Brooksville-BeforeandAfterSchoolApplication : Before & After School : Join A Club : Boys & Girls Club of Hernando County

Before & After School Program

Age Restriction: Child must be 5 years old and enrolled in Kindergarten. VPK students may not attend the before & after school program. DO NOT PROCEED if your child does not meet this age restriction.

Boys & Girls Club Unit:

Brooksville Unit

Fees and Attendance Notice

Fees and Attendance

A non-refundable registration fee of $50 per family is due upon registration.  The first week's fee of $70.00  is also non-refundable and is due upon registration.  You will receive an email from your Member Account Representative confirming receipt of the registration and advising the due date and total amount due (based upon available discounts and ELC co-payments, if applicable).  If payment is not received by the due date, your registration will be deleted and a spot will not be reserved for your child.

Upon the start of the program, weekly fees are due the Wednesday before the week of service. If full payment is not received by the Wednesday before the week of service, a late fee of $25.00 will be charged on the account balance.  If full payment is not received by Friday, services will be denied on Monday. The weekly fee reserves your child’s spot in the program whether or not your child attends.   Registration Fees and Weekly Fees are non-refundable.

Your child is allowed two (2) weeks of vacation where the fee will not be charged if your child does not attend at all.  To be used the vacation week must consist of absences of 5 consecutive days (Monday thru Friday) of a single week, where a week is defined as 7 consecutive days starting Saturday and ending Friday.

Parent/Guardian is required to notify their Unit Director of absences in advance.

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 Schedule:

Please indicate what days you anticipate your child will attend the program.

Monday
Tuesday
Wednesday
Thursday
Friday

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:

Child's First Name (Required)

First Name

Child's Middle Name

Middle Name

Child's Last Name (Required)

Last Name

Date of Birth (Required)

Date of Birth:

Gender (Required)

Gender:

Gathering of Information for Grants/Fundraising (Required)

Racial Identity

White
Black or African American
Asian
Native Hawaiian or Pacific Islander
American Indian or Native Alaskan
Some Other Race
Unknown

Ethnicity: Is Member Hispanic or Latino?

Yes, Hispanic/Latino
No, not Hispanic or Latino
Unknown

(Hispanic or Latino is a person of Cuban, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)

Primary Language Spoken in Home: (Required)

Primary Language Spoken in Home:

Address

Address:

City

City:

State

State:

Zip Code

Zip Code:

SCHOOL INFORMATION FOR 2024-2025 SCHOOL YEAR

School (Required)

School:

Grade (Required)

Grade:

Does member participate in any Education Programs

No Education Program
Homeless
ELL/LEP
Special Education/ESE
Gifted & Talented
Bilingual

Is Member Eligible for Free or Reduced Lunch? (Required)

Is Member Eligible for Free or Reduced Lunch?

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

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

Insurance Coverage: (Required)

Insurance Coverage

If Private, Insurance Company name: (Required)

If Private, Insurance Company name

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)

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

If yes, please describe... (Required)

If yes, please describe

This list should include all known allergies, including food allergies

Is Member currently on any medications? (Required)

Is Member currently on any medications?

If yes, please list (Required)

If yes, please list

If medications are to be given during Program Hours you must complete an Authorization for Prescription and Non-Prescription Medication form.

Has member had experience in the following:

Been in Foster Care
Currently in Foster Care
Never experienced Foster Care
Experienced Homelessness
Currently Homeless
Never experienced Homelessness

PHYSICAL INFORMATION

Eye Color (Required)

Eye Color

Hair Color (Required)

Hair Color

Skin Color/Features (Required)

Skin Color/Features:

Height (Required)

Height:

Weight (Required)

Weight:

HOUSEHOLD INFORMATION

Member Lives With... (Required)

Member Lives With...

Annual Household Income (Required)

Approximate only

Annual Household Income

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

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

Number of People in your Household: (Required)

Number in Household:

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

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

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

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

Current Head of Household (Required)

Current Head of Household

Is Member from a Single Parent Household: (Required)

Is Member from a Single Parent Household:

Military: Household member currently enlisted or has served

If yes, please indicate whether Active or Reserve and What Branch (Required)

If yes, please indicate whether Active or Reserve and What Branch

Is Member impacted by parent/caregiver serving in the military?

Yes
No
Not Applicable

Has a parent/guardian in the Member’s household been incarcerated at any point?

Does anyone in the Member’s household have or previously had any gang affiliations?

Does anyone in the Member’s household have experience with drug or alcohol abuse?

Has anyone in the Member’s household had an experience with Human Trafficking?

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. The primary contact is the only person who may make changes to Member's account information, including pick-ups/emergency contacts.

jic0xo1mame1

Relationship to Member (Required)

Relationship to Member:

Information/Permissions

Select all that apply:

Information/Permissions

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)

Terms & Conditions - PLEASE READ THIS COMPLETELY AND CAREFULLY

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: Registration and first week’s fees are due upon registration and are non-refundable. Upon the start of the program, weekly fees are due the Wednesday before the week of service. If payment is not received by the due date, a late fee of $25.00 will be charged. If full payment is not received by Friday services will be denied on Monday.  The weekly fee reserves your child’s spot in the program whether or not your child attends.

LATE PICK UP FEES: I will adhere to the program 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 terminated, in the event my child/children are picked up late three times.

