Parent Consent and Agreement to COVID-19 Procedures



Summer Program 2021 Gillette, WY June 7th, 2021 – August 20th, 2021 (54 Days)Summer Program Fees: $80 per week, $280 per month$764 full summer if paid by May 21st, 2021 Welcome to the Boys & Girls Clubs 2021 Summer Programming! Dear Parents and Guardians: Welcome to a new summer with the Boys & Girls Clubs of Campbell County! It is our pleasure to serve your children. Our summer will be full of fun and excitement! This packet provides essential information about our policies. Our staff is looking forward to providing the best experience for your child this summer. Your assistance will help us achieve this. Available Sites The Boys & Girls Clubs of Campbell County provides Summer Programming at our Main Site only. Ages Served We serve children ages 5-18 during our Summer Programming. Children under the age of 6 must be enrolled in Kindergarten for the 2021-2022 school year. Hours/Late Fees The Club will be open from 7:30 am to 5:30 pm Monday through Friday for Summer Programming. Any child not picked up by closing time, 5:30 pm, will be charged a $1 late fee for every minute past the closing time. This fee must be paid before the member is allowed to return to the program. If your child is left for more than one hour past closing, the proper authorities will be notified. Payment/Weekly Balances This year we will be implementing a significant change with our payment policy for our Summer Program. The Club will be moving to a pre-payment structure for our summer programming. This change ensures we can regularly collect for our Summer Programming fees and ensures we have space available for all members and families to utilize our services. The Summer Program fee is $16.00 per child per day. The Summer Program fees include breakfast, lunch, an afternoon snack, any planned field trips, and one Club shirt. A payment of $80.00 is required the Friday before the week your child is expected to attend. As per usual, you will only be billed for the days your child(ren) attend. Credit will remain on your account from week-to-week and will stay on the account until expended. Each Friday before attendance a payment equal to the weekly rate must be made in full. For example, if you paid $80 for the week, but your child only attended three days ($48), you would still have $32 on the account and would only need to make a $48 payment for the next week. As an alternative, you may choose to make monthly payments instead. The monthly fee for the summer is $280 per month. And again, similar to our weekly fee, we will only bill for the days your child was in attendance. Each month (June, July, August), you must make a payment equal to the monthly fee through the summer. For example, if you paid $280 for June and your child only attended ten days ($160), you would only need to make a $160 payment for the next month to bring your total back to $280 for the next month. If you receive DFS childcare assistance, we will review your parent contribution information from DFS. Your weekly or monthly rate will be based on your parent contribution for daily attendance. As this is very specific per child, we will reach out to you individually once we receive your application before our Summer Programming. This year we will also offer a one-time full summer payment at a discounted rate. Our one-time payment rate for our Summer Programming is $764.00 per child (savings of $100). If making a one-time payment, this payment must be received before May 21st, 2021. This is a non-refundable, non-transferable fee. For your child to attend any camp week, full payment must be received NO LATER than the Monday morning of that week. Lack of payment will result in your child(ren) not being able to attend the Club's Summer Program that week. Refund Policy Any remaining balances at the end of our Summer Programming will stay on a child's account for the school year. If your child(ren) will not be attending the Club during the school year, a refund of the remaining balance may be requested. No refund will be given for the full Summer Program fee. No refund will be given if a child is removed from the Summer Program in the event of disciplinary actions. Drop-off /Pick-up Upon arrival, parents/guardians must ensure their child(ren) enter the building and check-in to the Club through our Bus Room Entrance. Due to the ongoing concerns with COVID-19, no parents/guardians will be permitted inside the building. Please do not send your child to the Club if they are experiencing symptoms of COVID-19 or if they have been in close contact with someone who has tested positive for the