Member Registration Form

Child Abuse Regulations:

The Boys & Girls Clubs of Rutherford County (BGCRC) is required by law to report to the Department of Children’sServices any suspected child abuse of our members. All suspected child abuse will be reported immediately. I have received, read and had an opportunity to discuss with a staff member a summary of licensing requirements, parent letter regarding child abuse, Parent Handbook, and I have had a pre-placement visit.

Disclaimer:

By signing below, I certify the above information is true to the best of my knowledge. Some programs offered are federally funded and may require documentation of income. I agree to provide documentation of income upon request. I authorize Boys & Girls Clubs of Rutherford County to contact me if my child is injured and/or harmed in any way. I also authorize Boys & Girls Clubs of Rutherford County to seek medical attention for my child if he/she is injured and/or harmed and needs immediate medical assistance at a local hospital or emergency care center. I certify that Iand/or our family’s insurance provider will be responsible for any financial medical costs that may be associated withall medical attention and treatment given to my child. In consideration of the Boys & Girls Clubs granting my child the opportunity to participate in the After School/Summer program, I hereby release, indemnify and hold harmless the Boys & Girls Clubs of Rutherford County from any liability, claim or demand resulting from any legal medical attention and assistance that may be needed and provided as a result of an injury or harmful incident to my child.

BGCRC operates with a 1:20 staff/member ratio and that the following is required of Club members:

• Able to participate in Club programs independently, or with minor accommodations provided
• Able to use the restroom independently and safely, or with minimal verbal prompting
• Able to take direction and instruction from staff or volunteers
• Comfortable with, and able to interact in, a group environment fostering teamwork and positive behavior
• Interacts and participates in programs in a manner that is physically and emotionally safe for everyone
• Does not require physical intervention for redirection, assistance, or for any other reason

I understand that I must attend a parent orentation before my child can participate at the Boys & Girls Clubs of Rutherford County.

I hereby give the Boys & Girls Clubs of Rutherford County permission to ASSIST in the administration of the above medication, at the above dosage to my child.

All acceptable behavior at the Club can be broken down into three main rules. They are the following:

Respect Club Staff

Respect Club Members

Respect Club Property

 

The following is a list of more detailed behavior policies:

· Members must ALWAYS follow the instructions of the Staff. Failure to do so will result in suitable consequences.

· Members must be respectful to the staff and other members.

· Smoking, drugs, alcohol, and weapons are prohibited. We enforce a ZERO tolerance policy.

· Gang representation is prohibited at the Club.

· Please keep your hands to yourself at all times.

· Avoid the use of improper language.

· Listen during assembly and special events.

· Run outside or in the gym only.

· Show respect to the facility and equipment.

· All games are played under the “I’m next” system.

· Eat or drink in designated area.

· Phone calls are for emergencies only. Parents are free to call at any time.

· Bring membership cards everyday.

· Stay with your group at all times.

· Leave personal belongings at home. The Club will NOT be responsible if they are lost or damaged.

· All members are expected to present themselves with dignity, wash and dress neatly, as well as clean up his or her surroundings. The Director reserves the right to contact a parent/guardian in the event that a child is dressed inappropriately.

By signing below, I acknowledge that my child will be participating in the Project Learn Initiative at the Boys & Girls Club of Rutherford County.  I acknowledge that the programs of Project Learn include but are not limited to homework help, tutoring sessions, computer class, internet safety sessions, supervised internet access, and general health and well being activities.

 

Furthermore, in signing below, I give the Boys & Girls Club of Rutherford County and its representative’s permission to communicate with my child’s teachers and/or school about their academic performance.  I give the Boys & Girls Club of Rutherford County permission to view and/or possess copies of any academic performance information (standardized test scores, report cards, etc.)

I hereby give permission for my child to participate in the summer program field trips.

 

I also understand that the Boys & Girls Clubs of Rutherford County is not to be held responsible for any accidents related to these activities through the Club or held at the Club.

 

The parents of the youth agree that neither the Boys & Girls Club, nor their representatives, shall be held liable for any accidents or misfortunes while en route to or returning from said outing.

 

Calendar for field trips and times will be posted in main lobby and available for distribution at your request.  Please note field trip space is limited and violation of conduct code will result in inability to participate.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov.

1. I will not give out personal information such as my address, telephone number, parent’s work address/telephone number or the name and location of my school.

2. I will tell a staff member right away if I come across any information that makes me feel uncomfortable or is inappropriate.

3. I will never agree to get together with someone I met online.

4. I will never send a person my picture or anything else personal.

5. I will not respond to any messages that are mean or in any way make me feel uncomfortable. It is not my fault if I get a message like that. If I do I will tell a staff member right away so that they can contact the service provider.

6. I will not give out my internet password to anyone (even my best friends) other than my parents.

7. I will be a good online citizen and not do anything that hurts other people or is against the law.

To insure that the property and rights of others members are respected, proper behavior is required of all members who ride Club buses from school to the Club or on special field trips. The driver of the bus has the authority and responsibility to maintain order and safe conditions on the bus at all times.

 

Bus riders shall:

 

Enter the bus quickly and calmly, sit on the seat facing forward, with their feet in front of them, and their book bags in their laps.
Show respect for their fellow riders, the bus aide, and the bus driver at all times.
Follow direction given by the bus aide or bus driver.
Remain seated until excused by the bus aide or bus driver.
Keep all objects out of the aisles and inside of the bus. This includes heads, arms, hands, and any carry-on items.
Refrain from throwing anything inside or outside of the bus. All carry-on items must be safely placed in their laps.
Refrain from using inappropriate language, talking loudly, teasing or creating any other type of disturbance.
Refrain from pushing, shoving, hitting, and fighting.
Refrain from eating, drinking, or chewing gum while on the bus.
Refrain from playing radios, CD’s, video games, and using cell phones while on the bus.
Refrain from damaging the bus in any manner, such as cutting or tearing the seats or using a marker to deface bus property.
Be totally silent when instructed by the bus aide or bus driver at all railroad crossing.
 

(Note) The bus driver or bus aide may confiscate any carry-on item which he or she considers to be unsafe while traveling on the bus but will return it to the member or the Unit Director, upon arrival at the Club.

 

 

Parents please take the time to explain to your child these rules of proper bus behavior. You are also expected disciplinary actions if they should become necessary. By your signature below you acknowledge that both you and your child understand this policy.

 

I.                 Welcome!

 

II.                Who We Are                                                         

a. History (BGCA & BGCRC)

b.      Mission Statement

   1.     “To enable all young people, especially those who need us most, to realize their full potential as productive, caring and responsible citizens.”

c.     Club Code

   1.     “I believe in God and the right to worship according to my own faith and religion. I believe in America, and the American way of life, the constitution and the Bill of Rights. I believe in fair play, honesty, and sportsmanship. I believe in my Boys & Girls Club, which stands for all of these things.”

d.      Impact Areas (of programming)

   1.      Good Character & Citizenship

   2.      Academic Success

   3.      Healthy Lifestyles

 e.      Explanation of our structured programming

   1.      We provide activities and programs that are age appropriate (members grouped according to grades)

   2.      Members rotate to program areas according to a specific program/event schedule

   3.      Staff members stay with their groups, supervise and facilitate

   4.      Members are encouraged to try new activities and take advantage of new experiences

 

II.                Membership Requirements

a.      Youth must be between the ages of 5-18 (5 & 6 year olds must be in kindergarten - kindergarten ready does not qualify.)

b.      Completed application, with all necessary emergency contacts & information

c.      $40.00 membership fee (Membership expires on May 19, 2023)

 

III.              Days/Hours of Operation and Fees

a.      We are open Monday-Friday from afterschool dismissal - 6:30pm

b.      WEEKLY FEES: (afterschool) $40/week

  1.     Multi sibling discounts apply

  2.     NEW: $5 additional fee per child for full days out of school (teacher in-service days, holidays, etc.)

  3.     $85/week for school breaks (Fall, Winter and Spring Breaks) – sign up in advance

  4.     Weekly fees are to be paid 1 week in advance in order to maintain a spot in our program

  5.     Fees are to be paid regardless of attendance

  6.     Two one-week vacations are permitted without payment or loss of spot in the after-school program

  7.     If a member leaves the program, 2 weeks’ notice and payment is required

c.      LATE FEES: Any member who is picked up after closing will be subject to a fee of $1/per minute/per child.  These fees must be paid in full before the member returns to the Boys & Girls Clubs.

 

IV.              Club Membership Cards

a.      Members well receive a membership card.  The first card is issued at no cost.  However, there is a fee of $2 for each replacement card.

b.      All members must bring their membership card every day, as well as sign in/out every day. Participation in Club activities and programs will be limited in the event that a member forgets or loses their card; however, they must still sign in at the front desk.  

 

V.               After School Transportation

 

 a.      Members will be dismissed from school as “Boys & Girls Club”.  They must immediately go to the designated area for pick up. 

b.      It is the parent’s responsibility to inform the school of their child’s attendance to the Club.  They may not be dismissed appropriately otherwise.  We only know who is expected to attend based on who is waiting for Club staff/bus to arrive.

c.      Because of our VERY tight schedule, if a child is not in place when the Club staff/bus arrives, then it will be assumed that they are not attending the Club that day.  If a child is left behind because they were not in their designated pick-up area by the time of departure, the Club bus may not be able to return to pick up that child, and the parent would then need to be available to pick their child up from school.

 VI.              Membership Expectations

a.      Members are expected to follow the directions of and respect all staff, volunteers, and peers. They are also expected to follow the guidelines/rules in each program area at all times.

   1.     See Club Member Consequence Chart

b.      Equipment and property must be handled with care. In the event that a member causes damage, they (parents/guardians) will be subject to repair/replacement fees.

c.      The Boys & Girls Clubs implement a “Zero Tolerance” policy for the following behavioral challenges. Violation of this policy will result in an automatic suspension period. Some cases may result in expulsion.

   1.      Physical altercations and/or threatening the safety of others

   2.      All Forms of Bullying (see www.stopbullying.gov for additional information)

   3.      Theft

   4.      Vandalism

   5.      Inappropriate behavior (includes sexual behavior, drugs/tobacco/alcohol, weapons, etc.)

6.      Disrespectful attitude towards Staff, volunteers, and/or fellow members

d.      Suspension/Expulsion Policy

   1.     The Boys & Girls Clubs of Rutherford County reserves the right to suspend/expel any member at our discretion.  If a member is suspended/expelled at one Club, they will not be permitted to attend another Boys & Girls Clubs of Rutherford County Club Site (Murfreesboro, Smyrna, & Shelbyville) during that period. 

 e.      DRESS CODE: Members may not wear tank tops with straps less than 3 fingers width, open toed shoes, revealing or inappropriate clothing and/or accessories. Pants and shorts must also be worn at the waist and shorts/skirts must be at fingertip’s length.  

 e.   PERSONAL BELONGINGS: The Boys & Girls Clubs are not responsible for any lost or stolen items. Toys, dolls, electronics, games, trading/game cards, fidget spinners/cubes, slime, etc. are not permitted at the Club.

 f.    ELECTRONIC DEVICES: Members are permitted to bring their devices. However, they must be kept out of sight and may not be used while participating in Club activities, unless directed otherwise. Should devices be used without the authorization of staff will result in the device being confiscated until the end of the day. Parents, please refrain from texting and/or calling your children during program hours.

 g.   PHONE CALLS: Club phones are for emergency purposes only and are limited for use by members.

 

VII.            Safety & Illness

a.      The Club will update policies as needed in regards to COVID-19 – information can be found at www.bgcrc.net/safety/

b.      Please see out Parent Handbook to review full illness policy

 

VIII.          Drop Off/Pick Up Procedures

a.   Curb-side: Parents/guardians may pull up to the front of the Club, or park in designated parking spaces, to drop off or pick up their child(ren). Photo identification must be presented at pick-up and your child(ren) much be signed out.

 

IX.              Meals: Snack & Dinner

a.      We will offer an afternoon snack and dinner (dinner at Rutherford Clubs only) to members every day during designated scheduled times (times are TBA)

b.      Meals must be consumed only in the designated serving areas

 

X.               Parent Information

a.      Visitor Policy

   1.     No adult may pass the front desk/lobby area without properly signing in and receiving credentials

b.      Communication

   1.      Behavioral (needs, challenges, concerns, etc.)

   2.      Health (physical, emotional & mental) and medication

   3.      Restrictions & restraints

c.      Texting Service

   1.     Text (message): BGCsmyrna, BGCmboro, or BGCbedford to 88202

 

 XI.              Open Discussion/Q & A

                              

XII.            Welcome to the Boys & Girls Clubs Family! 

 

I have read and understand all of the policies and waivers.  

I promise to support my child in following the Club’s Code of Conduct. I understand that violation of the code will result in: time-out, loss of privileges, suspension and/or loss of membership.

By signing below I agree to all of the terms, rules, and standards and uderstand the consiquences if any are broken.