Member Information Child's Full Name: Address: Membership Application Application Date: *** Membership expires 8/10/2019 *** Club Name: Has your child previously attended a Boys & Girls Club? Yes - No Where? Birthdate: / / City: State: Zip: Home Phone: ( ) Cell Phone: ( ) Gender: Male Female Ethnicity: Asian Caucasian Hispanic/Latino African American Multi Ethnic Pacific Islander Other: School your child attends: Teacher: Grade: Does your child have siblings attending the Boys & Girls Club? Yes - No Is your child homeless or in foster care? Yes - No Eligibility for Support Services Does your family qualify for supportive services? Yes - No Please circle all that apply: Free/Reduced Price Lunch CalFresh Medi-Cal Housing Voucher Other: Parent/Guardian Contact Information Who does your child live with? Please circle: Both Parents Parent 1 Only Parent 2 Only Split Custody Grandparents Foster Parents Guardian Other: Parent/Guardian Name: Relationship: Workplace: Parent/Guardian Name: Relationship: Workplace: o Work phone: ( ) o Work phone: ( ) o Cell phone: ( ) o Cell phone: ( ) o Email: o Email: *** Please indicate the best way to contact you with a check mark next to the contact information*** Emergency Contact Information (who to contact if parent or guardian cannot be reached) Contact: Contact: Relationship: Relationship: Phone: Phone: In case of a medical emergency, the medical attendants may need to know the following information: Allergies: Medications (name, amount, frequency): Does your child have health insurance? Yes - No - Don't Know Illnesses or injuries: Insurance provider: Provider #: Physician's Name: Phone Number:( ) $10 Membership Fee Paid? Yes - No - NA I hereby give my consent to have my child treated by a physician or surgeon in case of sudden illness or injury while participating in a Boys & Girls Clubs of Central Sonoma County program. It is understood that the cost thereof will be at my expense. To protect the safety of staff and our members and reduce liability, Boys & Girls Clubs of Central Sonoma County staff does not dispense or store medication of any kind for our members. Member ID # Member Name: Parent or Guardian Signature Date: ***PLEASE TURN OVER. BOTH SIDES MUST BE COMPLETED TO BE ELIGIBLE FOR MEMBERSHIP***
Member Needs Does your child have any special needs? Please check all that Club staff should be aware of and provide detail below. o Special need/condition o Behavior concern/condition o Individaul Education Plan (IEP) o Allergy or Medical condition o Family circumstance Description: Required Response: ACKNOWELDGEMENT & CONSENT Acknowledgement & Consent Initials: I approve of my child s application for membership to Boys & Girls Clubs of Central Sonoma County. In consideration for allowing my child to become a member of the Club, I hereby agree that the Club, its officers, employees, volunteers, directors, and agents shall not be liable for any injury to my child, or for any loss, injury, or damage to my child s property, which occurs during my child s participation in any activities at, or sponsored by the Club. I further agree that my child, my child s heirs, executor, successors in interest, and legal representatives will not make a claim against, sue, or attach the property of the Club or the Club s representatives for the injury or damage resulting from negligence or other acts caused in any way whatsoever by the Club or the Club s representatives. I hereby release the Club and the Club s representatives from any and all causes of action and claims that I, my child, my heirs, successors in interest, executors and other legal representatives may have arising from these matters. School Information Initials: I give permission to Boys & Girls Clubs of Central Sonoma County and my child's school and district to exchange information regarding the child listed on this application. The purpose of exchange is to help both organizations do a better job of helping the student be successful in school, at the Club & in life. This information, which may include academic and behavior performance, will only be shared within state & federal guidelines. Surveys & Questionnaires Initials: I give permission for Boys & Girls Clubs of Central Sonoma County to survey my child. Surveys gather information about what has been done in the after school & summer program, attitudes towards it, and behaviors related to learning, safety, positive youth development, and health. The surveys may include questions about physical activity and nutritional habits, alcohol and other drug use, violence and bullying, and environmental assets. This data will help improve program services and demonstrate effectiveness of after school programs. This