Remote Learning HUB Registration

Remote Learning HUB Registration
DATE:

Month Day Year
Date
Club: *
1ST PARENT INFORMATION:

Please complete the fields below
Parents Name: *

First Name Last Name
Relationship to child:
Address *

Street Address

Street Address Line 2

City State

Zip Code
Home Phone #:
Cell Phone #: *
Work Phone #:
Parents Email *
example@example.com
Employer: *
Primary Contact for billing? *

Yes No
2ND PARENT INFORMATION:

Please complete the fields below
Parents Name:

First Name Last Name
Relationship to child:
Address

Street Address

Street Address Line 2

City State

Zip Code
Home Phone #:
Cell Phone #:
Work Phone #:
Parents Email
example@example.com
Employer:
Primary Contact for billing?

Yes No
How many children are you registering for? (1 - 4) *
MEMBER (CHILD) INFORMATION:

First Child
1st Child's Name

First Name Last Name
1st Child's Member #:
Please fill in your Child's member # [Example: 1234, 2345, 5678]
1st Child's Date of Birth

Month Day Year
Date
1st Child's Gender
1st Child's Shirt Size:
1st Child's Total # of years as a Club member?
MEMBER (CHILD) INFORMATION:

Second Child
2nd Child's Name

First Name Last Name
2nd Child's Member #:
Please fill in your Child's member # [Example: 1234, 2345, 5678]
2nd Child's Date of Birth

Month Day Year
Date
2nd Child's Gender
2nd Child's Shirt Size:
2nd Child's Total # of years as a Club member?
MEMBER (CHILD) INFORMATION:

Third Child
3rd Child's Name

First Name Last Name
3rd Child's Member #:
Please fill in your Child's member # [Example: 1234, 2345, 5678]
3rd Child's Date of Birth

Month Day Year
Date
3rd Child's Gender
3rd Child's Shirt Size:
3rd Child's Total # of years as a Club member?
MEMBER (CHILD) INFORMATION:

Fourth Child
4th Child's Name

First Name Last Name
4th Child's Member #:
Please fill in your Child's member # [Example: 1234, 2345, 5678]
4th Child's Date of Birth

Month Day Year
Date
4th Child's Gender
4th Child's Shirt Size:
4th Child's Total # of years as a Club member?
Additional Information

Please answer the following questions:
Are you currently in need of or interested in early care (7am to 8am)? *

Yes No
Will your child be enrolled in WCPS Virtual Academy? *

Yes No
Will your child be attending school in-person when allowed? *

Yes No
What days are they scheduled to be in school (Mon/Tuesday or Thursday/Friday)?
Does your child have a device to bring to the Club for Instructional Time (Tablet, Chromebook, Laptop)? *

Yes No
COST / FEES:
- Remote Learning HUB:
  - $25 a week for the 1st Child
  - Additional $20 a week for the 2nd Child
  - Additional $15 a week for the 3rd Child
  - Additional $15 a week for the 4th or more Children
- Early Care (7am - 8am) :
  - $20 a week for the 1st Child
  - Additional $15 a week for the 2nd Child
  - Additional $10 a week for the 3rd Child
  - Additional $10 a week for the 4th or more Children
- Membership fee of $25 per child is required if not a member already.
LUNCH WILL BE INCLUDED IN HUB FEES
Please check that you have read COST / FEES *

Yes
LEARNING HUB OPERATING SCHEDULE:
- 7:00am to 8:00am | "Early Care"
  - During this time, those that have signed up for early care may drop off their children early. Note: Space for early care may be limited.
- 8:00am to 12:00pm | "Instructional Time"
  - Instructional Time will consist of the children performing any school lessons for the day. This will be bia thier device or via one of our limited number of devices. Devices are not gauranteed by us. Each locations has a limited number of devices for use by children. It is highly encouraged to send your children with Chromebooks or Tablets if applicable to the Club.
- 12:00pm to 1:00pm | "Meal Time"
  - Meal Time will consist of the children getting a lunch. Please be sure to inform us of any food allergies.
- 1:00pm to 6:00pm | "Club Time"
  - Club Time will consist of our standard Club activies and programs.
Please check that you have read the Learning HUB Operating Schedule *

Yes
FINANCIAL ASSISTANCE:

Boys & Girls Clubs of Wayne County is committed to providing quality programs, regardless of one’s ability to pay the standard fees. Our financial assistance program is available for those who would otherwise be unable to enjoy the benefits of BGCWC programs.