virus. Upon departure from the Club, parents/guardians must be on the approved pick-up list and provide photo identification upon request. Again, we will not be allowing anyone inside the building. To expedite the pick-up process, please call ahead when arriving for pick-up. This is for the safety of our members, families, and employees. Open-Door Policy The Boys & Girls Clubs of Campbell County is a drop-in facility and has an open-door policy where members are advised to stay on Club premises; however, we cannot legally require a member to stay at the Club. The staff does not grant permission to leave, nor do we insist that children stay. Arrival and departure are strictly between parent/guardian and the child(ren). However, we will be monitoring all members and all entry and exit points in the building. Should a member decide to leave, Cub staff are instructed to remain in close contact until a parent/guardian or the property authorities arrive. As always, safety for our members is our top priority. If you have a specific concern, please notify our Executive Director. Discipline Our summer program aims to provide members with an atmosphere of fun, creativity, and respect through meaningful supervised experiences, encouraging positive personal development. Please feel free to speak with our Executive Director about our discipline policy. Your cooperation will assist us in achieving these goals. The Boys & Girls Clubs of Campbell County enforces the following codes of conduct: Respect for self, other members, staff, and property. Threats, violence, and foul language will not be tolerated. The Boys & Girls Clubs staff is instructed to take the following disciplinary actions: Verbal warning, time outs, "Calming Corner." Write Up, Parental notification. Dismissal from all Boys & Girls Clubs Summer Program. (It is at the Executive Director's discretion to give suspensions.) Fighting is an automatic two-day suspension. Sick Policy No child will be admitted to camp if any of the following conditions are present: A contagious disease (i.e. chickenpox, cold/flu, COVID-19, etc.) Any fever over 100 degrees; must be fever free for more than 24 hours Excessive sneezing or coughing Signs of vomiting and/or diarrhea A child will be sent home if any of the above conditions occur at Club. There is a space provided on the membership application for alternate emergency phone numbers. Ill children must be picked up within one hour of notification.Medication If your child requires medication, we prefer it is taken outside of Club hours. If it is necessary to bring medication to the Club for the safety of all, please alert the Executive Director to discuss a secure location to keep the medication while your child is at the Club. However, our policies do not allow for staff to administer medication, so it will be your child's responsibility to remember to administer the medicine him/herself. The Club will not administer any over the counter medications (Tylenol, Advil, Benadryl), herbal supplements, or controlled substances (Adderall, Vyvanse, Ritalin, etc.). Personal Items We encourage your child to bring only the necessities to the Club, as there will be no locked storage available. If your child decides to bring personal items, the Boys & Girls Clubs of Campbell County will not be responsible for lost, stolen, or damaged items. Children are discouraged from bringing cell phones, tablets, or any other gaming devices to the Clubs! However, we do encourage you to send your child(ren) with a hat, sunscreen and water bottle. Lunch/Snacks Your child will be provided a healthy breakfast, lunch, and afternoon snack throughout the summer. In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form (AD-3027)?found online , any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:(1) Mail: U.S. Department of AgricultureOffice of the Assistant Secretary for Civil Rights1400 Independence Avenue, SWWashington, D.C. 20250-9410;(2) Fax: (202) 690-7442; or(3) Email:?program.intake@.This institution is an equal opportunity provider. Required Forms A Summer Program application form must be completed and submitted before May 21st. Any child who has not submitted a Summer Program application will not be able to attend as space is limited. Additionally, you will need to submit the COVID release and waiver forms prior to the start of our Summer Programming. Schedules The Boys and Girls Club will be closed from May 31st through June 4th for the training of new staff and to allow the Club to properly clean and sanitize before the start of our Summer ProgrammingSummer Program will be closed on July 5th, 2021, in observance