2020 Membership Form

2020 Membership Form
Member's Personal Information
Child's First Name:
Middle:
Last:
Address

Address: (No PO Box)

Street Address Line 2

City

Zip
Gender:

Male Female
Parent Home Phone w/Area Code:
Parent Work Phone#/Ext.
DOB: (MM/DD/YYYY)
Age:
Ethnicity

African American American Indian/Alaska Native Caucasian Asian Hispanic/Latino Haitian Native Hawaiian/Pacific Islander Multi Racial
Primary Parent/Guardian Email:
example@example.com
School *
School Lunch Program: *

Free Reduced Ineligible
School Release Information: I understand that as a partner of the St. Lucie County School Board, the Boys & Girls Clubs of St. Lucie County will obtain academic information to better serve my child’s academic needs. I give permission for the Boys & Girls Clubs of St. Lucie County to access my child's academic school records:
*

Yes No
School/Skyward Id Number:
Teacher's Name:
Current Grade:
Medical Information
Doctor Name:
Doctor Phone Number:
Permission for Treatment by Doctor/Hospital?
List any Allergies:
List of daily medications?
List accommodations/assistance your child may need to be successful in our program:
Release of Child/Emergency/Authorized Pick-up/ Contact Information
Mother/Guardian Name:
Place of Employment/Occupation:
Cell Phone:
Father/Guardian Name:
Place of Employment/Occupation:
Cell Phone:
Additional Contacts and Authorized Pick-up List
Name:
Relationship:
Cell Phone:
Name:
Relationship:
Cell Phone:
Name:
Relationship:
Cell Phone:
List anyone who is NOT authorized to pick up your child:
Household Information: (This information is used for Grant writing purposes)
Check All Those Living In Current Household:

Mother Step-Mother Grandparent Father Step-Father Other
Total Number of people living in household:
Household Income

$0-$9,999 $10,000-$19,999 $20,000-$29,999 $30,000-$39,999 $40,000 & up
Head of Household *

Male Female
Single Parent? *

Yes No
Is Parent/Guardian a member of active/retired military? *

Yes No
TERMS & CONDITIONS: Please initial that you have read each paragraph.
Parent Handbook: I have received a copy of the Boys & Girls Clubs of St. Lucie County handbook and agree to abide by policies in the Parent Handbook, and that failure to do so can result in membership termination.
Club Rules & Code of Conduct: I agree to review the Club rules and Code of Conduct and consequences with my child. I under stand that membership can be suspended or revoked should behavior warrant such action.
Payment: Please keep record of payments, we do not provide annua statements. There are no refunds for membership fees.
Late Fees: I will adhere to the program hours I understand that I will be charged a late fee of $1 per minute (per child), for not picking my child up at the designated closing time. I understand that membership may be suspended until payment is made. I understand that repeated offenses can result in termination of membership.
Photo Release: With my initial give permission for my child to be photographed and/or videotaped for promotional materials and published materials in local or social media.
Medical Care: In the event the Boys & Girls Clubs of St. Lucie County is unable to reach me, or is on a field trip out of town, when my child has been injured or needs medical attention/treatment, I authorize the Boys & Girls Clubs of St. Lucie County to obtain medical or hospital care on an emergency basis, and I will be financially responsible for such care.
Open Door Policy
Boys & Girls Clubs of St.Lucie County offers an open door policy for children 13 years and older which means that members can sign themselves out of the Club to go home. If you grant your child permission to sign him/herself out to go home, you fully understand that your child may not return to the Club until the next day. You are also stating that you understand that your child is not being supervised during their time away.
Yes, my child is 13 years or older and has permission to sign him/herself out to go home.

Yes
No, my child does no permission to sign him/herself out to go home.

No
We are counting on you as the parent/guardian to have a relationship with your child whereby your child respects your wishes and will stay at the Club for the hours you say so. Again, we maintain an open-door policy for children 13 years and older.
Membership Agreement
I, _______________________________(PRlNT)do hereby give my son/daughter permission to attend and participate in activities sponsored by the Boys & Girls Clubs, including the "SMART' family of prevention programs and release Boys & Girls Clubs of St. Lucie County, Inc., its employees, directors, associates, and contributors from injury, loss or theft incurred by my child while participating. I further understand that the information provided here may be used by funders of this program (i.e. Boys & Girls Clubs of America, Children Services Council) for research purposes or to evaluate the program's effectiveness. All information provided on this form will be kept confidential. My signature indicates that I completed this application and understand the statements made within.
Parent/Guardian Signature:

Clear
Date:

Month Day Year
Date
Boys & Girls Clubs of St. Lucie County is taking the necessary precautions during the COVID19 pandemic to ensure the safety of our Club members, staff, and others during our BGC Programs.

With this said, it will be required for precautionary purposes, that parents/guardians dropping off and picking up Club members, must sign in/out their child at the designated check in/out station outside of the Club still maintaining good hand hygiene and social distancing of 6 feet apart.

It is also required that Club members’ temperatures be taken daily prior to entering the Club as suggested by the Centers for Disease Control & Prevention (CDC In the event that a Club member claims that he/she does not feel well, we will conduct an additional temporal or forehead temperature check to include the forehead only. Any Club member who has a temporal or forehead temperature reading of 99.4°F or higher, will be isolated from others, and the authorized parent/guardian will be contacted for immediate pickup. Per the CDC recommendations, Club members must not return to the Club until at least 24 hours after their fever is gone without the use of fever-reducing medications, or after symptoms have improved (at least 4-5 days after flu symptoms started

Additionally, due to the St. Lucie County executive order mandating face coverings, effective July 20,2020 to be worn by people visiting or working at an indoor place of business and worn outdoors where social distancing is not possible, ALL Club members attending Boys & Girls Clubs of St. Lucie County “BGCSLC” MUST wear face masks or he/she will not be able to participate.

Please note, any Parent/Guardian of Club member that does not give authorization for Boys & Girls Clubs of St. Lucie County to take the temperature as discussed above, or refusal to wear a mask, will not be able to attend the Club.
Child's Full Name
Parent's Name (Printed)
Parent Signature

Clear
Date

Month Day Year
Date
2020 REGISTRATION
Name

Child's First Name Child's Last Name
Child's Age
NOTE: All children must have a 2020 membership application on file.

Membership Fee $25 per year

We accept credit card, check or money order
LOCATIONS
Please put your initials beside preferred location

Allapattah Flats Bayshore Elementary Lakewood Park Manatee Academy Northport K-8 St. Lucie West K-8 Oak Hammock K-8 Westgate K-8 Forest Grove Middle Floresta Elementary Mariposa Elementary Palm Pointe Morningside Elem. Windmill Point Elem. Rivers Edge Elem. MidFlorida Event Ctr.
For weekly fee information please email Sean Howald, Lead Area Director at SHowald@bgcofslc.org

NOTE: There will be no refunds or credits of any kind for unattended weeks or behavioral removal.
Parent/Guardian Name (Please Print)
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
Daytime Contact Phone Numbers
This box is for Office Use Only
BGC ID Number:
Location:
Amount Paid:
Payment Type:
Check Number:
Check Date:

Month Day Year
Date
Payment From:
Payment Date:

Month Day Year
Date
Accepted By:
Date Entered in MTS:
Age Group:
Date entered into MTS (YES):

Month Day Year
Date
Ed Release:

Yes No
Open Door:

Yes No
Should be Empty:

2020 Membership Form

Member's Personal Information

Medical Information

Release of Child/Emergency/Authorized Pick-up/ Contact Information

Open Door Policy

Membership Agreement

2020 REGISTRATION

LOCATIONS