includes particpation in the National Youth Outcomes Initiatives through Boys & Girls Clubs of America. Copies of surveys may be requested at any time. Media Release Initials: I hereby consent to the use of my/my child s name, likeness and speech in any audio tape, video tape, film or photograph made in any Club activity for the business or publicity purposes of Boys & Girls Clubs of Central Sonoma County & its partners. I understand that any participation offers no remuneration and that my/my child s name, likeness and speech may be edited, produced, recorded for duplication and distribution throughout the United States and abroad. I expressly release Boys & Girls Clubs of Central Sonoma County & its partners, its licensees, assignees, affiliates and successors from any privacy, defamation, or other claims having arisen out of broadcast, exhibition, publication, or promotion of this program. Behavior Policy I understand that I am responsible for attending an orientation with my child before he/she receives his/her full-time membership card. Initials: Boys & Girls Clubs of Central Sonoma County has a discipline policy that gives positive guidance, allows for redirection and sets clear behavior limits. The discipline policy has been designed to assist members in developing self-control, self-respect, respect for others, and consideration for the rights and property of others. Members that do not follow set policies may require early pick up, suspension from the program, or explusion from the Club. I hereby give my permission to my child to become a member of Boys & Girls Clubs of Central Sonoma County. 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 the Boys & Girls of Central Sonoma County is not repsonsible for any property loss or personal injury. Attendance is contingent upon member's following Clubhouse expectations and exhibiting positive behavior. Clubhouse staff reserves the right to suspend or terminate attendance and/or membership at any time if those guidelines are not followed and I understand that no fees will be returned to me. Parent or Guardian Signature Date: Member Agreement I promise to take care of my Club and property, and respect the building, other members and staff at all times. I agree to bring my membership card to use at the Club and that I will not allow anyone else to use my card. I agree to attend the new member orientation with my mother, father, guardian or a consenting adult. Member s Signature Date: ***PLEASE TURN OVER. BOTH SIDES MUST BE COMPLETED TO BE ELIGIBLE FOR MEMBERSHIP***
Guerneville MS Camp Registration Form Middle School Camp serves Campers entering 6 th - 9 th grade. Camper s Name Grade Fall 2019 School Attending: Membership Fee Annual Membership started August 18 $10 ALL CAMP WEEKS! All June 10 th - July 19 th $450 for all 6 weeks $75/Week or $25/day $400 by March 31 st $$425 by April 30 th Week 1 June 10 - June 14 $75 Week 2 June 17-June 21 $75 Week 3 June 24-June 28 $75 Week 4 July 1 st -July 5 th (Closed July 4 th ) $75 Week 5 July 8- July 12 $75 Week 6 July 15-July 19 $75 CIT Shirt Counselor In Training (CIT) Shirt required for CIT shifts. Total Camp I understand that BGCCSC maintains a no refund/no credit policy on any and all Summer Camp Registration fees. I understand in the event that a Camper misses a bus or is not in attendance, Fieldtrip or Camp week payments will not be reimbursed. I have received, read and understand all guidelines outlined in the Camper Guidelines. Guardian Name Signature Date For Office Use Only. Cash.Total Paid Check (payable to Boys & Girls Clubs of Central Sonoma County). Check Number...Total Paid Credit (Circle: Visa, MasterCard, Discover or AMEX). Last 4 digits of Credit Card:...Total Paid Processed By Receipt # ($5) ALL FIELD TRIPS $65 Week 1 Game the Room Tue 6/11 (8:30-3) $16 Week 2 Vertex Wed 6/19 (11-4:30) $19 Week 3 MS Dance Friday 6/28 (11am-4pm) $10 Week 4 Rivers Edge Wed. 7/3 (8-2) $10 Week 5 MS Sports Tourney Wed 7/10 (11-4) (grades 6-9 ONLY) Week 6 ------------------------------------------------------------- ------------------------ ---------------------------------- $10 Total Fieldtrips TOTAL PAYMENT
