Please retain this page for your information. Chelsea Lang Interim Unit Director

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1 Dear Club Family, We are excited to have you join us at the Boys & Girls Club Academy Program for the school year! We will be offering great programs that will ensure another fun-filled and exciting year. The Academy programming will continue to focus on our three Priority Outcomes: Academic Success, Character & Leadership and Healthy Lifestyles with the goal of creating the highest quality programming and offering the highest quality staff. Membership form submission deadline for youth to attend the first week of school year programming is August 6, Completed applications will only be accepted at the Boys & Girls Club Traditional Unit (2008 Mulberry Street). Morning Program: Our morning program will be held at Stewart School in the north gym. Youth will enter at the north entrance and have the opportunity to participate in the school breakfast program at 7:25 a.m. Youth that would like breakfast need to be checked in no later than 7:20 a.m. Following breakfast, youth will be transported to their school at 8:00 a.m. Please note that youth will be transferred to public elementary schools only. Monday Friday program 5:30 am until bus pick up at 8:00 a.m. Stewart Elementary members will be supervised until 8:20 a.m. when school staff are on the playground. Must be five years of age by the date of enrollment Afternoon Program: Our afternoon program will be held at two locations: Stewart Elementary for all Yankton public elementary youth and Sacred Heart Elementary for youth who attend that school. Youth who are attending the Stewart Elementary site will be bussed from their school and will enter Stewart Elementary from the North entrance. Youth who attend the Sacred Heart Elementary site will walk to the school gym after being dismissed from their classroom. Monday Friday program After school until 6 p.m. Snack is served at 3:45 p.m. each day. Open on days that the Yankton School District is closed (see page 4) o 6:30 am 6:00 pm o Additional $25 for these full days o See Fees, Payment & Billing section for additional details on no school day billing processes. Registration: To register, please complete attached membership. An EFT form and credit card form is included in the packet. If you will be paying with CCA (Child Care Assistance), it is still a requirement to fill out an EFT or credit card form to ensure that a backup payment option is on hand. An additional $25 processing fee will be charged per billing cycle for all cash or check payments. Parent Orientation: Parent/Youth Orientation is a requirement for all members that are new to the Club/Academy. At least one parent/guardian is required to accompany their child to the orientation that will take place at our Traditional Unit (2008 Mulberry Street). Orientation for the Academy is offered every Thursday at 5:15 p.m. Orientation is required prior to youth attending the Academy program. Looking ahead: All Boys & Girls Club Academy memberships expire on the last day of the school year in the spring of If your child(ren) will be attending the Academy for the summer 2019 program, you will need to fill out a renewal membership application and submit it before the summer registration deadline of Monday, May 6 th, The renewal memberships will be available in March 2019.

2 2 Scheduling: If your child is not planning to attend, please let the Academy Program Coordinator know ( or for safety and ratio reasons. Status Change: If at any point you wish to change your child s Academy membership, an Academy Schedule Change Form must be submitted. In order for any necessary billing adjustments to be made, the completed form must be submitted at least 15 days in advance of the next billing date. When a child is withdrawn from the program with less than 15 days, your account will still be charged on the next billing date. The Boys & Girls Club does not pro-rate or issue refunds. Fees, Payment & Billing: The cost of the school year Academy is $110 per month for full-time morning program attendance and $110 per month for full-time afternoon program attendance. If your child attends both the morning and afternoon program, the cost would be $220 per month. Full-time billing will take place prior to attendance on 15th of each month. The first bill for the school year full time youth will be withdrawn on August 15th and will cover the billing period of August 15th September 14th. A late charge of $25 will be charged to your account if payment is not made by the 15th. If an EFT charge does not go through, you will be responsible for paying the bank fee as well as the $25 dollars to the Boys & Girls Club for a late payment. If the Boys & Girls Club has not received your payment by the last day of the month and it is the second time having a late payment, your family will be required to set up with EFT (Electronic Funds Transfer). There is no credit given for absences due to vacations, illnesses or holidays. The Boys & Girls Club does not pro-rate or give refunds. Receipts will be ed. There is no credit given for absence due to vacation, illness, holidays, or early withdrawal from program without appropriate advance notice. A 15 day notice must be given for withdrawing a child from the Academy Program. When a child is withdrawn with less than a 15 day notice, you will still be charged the rate that youth was signed up for. A schedule change form can be completed by contacting Jill Paulson or the Academy Front Desk. The Boys & Girls Club does not pro-rate or issue refunds. BGC prefers electronic withdrawal from a checking/savings account or by credit card. However, cash/check is an option. Due to the administration of cash and check payments, rates increase by $25 per billing period. o Cash/check payments are due to the Business Office at 1126 Southland Lane, Brookings, SD by 15 th of the month. The Academy does accept Childcare Assistance (CCA) reimbursements, but a back up form of payment must be on file. If the bill is not fully covered by CCA, any outstanding dues will be deducted from family s account. No-School Day Billing: On days the Yankton School District is scheduled to be closed, the Academy will be open from 6:30 a.m. until 6:00 p.m. On these days, the $25 fee will be added onto your monthly fee. Unlike monthly payments, due the month prior, no school day fees will be withdrawn from your account the following month. For full days, parents must sign their child up for the no school day one week in advance to ensure the Academy has the appropriate amount of staff for the day. Once signed up, 48-hour notice must be given to the Boys & Girls Club if the child is no longer going to attend the full day. If 48-hour notice is not given, the $25 fee will still be applied to the next billing cycle. If your member is picked up late, a late pick-up fee ($10.00 per 15-minute increments beginning at minute one after the program ends) will be charged to your upcoming bill. We are very excited about having your child in the program and the high level of quality programming and staff that the Academy programs will be offering this school year. Thank you for allowing The Boys & Girls Club the privilege of working with you and your family! For additional programming questions, please contact Chelsea Lang. For any additional billing questions, please contact Yura Elverud. Chelsea Lang Interim Unit Director clang@greatfuturessd.org Please retain this page for your information Yura Elverud Chief Financial Officer yelverud@greatfuturessd.org

