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

2021-2022 SCHOOL YEAR MEMBERSHIP APPLICATION - Waitlist

Unit Name (Required)

Unit Name:

Fees and Attendance Notice

Fees and Attendance

Input your initials. Your initials indicate you have read and understand the Fees and Attendance policy noted above. (Required)

Acknowledgment of Fees and Attendance Notice

Anticipated Start Date: (Required)

Anticipated Start Date

Anticipated Membership Type

Membership Type:

Before School Only
After School Only
Before & After School

MEMBER INFORMATION

The following information is required for membership at Boys & Girls Clubs of Hernando County.

This information will not be used individually but grouped and used for securing and maintaining local, state, and federal funding sources, including donations and grants. All information is held strictly confidential.

Please enter the following information for the Child you are enrolling as a Member of the Boys & Girls Clubs of Hernando County:

First Name (Required)

First Name

Middle Name

Last Name (Required)

Last Name

Date of Birth (Required)

Date of Birth:

Gender (Required)

Gender:

Gathering of Information for Grants/Fundraising (Required)

Racial Identity (Required)

Racial Identity

Ethnicity (Required)

Ethnicity

Primary Language Spoken in Home (Required)

Address

Address:

City

City:

State

State:

Zip Code

Zip Code:

SCHOOL INFORMATION

School

School:

Grade (Required)

Grade:

Does Member have a 504 or Individualized Education Plan (IEP)? (Required)

Free or Reduced Lunch? (Required)

Lunch Level:

MEDICAL INFORMATION

Doctor's Name and Telephone Number

Authorization for Medical Care (Required)

Initials indicate my agreement and understanding of the Authorization for Medical Care. (Required)

Please enter your initials indicating your agreement and understanding of the Authorization for Medical Care

Insurance Coverage: (Required)

Has Member been diagnosed with any of the following conditions:

Does Member have any other Serious Medical Issues, including dietary restrictions and/or allergies? (Required)

If yes, please describe...

This list should include all known allergies, including food allergies

Is Member currently on any medications? (Required)

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... (Required)

Annual Household Income (Required)

Do you receive vouchers from the housing authority or live in public housing? (Required)

Number of People in your Household: (Required)

Number in Household:

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

Is there an Adult Member(s)of the Household with a disability?

Current Head of Household

Is Member from a Single Parent Household: (Required)

Military: Household member currently enlisted or have served

Current/Former Military?

Contact Information (Required)

Please note that if there is a court order pertaining to a parent/guardian and contact with a member, you MUST provide a copy of the court order to the Unit Director. We cannot, by law, restrict access to a child by a parent without a valid court order. You may upload a copy of a court order using the upload button below, prior to submitting your application.

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: (Required)

EMail:

2nd Contact - 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

Work Phone:

Cell Phone

Cell Phone:

EMail:

3rd Contact - 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:

4th Contact - 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:

Terms & Conditions (Required)

PLEASE READ THIS COMPLETELY AND CAREFULLY.

PARENT RELEASE: You are agreeing to let your minor child engage in a potentially dangerous activity. You agree that, even if Boys & Girls Clubs of Hernando County uses reasonable care in providing this activity, there is a chance your child may be seriously injured or killed by participating in this activity because there are certain dangers inherent in the activity which cannot be avoided or eliminated. By signing this form you are giving up your child’s right and your right to recover from Boys & Girls Clubs of Hernando County, Inc. in a lawsuit for any personal injury, including death, to your child or any property damage that results from the risks that are a natural part of the activity. You have the right to refuse to sign this form, and Boys & Girls Clubs of Hernando County, Inc. has the right to refuse to let your child participate if you do not sign this form.

FEES AND ATTENDANCE: A non-refundable registration fee of $25 per year per family and the first week’s fee of $50 per child is due upon registration. Upon the start of the program, weekly fees are due the Friday before the week of service. If payment is not received by the due date, a late fee of $10.00 will be charged. The weekly fee reserves your child’s spot in the program whether or not your child attends.  Each program year, the child is 2 weeks of vacation where the fee will not be charged. Parent/Guardian is required to notify their Unit Director of absences in advance. Early Release Days are an additional $5 per day, per child. Professional Days, In-Service Days and Holidays the Club is open but School is closed is an additional $15 per day, per child. School Breaks, including Thanksgiving, Winter and Spring are an additional fee that will be posted. Children must be registered for Professional Days, In-Service Days, Holidays and School Breaks.

LATE FEES: I will adhere to the program for hours. I understand 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.

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 understand I will receive a copy of the Boys & Girls Club Program Handbook upon submission of this application. I agree to become familiar with the contents of the handbook.

CLUB RULES/CODE OF CONDUCT: I agree to review the Club's 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.

VIDEO SURVEILLANCE: I understand that the Westside Unit has video surveillance at the site and that I or my minor child are being videotaped while on campus. I also understand that the video cameras are located in common areas and that they are restricted from use in any lavatories on site.
 
CAMPS: I understand that accounts must be paid to date in order to register for any camp.
 
PROGRAMS: I understand my child may participate in Boys & Girls Clubs of Amercia's 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 covered, 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 your child to be successful in school, at the Boys & Girls Clubs, and in life. This release is valid for one year and may be revoked at any time by contacting the Boys & Girls Clubs of Hernando County 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, the 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 Clubs of Hernando County, your child will have access to the Internet. While precautions are being taken, it is possible that she/he may access inappropriate sites. Boys & Girls Clubs of Hernando County have rules and consequences for such behavior; however, Boys & Girls Clubs of Hernando County will not be responsible for the consequences of such access.
 
MISCELLANEOUS: I understand that the Boys & Girls Clubs of Hernando County are not responsible for lost or stolen items. Parents and Club members are responsible for their own transportation to and from the Club. 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 Chief Executive Officer.

Section 2.8 of the Child Care Facility Handbook, requires that parents are notified in writing of the disciplinary and expulsion policies used by the child care facility.  This information is contained in our Parent Handbook.

I certify that I am legally capable of executing this agreement, and that I have done so of my own free will on the date indicated below, on behalf of myself, my spouse, if not signed separately, and our child named above.

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

Date (Required)

Upload Documentation

Upload Documentation as you feel necessary

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The questions below are designed to help us understand and work effectively with your child.

Does your child have any physical or mental disabilities, developmental delays or emotional/behavioral disorders that we should be aware of to help your child be successful at BGCHC?

Has your child experienced any emotional trauma?

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Is your child receiving any services through special education?

WEST HERNANDO MEMBERSHIP APPLICATION

Before & After School