Middle School Guerneville Camp Camper s Name: Please select the fieldtrips that you give permission for your child to attend. Summer Fieldtrips Game the Room Tue 6/11 (8am-3:30pm) Vertex Wed 6/19 (11-4:30pm) MS Dance Fri 6/28 (11am-4pm) River s Edge Tue 7/3 (8am-2pm) MS Sports Tournament Wed 7/10 (grades 6-9 ONLY) Bolded field trips need an additional waiver on file to attend. I understand that a written permission slip must be on file, and fieldtrips must be paid in full in order for my Child to attend field trips. I understand that all Campers attending Fieldtrips are expected to arrive to Camp at least 30 minutes before the bus departure time. I understand that BGCCSC maintains a no refund/no credit policy on any and all Summer Camp Registration and Fieldtrip fees. In the event that a Camper misses a bus or is not in attendance, Fieldtrip or Camp week payments will not be reimbursed. I understand that a Boys & Girls Club fieldtrip T-Shirt must be worn by the Camper on all field trips in order to attend. I understand that the Club is not responsible for loss of property. I give authorization for the Boys & Girls Club to transport my child to and from the destination. I understand I may not drop off or pick up my child from the fieldtrip site. I authorize a Medical Physician, in the event of an emergency, to provide emergency medical treatment for my child. I understand that the Boys & Girls Club is not responsible for any personal injuries my child may sustain during the fieldtrip. I understand that Camp Staff will be accompanying Campers while on the field trip. I give my child permission to attend Boys & Girls Clubs of Central Sonoma County field trip(s) described above. Date Parent or Guardian Signature Emergency Contact 1 (Name/Number): Emergency Contact 2 (Name/Number):
GREAT SUMMERS START HERE. Swimming Permission Slip Camper s Name: Age: Dear Parent/Guardian, We will be swimming at the. I give authorization for the Boys & Girls Club to transport my child to and from the destination. I will not be dropping off or picking up my child from the swimming site. Members must meet the minimum criteria for beginning swimmers in order to be allowed to attend the swimming trips. Beginning Swimmers: Can hold his/her breath with their head submerged Can perform a front and back float Can perform a flutter kick on his/her front or back Is able to level off from a vertical entry into a floating position Can do a combined stroke (front or back) for at least 20 ft. without stopping. Must be able to swim without life jackets or other floatation devices (these items are not to be brought to Camp) Swimming Permission: I hereby certify that my child can perform the criteria listed above for a beginning swimmer. My child has my permission to swim unassisted on swim fieldtrips. I understand that my child will be required to pass a swim test in order to participate in any swimming fieldtrips. Furthermore, I acknowledge and agree that swimming can be a dangerous activity involving MANY RISKS OF INJURY. I understand that such risks include, but are not limited to: death, serious neck and spinal injuries that may result in complete or partial paralysis, brain damage, serious injury to internal organs, serious injury to bones, joints, ligaments, muscles, tendons and other skeletal components, and serious injury or impairment to other aspects of the body, general health, and well-being. I understand that neither Boys & Girls Clubs of Central Sonoma County nor its employees are liable for any injury sustained by my child while participating in Boys & Girls Clubs of Central Sonoma County s programs/fieldtrips. Parent or Guardian s Name: Parent or Guardian s Signature: Date: Emergency Contact Phone Number:
Join the Camp BGC Sunscreen Club! To help you protect your camper(s) from sunburn, we will apply spray-on sunscreen after lunch. Participation is simple! Simply check below that you d like to participate and turn in this permission form along with 2 large bottles of spray-on sunscreen. Child s Name: Child s Name: Child s Name: I give Boys & Girls Clubs of Central Sonoma County permission to apply sunscreen to my child/children once daily during summer camp. I understand that I am responsible for applying sunscreen before camp each morning. I ve purchased 2 bottles of spray-on sunscreen (30 SPF preferred) for each child participating. Parent Name: Parent Signature: Walk Home Permission Slip Name: Age/Grade: A WRITTEN PERMISSION SLIP & MEMBERSHIP APPLICATION MUST BE ON FILE IN ORDER FOR A MEMBER TO WALK HOME. I give my child,, permission to walk home from the Boys & Girls Clubs of Central Sonoma County from the Club after PM. I understand that the Club is not responsible for personal injury or loss of property. Parent or Guardian Signature Date Emergency Contact and Phone Number
GREAT SUMMERS START HERE. Camper Name Parent Name(s) Parent Phone Number(s) Emergency Contact Name Emergency Contact Phone Number Camper Personal Information My child has one or more of the following that Club staff should be aware of (please circle): Special Need/Condition Behavior Concern/Condition Medical Condition/Allergy Family Circumstance Individual Education Plan Description: Reaction / Required Response: Parent Signature: