Membership Application July 1, 2017 June 30, 2018 $25 first child / $20 second child / $15 third child Membership fees are non-refundable

Transcription

1 FOR OFFICE USE 555 Union Street, Manchester NH (603) Membership Application July 1, 2017 June 30, 2018 $25 first child / $20 second child / $15 third child Membership fees are non-refundable Date Received: Amount Paid: Staff: Receipt #: First Name: Middle Name: Last Name: Family Address: Home Phone: Nickname: Birth Date: Age: Gender: Male Female Member Status: New Member Former Member Ethnicity (check all that apply): Black White Hispanic European Other: Home Address: City: State: Zip: School: Grade September 2017: Father s First Name: Father s Last Name: Father s Employer: Father s Occupation Father s Work Phone #: Father s Cell Phone #:

2 Mother s First Name: Mother s Last Name: Mother s Employer: Mother s Occupation: Mother s Work Phone #: Mother s Cell Phone #: Step Parent/Guardian s First Name: Step Parent/Guardian s Last Name: Step Parent/Guardian s Work Phone #: Step Parent/Guardian s Cell Phone #: Members Lives With: Both Mother Father Mother/Stepfather Father/Stepmother Grandparent Guardian Number of Sisters & Step Sisters: Number of Brothers & Step Brothers: Total Number Living in Household: Medical Problems/Allergies: List Medications Members is Taking: Physician: Physician Phone #: Has Your Child Been a Member of the Boys & Girls Club Previously? Yes No Number of Years: Which Club: Family Income $0-$22,800 $22,801-$38,000 $38,001-$60,800 $60,801+ Financial Aid Attach one month s income verification for all adults in the household. You must fill out all information on this application when applying for financial aid or the application will be returned.

3 Emergency Contact Information: Name Relation to Child Phone # The following people, other than parents, have permission to pick up my child. Please note open door policy for members in grades 4-12 for school year program only. I agree to follow the rules and policies explained in the Member Behavioral Expectations of the Boys & Girls Club of Manchester. I realize that membership to the BGCM is a privilege and use of the Club could be taken away if the rules and policies are not followed. In order to be effective with behavior management, we reserve the right to suspend a youngster from the bussing and/or program effective the next day. Please make alternative care arrangements in advance. I have read and understand the Boys & Girls Club of Manchester s Open Door Policy as it is stated on the attached sheet and I am aware of all information on the sheet. I give my consent for my child to participate in Smart Moves prevention programs. Please feel free to contact the Unit Director to discuss the curriculum. I understand that: The Boys & Girls Club of Manchester Union Street Clubhouse is not subject to licensure under RSA 170-E:4. All grievances by parents or guardians with respect to the Club Program should be directed to the Chief Operating Officer.

4 Photographs in which my child may appear may be used in publicity and marketing as well as part of Club recognition or displays. In addition, photographs and videos in which my child may appear may be used on the Club s social media sites. My child may be asked to complete Club surveys used to measure the effectiveness of Club program. I agree to allow the Boys & Girls Club of Manchester to access my son/daughter s school attendance, grades and other information and records that will assist the Club in tracking and improving their educational performance. I realize my son/daughter may participate in activities and programs that are physical in nature and, as a result, may be at risk for injury. In consideration for being allowed to participate in any activities I agree to assume such risk and further agree to hold harmless the Boys & Girls Club of Manchester, its staff and volunteers from any and all claims, suits, losses, or related causes of actions for damages including, but not limited to, such claims that may result from injury or death, accidental or otherwise, during, or arising in any way from the participation in the activities of the program. Our Tax ID is printed on your receipt; year-end statements are not provided. For the security and safety of our members please be aware that individuals in our facilities and riding in our vehicles may be under video surveillance. All payments are entered and late payment notices are prepared at the Administrative Office. All questions regarding the status of your son/daughter s account should be directed to Kim Kuehl. She can be reached at x 225. Please contact Kim if you need a receipt for child care reimbursement funds/programs. Member Signature: Parent/Guardian Signature: Date:

