MEMBERSHIP FORM

MEMBERSHIP FORM
PARTICIPANT INFORMATION
Name *

First Name Middle Name Last Name
Other Name Used/Likes to be Called
Address *

Street Address

Street Address Line 2

City Province

Postal Code
Phone Number *
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Club Location
Date of Birth *

Month Day Year
Date
Gender *

Male Female Non-Binary Two-Spirit Other
Pronouns

He/Him/His She/Her/Hers They/Them/Theirs Other
School Name *
School MET No.
Grade *
PARENT/GUARDIAN INFORMATION
Child Resides With (check all that apply) *

Mother Father Both Parents Guardian Foster Parent(s) Grandparent(s) Aunt/Uncle Other
Parent/Guardian 1 Name *

First Name Last Name
Parent/Guardian 1 Address Same as Child? *

Yes No
If No, Parent/Guardian 1 Address

Street Address

Street Address Line 2

City Province

Postal Code
Parent/Guardian 1 Phone Number *
Please enter a valid phone number.
Parent/Guardian 1 Work Phone Number
Please enter a valid phone number.
Parent/Guardian 1 Cell Phone Number
Please enter a valid phone number.
Parent/Guardian 2 Name

First Name Last Name
Parent/Guardian 2 Address

Street Address

Street Address Line 2

City Province

Postal Code
Parent/Guardian 2 Phone Number
Please enter a valid phone number.
Parent/Guardian 2 Work Phone Number
Please enter a valid phone number.
Parent/Guardian 2 Cell Phone Number
Please enter a valid phone number.
Case Worker Name (if applicable)

First Name Last Name
Case Worker Phone Number (if applicable)
Please enter a valid phone number.
Parent/Guardian E-mail for Newsletters & Club Updates *
example@example.com
Your email address will be used to send you updates, opportunities and information
about programming within Boys and Girls Clubs of Winnipeg.
ADDITIONAL INFORMATION
Siblings who attend Boys and Girls Clubs (first and last names)
Family/Parent Status

Birth - Two Parents Blended Common-Law Guardianship Single Parent - Mother Single Parent - Father
Do you identify as any of the following?

First Nations Metis Inuit
Came to Canada as an Immigrant?
Country of Origin
Came to Canada as a Refugee?
Country of Origin
Visible Minority
eg: Asian, South America/African
Languages Spoken at Home
EMERGENCY CONTACT

Other than Parent/Guardian
Emergency Contact Name *

First Name Last Name
Emergency Contact Address *

Street Address

Street Address Line 2

City Province

Postal Code
Emergency Contact Phone Number *
Please enter a valid phone number.
Emergency Contact Cell Phone Number
Please enter a valid phone number.
Emergency Contact Relationship to Child/Youth *
Second Emergency Contact Name

First Name Last Name
Second Emergency Contact Address

Street Address

Street Address Line 2

City Province

Postal Code
Second Emergency Contact Phone Number
Please enter a valid phone number.
Second Emergency Contact Cell Phone Number
Please enter a valid phone number.
Second Emergency Contact Relationship to Child/Youth
Dietary Needs *

None Vegetarian Vegan Vegetarian but will eat poultry Lactose Free Gluten Free No Pork No Red Meat Halal Other
PARTICIPANT'S MEDICAL INFORMATION
Do you(your child) have a MB Health Card? *

Yes No
If No, Why? (i.e. new to Manitoba)
MB Health No. (6 Digits)
Personal Health ID No. - PHIN (9 Digits)
Physician's Name
Physician's Phone Number
Please enter a valid phone number.
Food Allergies
Other Allergies
Medical Conditions we should be aware of
(ie: Diabetic, ADHD, FASD etc.)
Does your child carry?

Epi-Pen Medical Alert Bracelet Inhaler Insulin
Please list any medications your child is presently taking
MEDIA CONSENT

Your child may participate in an event or activity run by the Boys and Girls Clubs of Winnipeg where photos, video or audio of Club members may be taken for promotional/educational/fundraising purposes. Please read this Media Consent Form carefully and indicate below your permission.
CHILD/YOUTH (17 YEARS OR UNDER) MEDIA CONSENT
*I hereby give Boys and Girls Clubs of Winnipeg and/or its member Clubs consent to use and reproduce my child’s/youth’s name/image for promotional purposes related to Boys and Girls Clubs of Winnipeg, its member Boys and Girls Clubs and/or external partners. My child’s/youth’s first name (unless otherwise authorized)/image may be published or used in newspapers, promotional videos, television commercials, program brochures, posters on World Wide Web or otherwise displayed to the public or used for other promotional/educational/fundraising purposes, either in whole or in part by the Boys and Girls Clubs of Winnipeg, its member Clubs, and/or external partners. I release Boys and
Girls Clubs of Winnipeg and its agents from any and all claims, of any nature, based on any uses of the above.
Select One *

I allow the use of my child's picture I decline the use of my child's picture
I certify that I am 18 years of age or over and am under no legal or contractual disability to grant the rights and license above.
Parent/Guardian Name *

First Name Last Name
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date
*Note: It is the parent/guardian’s responsibility to notify the office if the status of this consent changes.
CONSENT TO CHILD/YOUTH PARTICIPATION
1. Activity Participation

I give permission for my son/daughter to attend and participate in Boys & Girls Clubs activities that take place in or adjacent to the club building. I understand that my child’s membership at the Boys & Girls Clubs is a privilege and he/she may have her membership suspended or revoked if he/she does not adhere to club policies.