of Independence Day. Field trips will be offered throughout the summer. These trips may include the library, city pool, planetarium, rec center, Area 59 and/or Rockpile Museum. Please watch for schedule changes through Remind, on our Facebook page, and our website at If you have any questions regarding our policies, please speak with our Executive Director. Weekend MealsThrough our partnership with Edible Prairie Project, ALL MEMBERS will receive summer weekend meal bags. These will be distributed every Thursday, and each member will receive one. We want to encourage families who may not need a weekend meal bag to consider donating items to someone else in need. If you do not know of someone, help your child(ren) learn about the importance of giving back and donate the items to a local food bank, church, or daycare. 3524259525 Summer Health and Safety Protocols 00 Summer Health and Safety Protocols The health and safety of our members, staff, and their families is the Club’s first priority. To promote the safety and well-being of all who use the Club, we must follow certain precautions and procedures directed by the CDC, state, and county health officials. The Club will have a single clearly marked entry zone where parents/guardians can drop-off and pick-up their child(ren). Parents/guardians will not be allowed inside of the building. In the event of an emergency, parents must wear a mask, gloves, and have their temperature logged by staff prior to entry into the facility. Parents/guardians must be accompanied by a staff at all times. Any individual entering the Club out of the designated entry zone (parents/guardians, members, staff, etc.) must be screened for COVID-19. COVID-19 Screening Checklist Temperature below 100.1 degrees. Has individual been exposed to anyone that has tested positive for COVID-19? Is individual free of the following symptoms: Fever/chills Shortness of breath or difficulty breathing Cough Headache or muscle pain A new loss of taste or smell Members will have their temperature taken upon arrival to the Club and again at midday and will be logged. If a member exhibits any of the listed symptoms on the COVID-19 Screening Checklist, parents/guardians will be notified and asked to pick-up the youth immediately. There will be a designated space isolated from other people for the sick child to wait. If a parent/guardian is unable to pick up within 60 minutes of being notified, the authorities will be contacted. Parents/guardians are required to keep children home if the child or anyone in the household is exhibiting any symptoms from the COVID-19 checklist. Staff are required to stay home if they or anyone in their household is exhibiting any symptoms of COVID-19. Members must be escorted to their assigned group upon arrival. Staff will log their temperature upon arrival.Sanitation: All staff will be trained and required to follow proper cleaning and disinfecting protocols. The Club will be stocked with COVID-19 approved cleaning supplies. Areas will be disinfected any time a group changes program areas or vacates a program area and at the end of every program day. No less than twice a day. Frequently touched surfaces and supplies shall be disinfected between groups. Bathroom touch points will be disinfected no less than twice a day. Contaminated areas will be disinfected with an approved cleaner. All vehicles will be disinfected after each field trip. Programming: All field trips will follow current social distancing guidelines in regards to numbers and public interaction. Groups will occupy one room at a time and avoid interaction with other individuals and groups. Social distancing will be encouraged within groups. Meals and snacks will be served in the cafeteria utilizing a staggered schedule to ensure appropriate social distancingAll staff serving meals and snacks will be required to wear a mask and gloves. Staff will ensure that only one member uses a bathroom at a time. Members and staff must wash their hands or use hand sanitizer upon arrival. Hands must be washed or sanitized before and after all meals/snacks and after field trips. Personal Protective Equipment: Masks will be available for staff and members if an individual doesn’t have his/her own. If a parent/guardian desires their child(ren) to wear their own mask, a parent/guardian must provide one. Gloves must be worn for temperature checks, serving food, cleaning, accepting money, or any activity that involves physical contact with another individual. Hand sanitizer (>60% alcohol volume) will be available in all rooms. One staff from each group must carry hand sanitizer at all times. Staff