BOYS & GIRLS CLUB OF VERNON



BOYS & GIRLS CLUB OF VERNON

“SUPER SUMMER” 2017 REGISTRATION FORM

Summer Program dates: June 5-July 21, 2017 Closed July 4

ALL MEMBERS ARE REQUIRED TO FOLLOW CLUB RULES

ALL SUMMER ATTENDEES MUST BRING MEMBERSHIP CARD EVERY DAY

Summer Program is open to children Kindergarten - High School, by grade just completed (2016-2017 school year).

Children who were in Pre-K during the school year are not eligible to attend.

FEES:

Current Boys & Girls Club Membership is required (Summer Program fees are not the same as Membership)

Summer Program Fees: $25.00 per month for one child, $20.00 per month for each additional child in family (Summer Fees are for the program, not a meal charge)

First month fee must be paid with registration

Child’s Name: Grade Just Completed

Nickname (or Name Child Goes By) Date of Birth:

Gender: M ___ F ___ Race: African American ___ Asian American ___ Caucasian ____ Hispanic ___ American Indian ____

School attended in 2016-17: School Lunch: Free ____ Reduced ____ Regular ____

Home Address Home phone

(Use local address if child is visiting from out of local area)

City State Zip

Parent or Guardian Contact Information:

Name (please print)__________________________________________ Relationship to Child__

Employer ___________ Work Tel. ___________ Cell Phone #

Name (please print)___________________________________________ Relationship to Child

Employer ___________ Work Tel. ___________ Cell Phone #

Emergency Contact (if parents cannot be reached):

Name _____________________________ Relationship _______________ Home Tel. _________Work Tel.__________

Name _____________________________ Relationship _______________ Home Tel. _________Work Tel.__________

Medical Does child have serious health problems or limitations in activity? No ____ Yes _____

If yes, indicate type of problem:

Is child on special medications: No ____ Yes _____ If yes, explain: _________________________________

If medication is to be given by Boys & Girls Club staff, please complete the authorization to administer medication.

Food allergies or restrictions? __________________________________________________________________________

If food substitutions or restrictions are needed for medical reasons, we may ask for a Doctor’s statement

Household Information: NOTE: This Information is collected for reports and grant writing purposes

Child (or children) live with (Mark all that apply): Mother___ Stepmother___ Father___ Stepfather___ Grandparent___ Other_____________

Total Number of persons in Household (Adults & children): _______ Number of Children (under age 18) _______

Head of Household: Male ___ Female ___ Both ___ Single Parent? Yes ___ No ___

Does family receive: Medicaid _______ Food Stamps _______ SSI _______

Yearly Income Level (Total for household)

|Less than $5,000 ____ |$10,000 - $14,999 ____ |$20,000 - $24,999 ____ |$30,000 - $34,999 ____ |$40,000 - $49,999 ____ |

|$5,000 - $9,999 ____ |$15,000 - $19,999 ____ |$25,000 - $29,999 ____ |$35,000 - $39,999 ____ |$50,000 and up ____ |

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 Vernon, 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.

Medical Treatment

I give permission to the Boys & Girls Club of Vernon 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.

Data Collection

I give my permission to the Boys & Girls Club of Vernon 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.

Data Sharing

I understand that the Boys & Girls Club of Vernon 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 Vernon, 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 he or she 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.

I give my permission to the Boys & Girls Club of Vernon to 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 Vernon, including data collected via surveys or questionnaires. All information provided to BGCA will be kept confidential.

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 have received and read the Boys & Girls Club of Vernon information concerning:

Membership Requirements

Boys & Girls Club Code of Conduct

Parental Release Form

Discipline Policy & Procedure

Bullying Prevention Policy

I have read the completed application and this form, understand the rules of the Boys & Girls Club and request that my child be admitted into membership

Boys & Girls Club of Vernon strives to make the Club experience fun and educational for your child. It takes parental involvement and staff working together. Please read the above sections, and sign below.

Parent/Guardian Signature ________________________________ Date: ______/______/______

BOYS & GIRLS CLUB CODE OF CONDUCT

1. Have fun in the Club

2. Participate in programs and activities

3. Bring membership card every day

4. Play fairly and be honest

5. Be respectful of Boys & Girls Club staff and obey instructions

6. Say only good things about others

7. Resolve disagreements in a positive way

8. Be respectful of other members and their property

9. Take care of your Boys & Girls Club equipment and other Club property

10. Avoid use of improper language

11. Remove hats before entering building

12. Applaud efforts of other members

13. Run in the gym only – Walk in the halls

14. Participate only in program areas open to your age group

15. Listen during assemblies

16. Dress appropriately at all times – same Dress Code as in schools

17. Smoking, drugs, alcohol and weapons (or anything that may be considered a weapon) are prohibited

18. Cell phones, MP3 players, IPods, etc. may not be used in the Club. We recommend that members not bring them.

DISCIPLINE POLICY AND PROCEDURES

• Youth at the Boys & Girls Club of Vernon are expected to be responsible for and in control of their behavior.

