2024 Summer Camp Application - Waitlist Call Up : Summer Camp : Join A Club : Boys & Girls Club of Hernando County

Summer Camp Site:

Spring Hill Area Location: Westside Unit
Brooksville Area Location: Moton

Fees and Attendance Notice

Fees and Attendance

A non-refundable registration fee of $30 per child is due upon registration.  The first week's fee of $125.00  is also non-refundable and is due by April 1st.  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 Summer Camp registration will be placed on hold and a spot will not be reserved for your child.

Upon the start of the program, weekly fees are due the Friday before the week of service. If full payment is not received by the Friday before the week of service, a late fee of $25.00 will be charged on the account balance. 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 one (1) week 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

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 2023-2024 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

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)

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 have served

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

Yes
No
Not Applicable

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

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

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.

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 fees and weekly fees are non-refundable.  Registration Fee is due upon registration.  First weeks fee is due by May 13th.  Upon start of the program, weekly fee’s are due the Friday before the week of service.  If payment is not received by the due date a late fee of $25.00 will be charged.  The weekly fee reserves your child’s spot in the program whether your child attends or not.  The child is allowed one week vacation where fee will not be charged if child does not attend.  Parent is required to notify their Unit Director of absences in advance.  More than 3 late fees may result in your child’s termination from the program.

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

No file selected

Click or drag here to add files

Child's T-Shirt Size

Please select your child's T-Shirt size. If your child is between sizes, go up a size.

Youth Small
Youth Medium
Youth Large
Youth Extra Large
Adult Small
Adult Medium

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Backpack Color

Every effort will be made to ensure your child receives their chosen color, but we cannot guarantee it.

Orange
Pink
Black
Burgundy
White
Red
Blue

Shoe Size (Required)

Please indicate whether Child or Adult Size along with the size number (ex: Adult 8.5)

There will be 2 field trips this Summer to New Port Richey Recreation & Aquatic Center. To ensure the safety of your child please answer the below question honestly and select the most appropriate answer:

My child CAN swim without aids (i.e., floaties)
My child CANNOT swim

The registration fee is $30.00 per child and is due upon registration. You will be contacted within 2 business days with the date the first week's Summer Camp Fee is due. If payment is not made by that due date your registration is cancelled. Registration Fees are non-refundable.

Credit Card Information

Cardholder Name (Required)

Credit Card # (Required)

Expiration Date (Required)

Security Code (Required)

cardholders
Your security code is the 3-digit code at the end of the signature field on your card's back.

Billing Zip Code (Required)

Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged