If you have multiple children in need of child care, please complete a separate form for each child.
Youth Medical Information
Pick Up Information: (Two people authorized to pick up member-OTHER THAN PARENT)
Informed Consent and Acknowledgement
I understand and agree that my child (or ward) must be picked up by closing time or a fee will be charged which must be paid before my child (or ward) can return to the Club.
I understand and agree that BGCHC has an open door policy and cannot be responsible for my child (or ward)leaving the Club without permission. I understand that all members are free to come and go from the Club at their leisure.
I understand and agree that BGCHC does not refund membership fees and that my child (or ward) must obey all rules (Code of Conduct). I further understand that behavioral problems that cannot be solved can result in my child (or ward) being suspended from BGCHC without a monetary refund.
It is expressly understood and agreed that BGCHC shall not be responsible or legally liable for any losses of personal property, for any bodily injuries, or the results thereof, incurred and suffered by the applicant on any property of the BGCHC or in connection with any activities of any of its Units, or while engaged in any of the BGCHC’s activities away from the Club.
Internet Usage Agreement: The opportunity to use Club’s computers is based upon clear guidelines and agreements: (1) always be respectful of others, (2) never give out personal information over the computer, (3) always remember you are responsible for what you do online, (4) always follow the computer lab supervisor’s instructions, (5) never agree to meet in person with anyone you meet online and (6) never visit ‘off-limits’ web sites. Failure to uphold these agreements will result in revocation of the member’s online privileges.
Code of Conduct Play Fairly and Be Honest Be Respectful of Boys & Girls Club Staff Say Only Good Things About Others Resolve Disagreements in a Positive Way Be Respectful Of Other Members and Their Property Take Care of Your Boys & Girls Club Facility and Equipment Avoid Use of Improper Language Remove Hats Before Entering Building Applaud The Efforts of Others Run Outside Only Participate Only In Program Areas Open To Your Age Group Listen During Assemblies Dress Appropriately At All Times Smoking, Drugs, Alcohol and Other Drugs and Weapons Are Strictly Prohibited Stealing will not be Tolerated!
BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.