must frequently use hand sanitizer. Parent Consent and Agreement to COVID-19 ProceduresThe health and safety of our members, staff, and their families is the Club’s first priority. To promote the safety and well-being of all who use the Club, we must follow certain precautions and procedures directed by the CDC, state, and county health. Please read through each statement and initial next to each statement indicating you understand and agree to the mandatory procedures. ______ 1. I agree to a daily COVID-19 screening of my child(ren), including a temperature check, answering questions about the presence of any COVID-19 symptoms, and disclosure of any exposure to COVID-19. ______ 2. I agree that my child(ren)’s temperature will be checked and logged upon arrival at the Club and again at midday. ______ 3. I agree that if my child(ren) exhibits any of the listed symptoms, I will be notified immediately and will pick up my child within 45 minutes. ______ 4. I agree that I will provide a doctor’s note indicating that my child(ren) is free of COVID-19 for attendance to resume if they have been diagnosed or exposed to COVID-19______ 5. I agree to keep my child(ren) home if they or anyone in the household exhibits symptoms related to COVID-19. ______ 6. I understand that parents/guardians will not be allowed inside the building. In the event of an emergency, parents/guardians will be allowed inside the Club site but must be escorted by a staff member, wear a mask and gloves, and submit to a temperature check. ______ 7. I agree to provide an updated and current daytime phone number and an updated and valid emergency contact phone number. ______ 8. I understand that my child must wear a mask while attending Club a______ 9. I agree to comply with all procedures, expectations, and directives from all staff that is set forth by my the Club and that I will ensure my child(ren) will do the same. _____ 11. I have received and understand BGCCC’s Summer Health and Safety Protocols. Signature of Parent/GuardianDateName of Parent/GuardianName of Club Participant(s)FOR PARENTS/GUARDIANSAssumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.Boys & Girls Clubs of Campbell County has put in place preventative measures to reduce the spread of COVID-19; however, the Club cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending the Club could increase your risk and your child(ren)’s risk of contracting COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending the Club and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Club may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Club employees, volunteers, and program participants and their families.I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the Club or participation in Club programming (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless the Club, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Club, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Club program.Signature of Parent/GuardianDateName of Parent/GuardianName of Club Participant(s)Office Use OnlyApplication Date: _______/_______/______Staff initials: _______2021 SUMMER MEMBERSHIP APPLICATIONNote: Application must be filled out completely in order for membership to be valid.All personal information will be kept confidential and is used strictly for the safety of your child and in statistical reports necessary for fundingMEMBER INFORMATIONChild’s Name: (First, Middle Initial, Last): Cell Number:Mailing Address: Age: Ethnicity: ? African-American ??Hispanic or Latino ? Multi-Racial or Other ? Asian ? Native American ? Caucasian ? Pacific Islander Birth Date: (MM/DD/YY)Language spoken at home: ? English ?Spanish ?Other: Gender: ? Male ?Female? Transgender ? Non-BinarySchool: Grades Release for Outcome Measurement: ?Yes ?No Times normally in care:From: To: Shirt Size: ?YS ? YM ? YL ? YX?Small ? Med. ? Large ? XLGrade: USDA Milk & Meal Enrollment for CACFP: Days normally in care: ? M ? T ? W ? Th ? FCheck all that apply: ? Breakfast ? Lunch ? PM SnackAny health or allergy information we should know?Media Release*:? Yes? NoADDITIONAL MEMBER INFORMATIONChild’s Name: (First, Middle Initial, Last):Cell Number: Mailing Address: Age: Ethnicity: ? African-American ?Hispanic or Latino ?Multi-Racial or Other? Asian ? Native American? Caucasian? Pacific IslanderBirth Date: (MM/DD/YY)Language spoken at home: ? English ? Spanish ? Other: Gender: ? Male ?Female? Transgender ? Non-BinarySchool: Grade Release for Outcome Measurement: ? Yes ? No Times normally in care:From: To: Shirt Size: ?YS ? YM ? YL ? YX?Small ? Med. ? Large ? XL Grade: USDA Milk & Meal Enrollment for