or any other graphic depiction or likeness, to be used by the Boys & Girls Club and its activities. I also understand that the Club is not, nor does it claim to be, a licensed day care center.  I have read the completed parent handbook and understand the rules of the Boys & Girls Club and request that my child be admitted into membership.  I understand that my child/children’s membership may be suspended or canceled at any time, the sole decision resting in the judgment of the Unit Director and/or the Executive Director.

Input your initials. Your initials will act as your electronic signature, indicating your consent and agreement to the terms of this application

Date (Required)

BROOKSVILLE MEMBERSHIP APPLICATION

Before & After School