Boys and Girls Club of the Hoopa Valley Tribe Membership Form

Name of Youth Member

First NameLast Name

Address of Youth Member

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Youth Member Email Address

example@example.com

Youth Member Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Youth Member Birth Date

Date

Name of Parent/Guardian

First NameLast Name

Name of Parent/Guardian

First NameLast Name

Parent/Guardian Relationship

Parent/Guardian Home Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian Work Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian Email Adderss

example@example.com

Emergency Contact Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Names and phone numbers of people who can sign out child member

Medical Information of Member: Allergies; Current Medication; Medical Conditions:

Youth Center Code of Conduct for Members, Staff, Volunteers and Parent’s/Guardians 1. Sign in upon arrival and sign out upon departure every day, when not at the Teen Center you should be signed out. 2. Respect yourself, others, the facility, the equipment and the opportunity the Teen center provides. 3. Treat the world, and those around you with dignity and honor and try to make those around you comfortable. 4. Platinum Rule: Treat others the way they want to be treated. 5. Use positive communication and language. 6. Speak and act in a constructive way to build others up, even when they are different from you. 7. Help keep the Teen Center clean by always cleaning up after yourself as well as helping with the end of the day chores. 8. Make sure things are back where they belong and cleaner than before. 9. Place trash in the correct trash receptacle. 10. Be safe and have fun. 11. ABSOLUTELY NO: Drugs, alcohol, tobacco, weapons, violence, drug paraphernalia, sexual behavior, bullying, intimidation, vandalism, theft, property destruction, loitering outside, excessive laziness, or disrespectful language or behavior. Also NO instigating others to join you in these behaviors. Those with unexcused absences from school or who are ill or those who are guilty of violating the final rule will not be allowed into the Teen Center on those days.question

Code of Conduct Violation Procedure 1. Verbal reminder, three reminders/strikes per day. 2. One on two, or two on one lecture going over the rules and why it is necessary to follow them. 3. Incident report, call parent/guardian, atone or make up for transgression, or write lines. 4. 1 day suspension for the rest of the day, meet with Parents. 5. Multiple day suspension, meet with staff, child, and parents/guardian’s twice. Restitution.

I, the parent/guardian of First Name Last Name my 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 The Hoopa Valley Tribe 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 The Hoopa Valley Tribe 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 The Hoopa Valley Tribe to collect information via online or written surveys, questionnaires, interviews, and focus groups from my 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 the Hoopa Valley Tribe and my child’s school district to exchange information regarding my 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 andin life. This release is valid for one year and may be revoked at any time by contacting the school district or the Boys & Girls Club in writing.

Data Sharing- I understand that the Boys & Girls Club of The Hoopa Valley Tribe may share information about my 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 My minor child’s school or school district, and other information collected by Boys & Girls Club of The Hoopa Valley Tribe, 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 understand my child may be pictured in the paper and on social media sites like Facebook, bgca.net, etc. 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 The Hoopa Valley Tribe to share information about my 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 providedon this membership application form, information provided by My minor child’s school or school district, and other information collected by Boys & GirlsClub of The Hoopa Valley Tribe, including data collected via surveys orquestionnaires. All information provided to BGCA will be kept confidential.

Payments must be made by

Are you interested in scholarships to cover membership and program fees? If Yes Please answer the next section.

Number of People in the Household

Estimated Annual Household income

Social Welfare Programs (check all that apply)

Childs Family Setting (check all that apply)

Youth Member Print Name

Youth Member Signature

Date

Parent/Guardian Print Name

Parent/Guardian Signature

Date