Boys & Girls Club Membership

Membership Form - Decatur

Application must be filled out fully and accurately by parent/legal guardian
Child Information

Please review information carefully
First Name
Middle Name
Last Name
Name of Person Member Lives With
Home Phone Number
Email Address
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name
Emergency Contact Phone & Extension

Parent or Guardian Information

Please review information carefully
Father's First Name
Father's Last Name
Father's Work Phone & Extension
Father's Employer
Father's Occupation
Mother's First Name
Mother's Last Name
Mother's Work Phone & Extension
Mother's Employer
Mother's Occupation
Guardian's First Name
Guardian's Last Name
Guardian's Work Phone & Extension
Guardian's Employer
Guardian's Occupation

Medical & Emergency Information

Please review information carefully
Medical Problems & Allergies
Please explain to the best of your abilities
Medications
Please be detailed

Pick Up Information

All authorized pick-ups should be prepared to show Photo ID at Front Desk
Names of TWO persons authorized to pick up member (other than parent)
Person 1: First Name
Person 1: Last Name
Person 1: Phone Number
Person 2: First Name
Person 2: Last Name
Person 2: Phone Number
Persons NOT authorized to pick up child
Authorized Password:

Authorized Password is required to verify any changes in pickup for the day via phone, provide phone permission to walk home, or to request to talk to child, or ask about attendance of a child. This password should not be shared. Parents/guardians should be the only ones who know it. This password is not for pick up.
Enter Authorized Password
Is this member able to walk or ride bicycle to/from the Club?

YesNo
If yes, please check any applicable restrictions

They cannot walk or ride bicycle to club at allNo RestrictionsOnly in DaylightWith Sibling(s)Phone Permission NeededSummer Club Hours OnlyOther

Parent Release Form 2020 - 2021
I, the parent/guardian of the minor child listed on this application, for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever discharge the Boys & Girls Club of Adams County, Inc. and Boys & Girls Clubs of America, their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organizations such as staff, directors or volunteers, from all liability, claims, demands, or causes of action for any and all loss, damage, injury or death and any claim of damages resulting from use of facilities owned or controlled by the above organizations, or participation in activities of said organizations either at or away from the Club.

Medical Treatment
I give permission to the Boys & Girls Club of Adams County, Inc. to seek emergency medical treatment for my minor child if I cannot be reached. I will be responsible for any/all costs of medical attention and treatment.

Data Collection
I give my permission to the Boys & Girls Club of Adams County, Inc. to collect information via online or written surveys, questionnaires, interviews, and focus groups from the minor child listed on this application. Any and all information received will be kept strictly confidential. Data gathered through these means will be summarized in the aggregate and will exclude all references to any individual responses. The aggregated results of these analyses may be shared with Club staff, Boys & Girls Clubs of America (BGCA), funders, and other community stakeholders to evidence program effectiveness and/or Club impact on our members.

School Information
I give my permission to the Boys & Girls Club of Adams County, Inc. and South Adams Schools to exchange information regarding the minor child listed on this application. The purpose of the exchange is to help both organizations do a better job of helping the student be successful in school, in the Boys & Girls Club and in life. This release is valid for one year and may be revoked at any time by contacting South Adams Schools or the Boys & Girls Club in writing.

Data Sharing
I understand that the Boys & Girls Club of Adams County, Inc. may share information about the minor child listed on this application with Boys & Girls Clubs of America (BGCA) for research purposes and/or to evaluate the program’s effectiveness. Information that will be disclosed to BGCA may include the information provided on this membership application form, information provided by the minor child’s school or school district, and other information collected by Boys & Girls Club of Adams County, Inc., including data collected via surveys or questionnaires. All information provided to BGCA will be kept confidential.

Technology
As a member of the Boys & Girls Club, your child will have access to the Internet. While precautions are being taken, it is possible who s/he may access inappropriate sites. The Boys & Girls Club will have rules and consequences at the Club for such behavior; however we will not be responsible for the consequences of such access.

Miscellaneous
I understand who the Boys & Girls Club is not responsible for lost or stolen items. Parents and Club members are responsible for their own transportation to and from the Club. As a drop-in facility, we are not responsible for Club members’ whereabouts.

I give permission for my child’s picture, moving pictures, or any other graphic depiction or likeness, to be used by the Boys & Girls Club and its activities. I also understand who the Club is not, nor does it claim to be, a licensed day care center.
I have read the completed application and this form, understand the rules of the Boys & Girls Club and request who my child be admitted into membership.

I give my permission to the Boys & Girls Club of Adams County, Inc., to share information about the minor child listed on this application with Boys & Girls Clubs of America (BGCA) for research purposes and/or to evaluate the program’s effectiveness. Information that will be disclosed to BGCA may include the information provided on this membership application form, information provided by the minor child’s school or school district, and other information collected by Boys & Girls Club of Adams County, Inc., including data collected via surveys or questionnaires. All information provided to BGCA will be kept confidential.
Parent / Guardian Name

First NameLast Name
Parent / Guardian Signature

Clear
Date

MonthDayYear
Date

Photograph, Social Media and Video Opt Out Option
I authorize the Boys & Girls Club of Adams County to use my members image for advertising, media, video, audio, or other marketing purposes of Boys & Girls Club of Adams County.
Do you agree to the statement above?

YesNo

For Parents / Guardians
Assumption of the Risk and Waiver of Liability Relating to
Coronavirus/COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the
World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.

Boys & Girls Clubs of Adams County (“Club”) has put in place preventative measures to reduce the spread of COVID-19; however, the Club cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending the Club could increase your risk and your child(ren)’s risk of contracting COVID-19.

- - -

By signing this agreement, I acknowledge the contagious nature of COVID-19 and
voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending the Club and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Club may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Club employees, volunteers, and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the Club or participation in Club programming (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless the Club, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Club, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Club program.
Name of Parent / Guardian
Name of Club Participant(s)
Current Date

MonthDayYear
Date
Signature of Parent / Guardian

Clear

Additional Members
Do you have another member you wish to enroll with us?

Yes, I have moreNo, I am finished
Children's Full Names
Please list each child's gender
Please list each child's birthday
Please list each child's age
Please list each child's Ethnicity
Please list each current school, grade & teacher *
This is very helpful information for us, so please make sure all information is included.
Have any of these children been members of the Boys & Girls club before?
Please be specific about which child, the location of the Boys and Girls club and for how many years.
Please list any medical problems, allergies or medications. Please be specific to each child.
Be specific
Should be Empty:

Membership Form - Decatur

Child Information

Child Demographic

Parent or Guardian Information

Medical & Emergency Information

Pick Up Information

Confidential Information

Parent Release Form 2020 - 2021

Photograph, Social Media and Video Opt Out Option

For Parents / Guardians

Additional Members