3 3 Important Billing Information Monthly School Year Academy Payment Schedule Full-Time $110 for Morning Program and $110 for Afternoon Program 1st Day of School September 14 th Billed August 15, 2018 September 15 th October 14 th Billed September 17, 2018 Schedule change due date September 1, 2018 October 15 th November 14 th Billed October 15, 2018 Schedule change due October 1, 2018 November 15 th December 14 th Billed November 15, 2018 Schedule change due November 1, 2018 December 15 th January 14 th Billed December 17, 2018 Schedule change due date December 1, 2018 January 15 th February 14 th Billed January 15, 2019 Schedule change due date January 1, 2019 February 15 th March 14 th Billed February 15, 2019 Schedule change due date February 1, 2019 March 15 th April 14 th Billed March 15, 2019 Schedule change due date March 1, 2019 April 15 th Last Day of school Billed April 15, 2019 Schedule change due date April 1, 2019 Full-time monthly summer billing resumes May 15, 2019 Please retain this page for your information

4 4 IMPORTANT DATES Yankton Public School District CLOSED Dates DATE OPEN ACADEMY SITES October 19, 2018 Sacred Heart Elementary November 12, 2018 November 21, 2018 November 23, 2018 December 24, 2018 January 2, 2019 January 25, 2019 February 18 & 19, 2019 March 15, 2019 April 18-22, 2019 Stewart Elementary Stewart Elementary Stewart Elementary Sacred Heart Elementary Stewart Elementary Sacred Heart Elementary Stewart Elementary Stewart Elementary St. Ben s Elementary CLOSED Dates DATE OPEN ACADEMY SITES February 15, 2018 Sacred Heart Elementary* March 8, 2018 Sacred Heart Elementary* *On dates above that listed St. Ben s as an open site, a minimum of 10 youth must be signed up. If less than 10 youth are signed up for the St. Ben s site on the closed dates mentioned above, St. Ben s will NOT be open. Boys & Girls Club Academy CLOSED Dates DATE ACADEMY CLOSED September 3, 2018 November 22, 2018 December 25, 2018 January 1, 2019 May 27, 2019 Labor Day Thanksgiving Day Christmas Day New Year s Day Memorial Day Please retain this page for your information

5 5 Membership Form Checklist: Below is a quick overview of what needs to be filled out before handing in your child s membership packet. For memberships to be accepted and youth able to attend, the application must be completed in its entirety-thank you! Your child s application must be turned in by August 6 th for them to attend the first week of school year programming. Page 6 Page 7 Page 8 Page 9 Youth s Siblings Information Income Information Parent Guardian Information (Address, Phone Numbers, , Place of Employment) Youth Information (Name, DOB, Gender, Ethnicity, Number in Household, School Information) Medical Information Name and phone number of child s physician Additional Emergency Contacts (at least two that are not parents/guardians) Individuals not allowed to pick up youth Mark Yes/No for each question in box Permission Information (Yes/No/Not Applicable and Initials) Release Form (Signed by parent) Page 10 Billing Schedule Pages 11 & 12 EFT Form for Automatic Withdrawal or for Credit Card Office Use Only Unit Director Compliance Business