5 Boys & Girls Club of Manchester School Year Registration Two weeks program fees must be pre-paid at time of registration Member Name: Bussing available from: Grades $25 Weekly Fee Bussing Grades 6-8 $15 Weekly Fee Bakersville Green Acres McDonough Parker Varney Weston Beech St Hallsville McLaughlin Parkside Wilson Gossler Hillside Northwest Southside Amount Paid: $ Start Date: Kids Club Grades $20 Weekly Fee Amount Paid: $ Start Date: Before School Program Grades K-5 - $25 Weekly - $10 per day for drop off Bussing is only provided to the following schools: Bakersville Green Acres Jewett Parker Varney Weston Beech St Hallsville McDonough Smyth Rd Wilson Gossler Highland Northwest Webster Polaris Amount Paid: $ Start Date: Highland Goffes Falls Grades K-5 - $60 Weekly Fee Amount Paid: $ Start Date: Highland Part Time Care - $175 for 10 Days (No refund if not used in current year) Amount Paid: $ Start Date: Jewett Street School Grades K-5 - $60 Weekly Fee Amount Paid: $ Start Date: Jewett Part Time Care - $175 for 10 Days (No refund if not used in current year) Amount Paid: $ Start Date:

6 Vacation Camp Grades K-8 $75 if paid in advance / $100 within a week Winter February Spring April Amount Paid: $ Amount Paid: $ No School Day Grades $15 Daily Fee in advance / $20 within a week September 19 th November 7 th Amount Paid: $ Amount Paid: $ State of NH Childcare Title 20 - Highland and Jewett St School Only When you are approved by the State or NH for Childcare be sure to get form 253 from your caseworker and bring to Boys & Girls Club office to be completed, once completed return to your caseworker. You will receive a letter in the mail from the State of NH which states that we are linked as your provider. Bring this letter to our office with this completed registration application. You will be required to pay your membership fee and we will bill the State of NH for weekly fees and bill you weekly for the balance due. Weekly payments are due by 6PM on Fridays every week regardless of the amount of days your child attends or the number of days of school that week. A $5 late fee will be added to all accounts paid late. Consistent late payments can be reason for suspension from the program. Should the Club or site be closed at the end of a week, then payments will need to be made no later than the first day the Club or site is open for the following week Payments may be placed in the drop box at the program site. If paying by check, please put the members name in the memo area of the check for clear identification. No receipt is given for payment by check. If you pay by cash, please enclose it in an envelope with the members name on it and request a receipt from a member of the site staff. All cancellations must be submitted in writing to the Administrative Office. You will be billed for services until written notification is received. In the event of a mistake in logging your payment you must provide the cancelled check or cash receipt to verify payment. If you choose to pay by the month, please be aware that some months may have 5 payments due during that month. It is your responsibility to make the appropriate payment for the month. Should you not make the correct payment you will receive a late payment notice for the fifth week if you forget and you will be obligated to pay the associated late fee. All payments are entered and late payment notices are prepared at the Administrative Office. All questions regarding the status of your son/daughter s account should be directed to Kim Tatman. She can be reached at x 225. Please contact Kim if you need a receipt for child care reimbursement funds/programs. Parent/Guardian Signature: Date:

7 Payment Due Dates Due Date Paying the Week of at time of registration 9/4/17 at time of registration 9/11/17 9/8/17 9/18/17 9/15/17 9/25/17 9/22/17 10/2/17 9/29/17 10/9/17 10/6/17 10/16/17 10/13/17 10/23/17 10/20/17 10/30/17 10/27/17 11/6/17 11/3/17 11/13/17 11/10/17 11/20/17 (no payment for week of 6/11/18) 11/17/17 11/27/17 11/24/17 12/4/17 12/1/17 12/11/17 12/8/17 12/18/17 12/15/17 1/1/18 12/22/17 1/8/18 12/29/17 No Payment 1/5/18 1/15/18 1/12/18 1/22/18

8 1/19/18 1/29/18 1/26/18 2/5/18 2/2/18 2/12/18 2/9/18 2/19/18 2/16/18 3/5/18 2/23/18 3/12/18 3/2/18 No Payment 3/9/18 3/19/18 3/16/18 3/26/18 3/23/18 4/2/18 3/30/18 4/9/18 4/6/18 4/16/18 4/13/18 No Payment 4/20/18 4/30/18 4/27/18 5/7/18 5/4/18 5/14/18 5/11/18 5/21/18 5/18/18 5/28/18 5/25/18 6/4/18 6/18/18 No Payment Last projected payment is due 5/25/18 for the week of 6/4/18, there is no payment 6/18/18 for the week of 6/11/18.