2. Drop-In Policy

I understand that the Boys & Girls Clubs operate with an open door policy and is a drop-in program. During operating hours members are free to come and go as they choose. Parents and club members are responsible for their own transportation to and from the club. The club is not a day care provider. The Boys & Girls Clubs is a nonprofit, youth development organization that provides a variety of free recreation activities supervised by club staff.

3. Field Trips (Outings)

I understand that the Boys & Girls Clubs organize a variety of field trips for members. Separate consent forms will be used for these outings and only members with a complete membership application and current emergency contact can attend club outings.

4. Medical Emergency

In the case of an emergency, I understand that a reasonable effort will be made to contact me. In the event that I cannot be reached, I consent that my child be given medical attention and if necessary medical treatment at a local health care agency.

5. Data Collection

Your child may be asked to participate in a survey/questionnaire while at Boys and Girls Clubs of Winnipeg. All information obtained from your child will be kept confidential and will be used to increase program quality. Steps to maintain anonymity are in place and will be made clear throughout the survey process. Any information processed through our data collection process will not be associated with your child’s name.

6. Waiver of Liability

I agree to release the Boys & Girls Clubs of Winnipeg Inc., its successors and assigns, its employees, agents and representatives from any and all responsibility or liability whatsoever for any loss, damage or injuries occurring to my child, myself and/or any property of either of us arising from any case whatsoever including, but not limited to the negligence of the Boys & Girls Clubs of Winnipeg Inc., and/or its employees, agents and representatives.
*

Yes, I have read the above and consent to my child becoming a member of the Boys & Girls Clubs of Winnipeg.
Parent/Guardian Name *
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date
VIRTUAL PROGRAMMING
In an effort to continuously serve members during the Club closure, Boys & Girls Clubs of Winnipeg is providing distance-based, virtual programming for Club members, through which Club staff will facilitate program activities through online platforms.

Boys & Girls Clubs of Winnipeg will use software, tools and applications provided by third parties that members, parents/guardians and/or staff will access via the Internet and use for purposes of communication and programming. These platforms include: Zoom and email to parent/guardians.

This letter seeks consent for your child to utilize Zoom for distance-based, virtual Club program purposes. Zoom is an online video communications company, with an easy, reliable cloud platform for video and audio conferencing, collaboration, chat, and webinars across mobile devices, desktops, and telephones.
- Zoom does not sell your personal data. Whether you are a business or a school or an individual user, they do not sell your data.
- Your meetings are yours. Zoom does not monitor them or even store them after the meeting is done unless they are requested to record and store them by the meeting host. Zoom alerts participants via both audio and video when they join meetings if the host is recording a meeting, and participants have the option to leave the meeting.
- When the meeting is recorded, it is, at the host’s choice, stored either locally on the host’s machine or in the Zoom cloud. They have robust and validated access controls to prevent unauthorized access to meeting recordings saved to the Zoom cloud.
- Zoom collects only the user data that is required to provide you Zoom services. This includes technical and operational support and service improvement. For example, they collect information such as a user’s IP address and OS and device details to deliver the best possible Zoom experience to you regardless of how and from where you join.
- Zoom does not use data they obtain from your use of their services, including your meetings, for any advertising. Zoom does use data they obtain from you when you visit their marketing websites, such as zoom.us and zoom.com. You have control over your own cookie settings when visiting their marketing websites.
Please be aware that each application collects different information about its users and has its own privacy terms and conditions to which members must adhere. Please review these carefully before registering your member ’Zoom Meetings’ privacy policy can be found here: https://zoom.us/privacy.

In order to participate in virtual Club programming, you will need to provide the following:
- A device that your child can access with video and microphone capabilities, a smart phone tablet, laptop or desktop computer and access to WiFi. We also require a parent/guardian email address, a quiet space for your child to participate in the program for up to 1 hour at a time and an adult needs to be present in the home when the child is attending the virtual program.
We will use the online applications for the following program activities:
- For virtual programs and group chats.
Our commitment to keeping the young people we serve safe is always our number one priority. Boys & Girls Clubs of Winnipeg will actively monitor member activity on Zoom and will make every effort to protect member information by, among other things, maintaining control of, and access to, the data collected; prohibiting re-disclosure of member information; limiting the purposes for which the online platforms may use member information; ensuring there is no advertising and that no member information is collected for commercial purposes.

Further, all activities online must comply with Boys & Girls Clubs of Winnipeg’s safety policies, including our Child Protection Policies which cover the Code of Conduct, Acceptable Use Policy, Internet Safety Policy, Prohibition of 1:1 Contact Policy, which are available upon request by contacting reception@wbgc.mb.ca .
*

I give permission for my child to participate in distance-based online Club experiences at Boys & Girls Clubs of Winnipeg. I do not give permission for my child to participate in distance-based online Club experiences at Boys & Girls Clubs of Winnipeg.
Parent/Guardian Name *
Parent/Guardian Email *
example@example.com
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

MEMBERSHIP FORM

PARTICIPANT INFORMATION

PARENT/GUARDIAN INFORMATION

ADDITIONAL INFORMATION

EMERGENCY CONTACT

PARTICIPANT'S MEDICAL INFORMATION

MEDIA CONSENT

CONSENT TO CHILD/YOUTH PARTICIPATION

VIRTUAL PROGRAMMING