6 Mulberry Street, Yankton, SD Tel ACADEMY MEMBERSHIP APPLICATION OFFICE USE ONLY Membership #: Entry Date: Date Received: New/Renewal: Expiration Date: Start Date: Club Card Printed: Processed By: Payment Type: Orientation Date: Picture Taken: Receipt #: Please select if your child will be a Full-Time AM and/or PM: Full-Time AM Full-Time PM Youth Name: First: Last: Member s Sibling(s): Name Age Full/Half/Step Name Age Full/Half/Step Please Mark the Appropriate Line regarding Annual Household Income (this is for grant purposes only) 0-$35,850 $35,851-$41,000 $41,001-$46,100 $46,101-$51,200 $51,201-$55,300 $55,301-$59,400 $59,401-$63,500 $63,501-$67,600+ Parent/Guardian Information: Both parents/guardians information needs to be filled in below: Parent/Guardian: Address: Gender: M F City: State: Zip: Home Phone: Cell Phone: Work Phone: Place of Employment: Parent/Guardian: Home Phone: Cell Phone: Work Phone: Place of Employment: Check this box if home address is same as above If single parent, please check this box Address: Gender: M F City: State: Zip:

7 7 Youth Information: First Name: Middle: Last: Date of Birth: Gender: M F Ethnicity: African American Asian Number in Household: Hispanic Multi-Racial Estimated High School Graduation Year: Caucasian Native Hawaiian/Pacific Islander Native American: (Tribe) School: Grade: School Year: Medical Information: Name of Child s physician: Physician phone number: Does your child have asthma? Yes No Does your child have an allergy? Yes No Do they use/carry an inhaler? Yes No N/A If yes, please list allergy and associated symptoms: Allergy Symptom(s): Allergy Symptom(s): Does your child have other medical conditions or diagnoses? Yes No If yes, please explain: The Boys & Girls Club is a drop-in recreational facility, not a licensed daycare facility, and is not responsible for or allowed to dispense, store and/or oversee medication of any kind, including all non-prescription medications. Parents/Guardians are able to come to and sign in to the Boys & Girls Club and administer medication to their child. The Boys & Girls Club can follow its incident and accident policies and procedures, including: Support your child through a team effort Call 911 in case of an emergency situation Follow normal incident/behavior protocol, if needed, as outlined through Boys & Girls Club of Brookings, SD, Inc. policy By signing my name below, I certify that I have read, understand and agree to the above. Parent Name Date ADDITONAL EMERGENCY CONTACTS in addition to Parents/Guardians *MUST HAVE AT LEAST 2 CONTACTS* Name: Name: Phone Number: Phone Number: Town: Town: Relation to the Child: Relation to the Child: Name: Phone Number: Town: Relation to the Child: Name: Phone Number: Town: Relation to the Child:

8 8 Please write below if someone is NOT ALLOWED TO PICK UP MEMBER If a biological parent, legal documentation must be provided Name: Relationship to Member: Please write below if someone is NOT ALLOWED TO PICK UP MEMBER If a biological parent, legal documentation must be provided Name: Relationship to Member: Does this contact live in the Member s household? Yes [ ] No [ ] (If not, please fill in address below) City/State/Zip: Brief description of individual (Please provide a picture if possible) Does this contact live in the Member s household? Yes [ ] No [ ] (If not, please fill in address below) City/State/Zip: Brief description of individual (Please provide a picture if possible) Please check one item from each group below: Single Parent: Yes No Is the member a child of Military personnel and not living on a base? Yes No Are you willing to volunteer at the Club? Yes No Permission Information I give my permission to the Boys & Girls Club of Brookings and Yankton Community Schools 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 the student be successful in school, in the Boys & Girls Club and in life. This release is valid for one year and may be revoked at any time by contacting Yankton Community Schools or the Club in writing. Yes No Parent Signature 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. Yes No Parent Initials

9 9 RELEASE FORM 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 Brookings Cooperation, 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 Brookings to seek emergency medical treatment for my minor child if I cannot be reached. I understand that Club employees cannot transport children to the hospital and that if a life threatening situation occurs, the AMBULANCE will be contacted first and then the PARENTS. I will be responsible for any/all costs of medical attention and treatment. Surveys and Questionnaires I, the parent/guardian of the minor child listed on this application, give permission for Boys & Girls Club of Brookings to survey my child about his or her Club experience and behaviors, skills and attitudes using Boys & Girls Clubs of America s Youth Development Outcome Measurement Tool Kit surveys or other survey instruments. Restraining I understand that when a youth is in a dangerous situation to themselves or others they will be removed from the situation. Miscellaneous I understand that the Boys & Girls Club is not responsible for lost or stolen items. Any items placed in the lost and found will be discarded on the 15th of every month. Late Fees I understand that my child/children must be picked up by closing time each day. I understand that I will be charged $10.00 per child for every 15 minutes that my child/children remains at the club after closing time. Time is rounded up to next 15 minutes. For example: 1-14 minutes that child/children remain at the club after closing time = $10.00 per child minutes that child/children remain at that club after closing time = $20.00 per child, etc. 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. I understand it is a Boys & Girls Club membership requirement that all youth and guardians attend orientation prior to attending the Academy. All youth are unable to attend the Academy until the orientation is attended by youth and guardian, even if in the same family. I also Parent understand that if I have completed orientation in the past it is my responsibility to go to the Club website at and Initials read, review and follow the Boys & Girls Club parent handbook and listen to the recorded orientation. I hereby give my permission for my child to become a member for the Boys & Girls Club of Yankton Academy. I understand that the Club is Not Responsible for the time or manner in which he/she may arrive at or leave the Club, and that the Boys & Girls Club of Brookings, SD, Inc. and its property are not responsible for personal injury or loss of property. Parent Signature: Date:

10 10 Boys & Girls Club School Year Program Schedule Please select either full time AM or PM. You will be billed according to this schedule. If you need to make any changes, a 15 day notice must be given by contacting Chelsea Lang, Interim Unit Director, via phone ( ) or by (clang@greatfuturessd.org). Youth s Name: Parent/Guardian signature: Date: School Year Payment Schedule (please select one): Full-Time AM ($110 per month) Full-Time PM ($110 per month) 1st Day of School September 14 th Billed August 15, 2018 September 15 th October 14 th Billed September 17, 2018 Schedule change due date September 1, 2018 October 15 th November 14 th Billed October 15, 2018 Schedule change due October 1, 2018 November 15 th December 14 th Billed November 15, 2018 Schedule change due November 1, 2018 December 15 th January 14 th Billed December 17, 2018 Schedule change due date December 1, 2018 January 15 th February 14 th Billed January 15, 2019 Schedule change due date January 1, 2019 February 15 th March 14 th Billed February 15, 2019 Schedule change due date February 1, 2019 March 15 th April 14 th Billed March 15, 2019 Schedule change due date March 1, 2019 April 15 th Last Day of school Billed April 15, 2019 Schedule change due date April 1, 2019 Monthly Summer Billing resumes May 15, 2019 This schedule must be submitted with your application.

11 11 AUTHORIZATION FOR PAYMENT BY CHECKING OR SAVINGS ACCOUNT I authorize The Boys & Girls Club of Brookings, SD, Inc. to initiate debit entries to my account indicated below. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. (Name Please Print) (Youth s Name Please Print) (Address Please Print) (Phone Number) (Name of Financial Institution) (Address of Financial Institution Street, City, State and Zip Code) Checking / Savings Account # (Please circle one) Bank Routing Number (# between these symbols: : : on the bottom left corner of check) I would like to pay cash or check each month. (Reminder: an additional $25 fee will be added each month) I have been approved for Child Care Assistance. Please retain this information as back up payment options. Payments will be debited on the 15th day of the month Reminder, full non-school days are an additional $20 per day cost. If your child is signed up but does not attend, you will still be charged. **PLEASE ATTACH A VOIDED CHECK** This authorization will remain in effect until the total payment amount has been debited or until I notify you in writing to cancel it in such time as to afford the financial institution a reasonable opportunity to act on it. I can stop payment of any entry by notifying my bank or the Boys & Girls Club of Brookings up to ten business days prior to my account being charged. I understand that there may be a fee charged by my financial institution for any stop payment I authorize. I understand that the amount I have authorized may vary with the guidelines stated here, and I will be notified at least 10 days prior to the transfer if that amount falls outside of these guidelines. I understand that choosing electronic payments will move the ACH transaction to the nearest working day, should that date occur on a holiday, weekend, or any other non-working day for the banking institution. Name (Please Print) Signature Date

12 12 AUTHORIZATION FOR MONTHLY PAYMENT VISA / MASTERCARD ONLY I authorize The Boys & Girls Club of Brookings, SD, Inc. to charge my credit card number indicated below. I acknowledge that the transactions must comply with Visa/MasterCard regulations. (Name on Card Please Print) (Youth s Name Please Print) (Address Please Print) (Phone Number) (Credit Card Account Number) (Expiration Date) I would like to pay cash or check each month. (Reminder: an additional $25 fee will be added each month) I have been approved for Child Care Assistance. Please retain this information as back up payment options. Payments will be debited on the 15th day of the month Reminder, full non-school days are an additional $20 per day cost. If your child is signed up but does not attend, you will still be charged. This authorization will remain in effect until the total contribution has been charged to my account or until I notify you in writing to cancel it in such time as to afford The Boys & Girls Club a reasonable opportunity to act on it. I can stop any transaction by notifying The Boys & Girls Club up to 10 business days prior to my credit card being charged. I understand that choosing monthly contributions will move the transaction to the nearest working day, should that date occur on a holiday, weekend, or any other non-working day for the banking institution. Name (Please Print) Signature Date

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