CACFP: Days normally in care: ? M ? T ? W ? Th ? FCircle all that apply: ? Breakfast ? Lunch ? PM SnackAny health or allergy information we should know?Media Release*:? Yes? NoADDITIONAL MEMBER INFORMATIONChild’s Name: (First, Middle Initial, Last):Cell Number:Mailing Address: Age: Ethnicity: ? African-American ? Hispanic or Latino ? Multi-Racial or Other? Asian ? Native American? Caucasian ? Pacific IslanderBirth Date: (MM/DD/YY):Language spoken at home: ? English ? Spanish ? Other: Gender: ? Male ?Female? Transgender ? Non-BinarySchool: Grade Release for Outcome Measurement: ? Yes ? No Times normally in care:From: To: Shirt Size: ?YS ? YM ? YL ? YX?Small ? Med. ? Large ? XL Grade:USDA Milk & Meal Enrollment for CACFP: Days normally in care: ? M ? T ? W ? Th ? FCircle all that apply: ? Breakfast ? Lunch ? PM SnackAny health or allergy information we should know?Media Release*: ? Yes ? No ADDITIONAL MEMBER INFORMATIONChild’s Name: (First, Middle Initial, Last):Cell Number:Mailing Address: Age:Ethnicity: ? African-American ? Hispanic or Latino ? Multi-Racial or Other? Asian ? Native American? Caucasian? Pacific IslanderBirth Date: (MM/DD/YY):Language spoken at home: ? English ? Spanish ? Other: Gender: ? Male ?Female? Transgender ? Non-BinarySchool: Grade Release for Outcome Measurement: ? Yes ? No Times normally in care:From: To: Shirt Size: ?YS ? YM ? YL ? YX?Small ? Med. ? Large ? XLGrade:USDA Milk & Meal Enrollment for CACFP: Days normally in care: ? M ? T ? W ? Th ? FCircle all that apply: ? Breakfast ? Lunch ? PM SnackAny health or allergy information we should know?Media Release*: ? Yes ? No MEMBER MEDICAL INFORMATIONInsurance Company:Insurance Policy Number:If your child(ren) does not have health insurance may we contact you: ? Yes ? No I give permission for my child(ren) to speak to a licensed mental health professional if there is a special need: ? Yes ? No *MEDIA RELEASEIn addition, I authorize BGCCW and partners, to use and reproduce all photographs, audio or video which may be taken in connection with Club activities for any purpose whatsoever (including print materials, audio, video and internet) without compensation. All negatives and positives together with prints and video footage shall constitute BGCCW property, solely, and completely. PRIMARY CONTACT INFORMATIONName:Primary Phone Number: Mailing Address: * Email (for Billing) *:Relationship to member: ? Mother ? Grandma? Other: ? Father ? Grandpa Place of Employment:Work Number:Name:Primary Phone Number: Mailing Address: Email:Relationship to member: ? Mother ? Grandma? Other: ? Father ? Grandpa Place of Employment:Work Number:REQUIRED: EMERGENCY CONTACTIn the event that the parents/guardians listed above cannot be reached in an emergency, this person is authorized to act on my behalf. Please list adults who live outside the home.Name:Primary Phone Number: Relationship to member: Authorized to pick up: ? Yes ? NoName: Primary Phone Number: Relationship to member: Authorized to pick up: ? Yes ? NoHOUSEHOLD INFORMATIONYearly household income: Family Size: (number of people living in household)Family Setting: ? Both parents? Grandparents ? Single parent? Foster Parent(s)? Aunt/Uncle? Other: Click hereChild eligible for Free/Reduced Lunch: ? Yes ? NoAUTHORIZED TO PICK UPName:Phone Number:Relationship to Member: Approved to receive Member Info: ? Yes ? No Name:Phone Number:Relationship to Member: Approved to receive Member Info: ? Yes ? No Name:Phone Number:Relationship to Member: Approved to receive Member Info: ? Yes ? No Name:Phone Number:Relationship to Member: Approved to receive Member Info: ? Yes ? No *We encourage all of our members to attend all days throughout the summer so they do not miss out on valuable and rewarding programming. Members who regularly fail to attend at least 3 times a week may be asked to allow a member from the waiting list to fill their spot. The Club leadership understands that unforeseen circumstances may arise that necessitate a schedule change. We ask that parents keep the Club informed of any changes in regular attendance, so that we may better plan and prepare for an amazing summer with our members!SUMMER ATTENDANCE SCHEDULEPlease provide any pre-planned dates where the member will not be attending the club at least 3 times a weekFrom:To:From:To:From:To:From:To:From:To:USDA NON-DISCRIMINATION In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form (AD-3027)?found online , any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:(1) Mail: U.S. Department of AgricultureOffice of the Assistant Secretary for Civil Rights1400 Independence Avenue, SWWashington, D.C. 20250-9410;(2) Fax: (202) 690-7442; or(3) Email:?program.intake@.This institution is an equal opportunity provider.CONSENT RELEASESIn consideration of the benefits to be received, and in view of the fact that Boys and Girls Clubs of Campbell County will be providing educational and recreational programs and that participation is voluntary, and having confidence that every precaution will be taken to ensure the safety and wellbeing of myself, my child, I agree to my and/or my child’s participation in the project activities as follows:LIABILITY AND MEDICAL EMERGENCYI, for myself and on my behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS the Boys & Girls Clubs of Campbell County, its officers, officials, agents and/or employees, other participants, sponsors advertisers, and if applicable, owners and leasers of premises used to conduct the event (“releasees”), from any and all claims, demands, losses, and liability arising out of or related to any injury, disability or death my child may suffer, or loss of damage to a person or property, whether arising from the negligence of the releasees or otherwise, to the fullest extent of the law.DATA COLLECTION:I hereby give permission to Boys & Girls Clubs of Campbell County, Boys & Girls Clubs of America and other partner organizations to release educational records; including but not limited to attendance records, grades, state assessment test (or other test) scores, academic tests, behavior referrals, and suspension/expulsion records and/or delinquency/criminal and other records to Boys & Girls Clubs of Campbell County for the purposes of evaluating the success of the programs and to be able to more effectively serve my child. I also give permission to BGCCC to collect information via online or written surveys, questionnaires, interviews, and focus groups from the minor child(ren) listed in this application. Any and all information received will be kept strictly confidential. Results of the analyses may be shared with Club staff, Boys & Girls Clubs of America, funders, and other community stakeholders to evidence program effectiveness and/or Club impact on our members.MEMBERSHIP AGREEMENT AND PERSONAL PROPERTYI understand that my child must be at least 5 years old to attend regular programming of the Boys & Girls Clubs of Campbell County. I understand that if my child has frequent accidents they must wear a disposable garment. I understand that if my child is left at the facility after closing, I will be charged a late fee (starting with the first minute). I also understand that if my child is left more than 45 minutes after closing that the Club will contact the proper authorities. I understand membership is voluntary and have confidence that every precaution will be taken to ensure the safety and well-being of my child. I further understand that membership is a privilege and can be revoked at any time. Boys & Girls Clubs of Campbell County has the right to send your child(ren) home at any time due to discipline issues. In the event a parent or emergency contact cannot be reached for pick-up, the police will be called. We will make every attempt possible to contact the parent or emergency contact before this step is taken. BGCCC is not responsible for the loss of personal property. Children are encouraged to leave valuables at home. FIELD TRIP AGREEMENTBoys & Girls Clubs of Campbell County Wyoming will provide transportation for field trips. I agree on behalf of myself, my child named herein, or our heirs, successors and assigns, to hold harmless and defend BGCCC, its officers, directors and agents, and the chaperons or representatives associated with the event, arising from or in connection with my child attending or being transported to and from the event, or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate Boys & Girls Clubs of Campbell County, its officers, directors and agents, chaperons, or representatives associated with the event for reasonable attorney’s fees and expenses arising in connection therewith. If my child arrives late for a field trip and the group has departed, I assume full responsibility for my child and he/she/they will not be left unsupervised at the program site.I acknowledge I have received and understand the membership form.Parent/Guardian Signature: ___________________________________________________ Date: ________________________________I promise to respect myself, respect others and respect the Boys & Girls Club.Member Signature: ___________________________________________________ “This institution is an equal opportunity provider.” ................
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