9 Weekly Checking Account Authorization Child s Name: Programs: Weekly Fee: First Date of Charge: Routing Number: Account Number: Account Holder Name: Address: City: State: Zip: Phone Number: You must attach a voided check I authorize the Boys & Girls Club of Manchester to withdraw my weekly payment from the account listed above. Signature: Date:

10 Child s Name: Holiday & Family Assistance Program Each year with help from community sponsors we are able to offer assistance for both Thanksgiving and Christmas. As part of the Thanksgiving program a family would receive everything they need to cook a Thanksgiving Dinner. Typically baskets include: Turkey, veggies, potatoes, rolls, and some form of dessert. Each basket differs based on our community partners and what they choose to include. As part of the Christmas program a family is asked to fill out a wish list which is then handed to our community sponsors. These sponsors use the list as a guide to purchase presents that they wrap and return to the Club a few days prior to Christmas. If you receive Holiday assistance from another community organization you will not qualify for our program. If you believe you will need assistance please indicate which program(s) you will be needing **This does not guarantee you a spot in the program. Space is limited to the number of sponsors available. You will be contacted in early November if we are able to assist your family. Thanksgiving Holiday Assistance Christmas Holiday Assistance **In addition, the Club may be able to provide our members with assistance in additional areas such as warm coat drive, clothing and footwear, vision and dental assistance & more. Please contact Individual Services Director, Stephanie Lee, regarding these services. Also please remember that dinner is provided our members each night at 5pm and a member s family is always welcome to join them for dinner. If you have an additional questions, please contact our Individual Services Director Stephanie Lee at x 223 or by slee@mbgcnh.org.

11 BOYS GIRLS CLUB OF MANCHESTER UNION ST. CLUBHOUSE SCHEDULE OF OPERATION DATE DESCRIPTION TUESDAY, SEPT. 5, 2017 UNION ST. CLUBHOUSE BEFORE & AFTER SCHOOL PROGRAMS BEGIN 6:30AM-8:20AM & 2PM-8PM TUESDAY, SEPT. 19, 2017 CITY PRIMARY VOTING DAY--NO SCHOOL UNION ST. CLUBHOUSE OPEN 6:30AM-6PM, $15 FEE MONDAY, OCTOBER 9, 2017 COLUMBUS DAY--NO SCHOOL CLOSED TUESDAY, NOV. 7, 2017 CITY ELECTION VOTING DAY--NO SCHOOL UNION ST. CLUBHOUSE OPEN 6:30AM-6PM, $15 FEE THURSDAY, NOV. 9, 2017 ANNUAL MEETING / HALL OF FAME EVENT UNION ST. CLUBHOUSE CLOSING AT 5:30PM FRIDAY, NOV. 10, 2017 VETERAN'S DAY--NO SCHOOL CLOSED WEDNESDAY, NOV. 22, 2017 THANKSGIVING RECESS-NO SCHOOL CLOSED THURSDAY, NOV. 23, 2017 THANKSGIVING RECESS-NO SCHOOL CLOSED FRIDAY, NOV. 24, 2017 THANKSGIVING RECESS-NO SCHOOL CLOSED MONDAY, DEC. 25 TO CHRISTMAS RECESS CLOSED MONDAY, JAN. 1, 2018 CHRISTMAS RECESS CLOSED TUESDAY, JAN. 2, 2018 PROGRAM RE-OPENS 6:30AM-8:20AM & 2PM-8PM MONDAY, JAN. 15, 2018 MARTIN LUTHER KING, JR. DAY--NO SCHOOL CLOSED MONDAY, FEB. 19, 2018 PRESIDENTS DAY--NO SCHOOL CLOSED MONDAY, FEB. 26 TO WINTER SCHOOL VACATION CAMP(EXTRA FEE REQUIRED) CLOSED FRIDAY, MAR. 2, 2018 AT UNION ST. CLUBHOUSE MONDAY, APR. 23 TO SPRING SCHOOL VACATION CAMP(EXTRA FEE REQUIRED) CLOSED FRIDAY, APR 27, 2018 AT UNION ST. CLUBHOUSE MONDAY, APR 30, 2018 SPRING HOURS BEGIN 6:30AM-8:20AM & 2PM-7PM, 2-8PM TEENS ONLY MONDAY, MAY 28, 2018 MEMORIAL DAY CLOSED TUESDAY, JUNE 12, 2018 UNION ST. CLUBHOUSE SCHOOL PROGRAM ENDS MONDAY, JUNE 18, 2018 CAMP FOSTER SUMMER DAY CAMP BEGINS-TENTATIVE ***UNION ST. CLUBHOUSE OPEN ON SNOW DAYS, 6:30AM-6PM, NO FEE FOR KIDS CLUB OR BUSSING MEMBERS, ALL OTHERS $15 FEE ***GRADES 1-3 MEMBERS MUST BE PICKED UP BY 7PM. ***LATE PICK-UP FEE OF $1/MINUTE IS CHARGED FOR PICK-UPS AFTER 6PM. A MAXIMUM OF $30 CHARGED. ***SINGLE DAY DROP OFF SERVICE AVAILABLE FOR BEFORE SCHOOL PROGRAM, $10 FEE