• Children make choices about their behavior and sometimes they may not make the best choice. Staff will work with them to make better decisions about how they behave at the Club.

• We expect children to treat others with respect, just as we expect our staff to treat others with respect.

Inappropriate behavior will result in the following discipline referral process:

1. Each child is given verbal warnings before a formal discipline referral. Staff will discuss inappropriate behavior with members.

2. If child continues inappropriate behavior, he/she will receive a discipline referral, the incident will be recorded in writing and a copy will be sent to the parent/guardian.

3. If a second offense is committed within 1 month, the parent will be notified in writing and the child will be suspended from the Club for 1 month.

4. Upon readmission, if the child receives another discipline referral within 60 attendance days, the child will be suspended from the Boys & Girls Club for the remainder of the semester or 6 weeks, whichever is longer.

5. Some offenses may be considered to be serious enough for immediate suspension. The parent/guardian will be contacted and terms of readmission will be discussed.

Inappropriate behavior includes:

• Hitting, roughing, or physical abuse

• Damaging or stealing property (from Club or other members)

• Throwing objects

• Disrespectful, abusive language

• Disrespectful, abusive behavior

• Continued disruptive behavior

BULLYING PREVENTION POLICY

The Boys & Girls Club of Vernon is committed to providing a safe and civil environment and will not tolerate any form of bullying at any Club site activities or outside of Club activities.

Bullying is an intentional repeated unpleasant or unwanted negative behavior by verbal, physical, written, or electronic means and/or any action motivated by race, color, religion, ancestry, national origin, gender, sexual orientation, gender identity, mental disability, physical disability, appearance or socioeconomic statue done by one or more persons directed against a person who has difficulty defending himself or herself.

Staff and volunteers who observe an act of bullying shall take immediate, appropriate steps to intervene and shall report it to their supervisor. All incidents shall be documented in writing.

If an issue has not been appropriately resolved, the organization will inform the parent or guardian of those directly involved. Depending upon the frequency and severity of the incident, the organization may act through intervention, counseling, correction, and/or referral to law enforcement will be used to remedy.

Possession of Telecommunications or Other Electronic Devices

Members shall not:

• Use a telecommunications device, including a cellular telephone, or other electronic device in violation of Boys & Girls Club rules.

Members may not use a cell phone during Boys & Girls Club hours. If they need to contact parents, they may get permission to use the Club phone. If a member brings a cell phone to the Club, it must remain in his/her pocket. If it is out, it will be taken up and returned when the member leaves. No exceptions. Members may not step outside to use cell phones. This is for their safety.

I-pods and MP3 players may not be used in the Club.

We strongly recommend that members not bring the above items to the Club. We are not responsible for them.

Misuse of Technology Resources and the Internet

Members shall not:

• Violate policies, rules or agreements regarding the use of technology resources.

• Send, post, or possess electronic messages that are abusive, obscene, sexually oriented, threatening, harassing, damaging to another’s reputation, or illegal, including cyberbullying and “sexting”.

• Use e-mail or Web sites to engage in or encourage illegal behavior or threaten Club safety.

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. As a drop-in facility, we are not responsible for Club members’ whereabouts.

I also understand that the Club is not, nor does it claim to be, a licensed day care center.

HEALTH CARE & ILLNESS

If your child is ill he/she must stay home from the Boys & Girls Club.

In the event your child becomes ill at Boys & Girls Club, we will contact you and/or your emergency contact and ask that you pick them up as soon as possible.

Children are to be kept home or will be sent home if they have the following symptoms:

a) Fever (over 99 degrees F.)

b) Vomiting and/or diarrhea

c) Unexplained rash or skin infections such as, but no limited to:

Impetigo**

Pinkeye**

Boils

Ringworm**

** Re-admittance requires proof of treatment

d) Hepatitis

e) Head Lice ***Information available on treatment, please contact office.

*** Children will not be able to return or participate in any Club activities, including sports, until nits are no longer visible.

f) Strep Infections/Scarlet Fever

g) Whooping Cough

h) Any communicable disease such as: Chicken Pox, Mumps, Measles, Mononucleosis require an incubation period.

Please advise the office if your child has been exposed to or has any of these communicable diseases, re-admission information will be given at that time.

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FOR OFFICE USE Summer Fees Paid ____________ Cash _____ Check # ___________ Receipt # _____________

Membership Paid _____ Cash _____ Check # __________ Membership # Membership Expiration____ _________

Posted ____________ Notes: _____

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