PICK UP/DROP OFF TIMES:  Specific drop off and pick up times may vary by school site and are detailed in the Parent Handbook.  These times may be adjusted over the course of the school year at the request of the school or to insure the safety of the children in our care.  You will be notified of changes to the drop off/pick up times.

PARENT HANDBOOK: I understand I will receive a copy of the Boys & Girls Club Preschool Program Handbook upon submission of this application and that a copy will be available on-line at www.bgchernando.org.   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, including mine or my authorized pick-ups, warrant such action.

VIDEO SURVEILLANCE: WESTSIDE ONLY:  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.

SCHOOL SITES: I understand that the before & after school program is located on a Hernando County School District (HCSD) school site and that by enrolling my children in this program that I must abide by all HCSD rules, in addition to Boys & Girls Club of Hernando County, Inc. rules and requirements.
 
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.

PARENT COMMUNICATION:  The Boys & Girls Clubs of Hernando County will communicate with the Primary Contact regarding the registered member.  Please make sure that all contact information is kept current.  Also, the Club may use Class Dojo and you authorize the Club to use Class Dojo to communicate information pertaining to your child and the club site with you.

ABCMOUSE:  For our VPK members, the Club has registered accounts with ABC Mouse.  ABC Mouse is an online program that uses games, puzzles and other fun activities to help kids practice letters, numbers and more.  By registering your child in our VPK program you are authorizing us to add your child to the preschool’s ABC Mouse.

PROCARE:  The Boys & Girls Club of Hernando County has contracted with Procare for our member database.  You agree to activate your Procare account upon registration.  You also agree to read communications from the Club through Procare messaging and email.  Instructions for using Procare are available on our website.

SIGN IN/SIGN OUT:  Each Parent/Guardian shall be provided PIN codes for themselves and each authorized Pick Up.  It is the Parent/Guardian’s responsibility to ensure each authorized pick up receives their PIN codes.  The PIN codes are specific to each individual and must NOT be shared.  Parent/Guardian and Authorized Pick-Ups agree to use the PIN pad to sign the children in and out of the program.  Repeated sharing of a PIN code or not using the PIN pad shall result in your child being dismissed from the program.

FOOD PROJECTS AND SPECIAL OCCASIONS:  The program will be doing food projects throughout Summer Camp that may involve the consumption of food provided by local, licensed restaurants/food vendors or purchased from area grocery stores.  In addition, special occasions throughout the year may include the Club purchasing food from local, licensed restaurants and/or food vendors to be consumed by the children, such as, but not limited to a Pizza Day.  By signing this application, you are granting permission for your child to participate in the food projects or special occasions and consume food related to these activities.
EARLY LEARNING COALITION PROVIDER:  The program is a contracted provider with the Early Learning Coalition.  Parent’s with ELC must sign their child(ren) in and out daily.

FOOD PROGRAM Please take the time to visit www.choosemyplate.gov website to get some really healthy food choices and inexpensive ways to prepare meals. Staff and children follow sanitary food handling as well as staff is/are aware of all children’s food allergies, and daily monitoring of healthy food choices provided by parents.

SECTION 2.8 OF THE CHILD CARE FACILITY HANDBOOK, DISCIPLINARY & EXPULSION POLICIES, requires that parents are notified in writing of the disciplinary and expulsion policies used by the child care facility.  These policies are detailed in the Preschool Parent Handbook, Page 14.

SECTIONS 7.1 AND 7.2 OF THE CHILD CARE FACILITY HANDBOOK, requires a current physical examination (Form 3040) and immunization record (Form 680 or 681) within 30 days of enrollment in our Preschools/Daycares..

SECTION 7.3 OF THE CHILD CARE FACILITY HANDBOOK, INFLUENZA BROCHURE. Requires that parents of children enrolled in the facility receive detailed information regarding the causes, symptoms and transmission of the influenza virus in an effort to educate those parents regarding the importance of immunizing their children against Influenza as recommended by the Advisory Committee on Immunization Practices of the Centers of Disease Control and Prevention.  The brochure must be signed annually during the months of August and September.

SECTION 7.3 OF THE CHILD CARE FACILITY HANDBOOK, CHILD CARE FACILITY BROCHURE, requires that parents receive a copy of the Child Care Facility Brochure, “Know Your Child Care Facility” (CF/PI 175-24).  The “Know Your Child Care Facility” brochure is also available on-line at:  https://eds.myflfamilies.com/DCFFormsInternet/Search/OpenDCFForm.aspx?FormId=860

SECTION 7.3 OF THE CHILD CARE FACILITY HANDBOOK, DISTRACTED ADULT BROCHURE, requires that parents of children enrolled in the facility receive information regarding the potential for distracted adults to fail to drop off a child at the facility.  The brochure must be signed annually in the months of April and September.

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.

CHILD & CLUB SAFETY HANDBOOK:  Safety is our #1 priority.  We do mandatory and ongoing background checks on all potential staff and volunteers, each of whom must follow strict policies and procedures.  Boys & Girls Clubs of Hernando County employs a zero-tolerance policy for any disregard of our procedures.  If any issues or concerns are brought to our attention, we immediately contact the police and Child Protective Servies.  We incorporate the national BGCA safety standards and wor with other community organizations to strengthen our safety programming consistently through new training.  For more details on our safety policies, please see the Child & Club Safety Handbook (you may request a copy at the site or may view it on-line at https://bgchernando.org/who-we-are/commitment-to-safety.html.

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

No file selected

Click or drag here to add files