12 Free Dental Visits A free service available to all members The Boys & Girls Club of Manchester is proud to announce a new arrangement with Virtudent to provide free dental care to our members, whether or not they already have access to dental care or insurance coverage. VIRTUDENT VISITS Virtudent will be bringing the dentist s office to the Boys & Girls Club (BGC). This dental program is available to all members at no cost. A New Hampshire licensed hygienist will be onsite to provide the following services for those who enroll: We come to the Boys & Girls Club. Our hygienist performs a screening and takes x-rays & pictures All enrolled members: will receive an oral health screening, a fluoride treatment, and oral hygiene instructions. Most enrolled members: will receive a dental cleaning, x-rays as needed, intraoral photographs and a review of their records within 72 hours through telemedicine by a NH licensed dentist. Some enrolled members: may receive sealants and/or other cavity preventing topicals if determined necessary. Some patients may also need to be scheduled for further dental treatment or specialty services and will be referred to a dental provider in your community. Referrals are dependent upon the extent of the dental disease as well as the behavior of the patient. Virtudent will refer your child to the dentist or clinic you select on this form. Enrolled members will be seen while they are at the club. BGC staff, or other personnel selected by BGC, will walk enrolled members to the treatment area. Parents/Guardians will receive a copy of the Virtudent treatment report by . Virtudent will also send that same treatment report to the dentist or clinic you select on this form. If you are interested in participating in this program, please return this form to your Boys & Girls Club Site Director at your earliest convenience. The Boys & Girls Club will forward this form to Virtudent on your behalf. We are thrilled to be able to provide this service to our members and encourage all families to take advantage of this great opportunity! Your child then receives preventative care on-site and a diagnosis from a remote dentist If additional treatment is needed, we refer to a qualified local dentist. Boys & Girls Club of Manchester / 555 Union Street / Manchester, NH (603)

13 Your Child s Health History Your Child s Dental Health History Name of Physician: Name of Dentist: Is child taking any medicine: Date of last dental visit: If so, what? Does child see a dentist regularly or for emergencies only? Does child have any allergies? Check all that apply: oantibiotics, ocolophonium, ofoods, olatex, openicillin, oresins, oother: If so, to what? Have you any concerns about your child s teeth Explain: Does your child have a developmental disability? yes no If yes, explain: Does your child need antibiotics before dental treatment? yes no If yes, explain: Has your child ever had any of the following? Please check YES or NO for each condition: Other medical or dental conditions in your child s history? Please explain: Boys & Girls Club of Manchester / 555 Union Street / Manchester, NH (603)