Eligibility is determined based on applicant’s income and is administered on a sliding scale. The Financial Assistance Application, along with the required documentation, must be submitted with the registration form. Once processed, you will be notified whether your application was approved.

Your child will not be registered for the Learning HUB until after the Financial Assistance Application has been processed. You will be notified before asking to pay the balance due. Please inquire with our Club Director for more information.
Please check that you have read the Financial Assistance Policy *

Yes
ADMISSIONS & ENROLLMENT:

The Boys & Girls Clubs of Wayne County reserves the right to deny HUB services if any of the following conditions exist:
- The participant is not participating in or benefiting from the program.
- The staff cannot provide adequate or safe care for the participant.
- The staff cannot provide adequate or safe care to other enrolled participants due to the behaviors of a participant.
- The child has not been properly registered.
- Full payment has not been received by the due date
Please check that you have read the Admissions & Enrollment Policy *

Yes
LOST ARTICLES:

The lost and found for each session will be stored separately. Labeled items will be returned. Unlabeled items will be held for two-weeks after which they will be donated to Goodwill. Unlabeled socks and underwear will be thrown away at the close of each day. We are not financially responsible for children’s losses, but will make every effort to locate the lost items. Please clearly label all items with your child’s first and last name.
Please check that you have read the Lost Articles Policy *

Yes
PAYMENT POLICY:

I understand that fees associated with the Learning HUB must be paid for in advance. Registration and full payment are due the Friday before the week of the Learning HUB. If I have a past due balance my child will not be able to attend the Learning HUB until all balances are paid up to date.

I accept that there are no refunds for no-shows, or partial payments. I acknowledge the fees are: $25 a week for the 1st Child, Additional $20 a week for the 2nd Child, Additional $15 a week for the 3rd Child, and an Additional $15 a week for the 4th or more children.

I understand that the fee is a fixed rate no matter how many days the child plans to attend.

Each child must be a member of the Boys & Girls Club to attend the Learning HUB. Membership to the Boys & Girls Club is $25/Year effective Aug. 10th, 2020. If your child is not a member, you will be required to complete a Membership application and the membership fee is due when paying for the first week.

Note: Memberships are valid per calendar year, not school year.
Please check that you have read the Payment Policy *

Yes
CANCELLATION & REFUND POLICY:

There are no refunds for programs, unless the Club Director is notified ahead of time in writing and parents have proof of illness. NO EXCEPTIONS. Fees for programs are based on a per week basis. BGCWC will not deduct days missed from your fee. When you enroll for a week of programs, you are reserving time, space, staff and provisions for your child, whether or not he/she attends.
Please check that you have read the Cancellation/Refund Policy *

Yes
Parent / Guardian (Print) *
Please type your name here before signing.
Signature *

Clear
Date

Month Day Year
Date
After you click on submit you will be taken to another form. This is our COVID-19 Liability Release Form. Registrations submited without the COVID-19 Liabiltiy Release submitted will NOT be processed.
Do you understand that you will be taken to a second form to complete? And that if you do not complete the second form this registration will not be processed? *

Yes, I understand. No
Should be Empty:

Remote Learning HUB Registration

1ST PARENT INFORMATION:

2ND PARENT INFORMATION:

MEMBER (CHILD) INFORMATION:

MEMBER (CHILD) INFORMATION:

MEMBER (CHILD) INFORMATION:

MEMBER (CHILD) INFORMATION:

Additional Information