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.