MEDICAID - 2022-2023 Teen After-School Program Registration Form

2022-2023 Teen After-School Program Registration Form

APPLICATION PART A
You must provide Medicaid information within two business days after completing the two-part application. Membership cards are not valid proof of Medicaid coverage.

PARENT/GUARDIAN/CAREGIVER INFORMATION
Primary Parent/Guardian/Caregiver*

First NameLast NameSuffix
Relation to Club Member*
Cell Phone Number*
Ex. (123) 456-7890
Home Phone Number
Ex. (123) 456-7890
Email*
example@example.com
Employer and Location*
Work Phone Number
Ex. (123) 456-7890
Parent/Guardian/Caregiver

First NameLast Name
Relation to Club Member
Cell Phone Number
Ex. (123) 456-7890
Home Phone Number
Ex. (123) 456-7890
Email
example@example.com
Employer and Location
Work Phone Number
Ex. (123) 456-7890

EMERGENCY CONTACT INFORMATION
Emergency Contact*

First NameLast Name
Relation to Child*
Phone Number*
Ex. (123) 456-7890
Alternate Phone Number
Ex. (123) 456-7890

MEDICAL INFORMATION
Please detail any medical and/or behavioral issues and/or allergies: *
Ex. ADHD, allergic to shellfish
Does this child have health insurance?*

YesNo
Should the child for which this application is being completed suffer from an injury or illness while in the care of the Boys & Girls Club and Club personnel is unable to contact me or the designated emergency contact immediately, it shall be authorized to secure such emergency medical attention, services, and care for the child as it may be deemed necessary by Club personnel. I shall assume full responsibility for payment for any such attention, care, and services. I hereby release, indemnify, and hold harmless the Boys & Girls Club, the Georgia Department of Human Services, as well as any office, director, employee, or agent of the Club 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 at the time of entering my child in the Boys & Girls Club after-school program.

I agree to keep the Boys & Girls Club informed of changes in contact information, including telephone numbers, where I can be reached.

The Boys & Girls Club agrees to keep me informed of any incidents requiring professional medical attention involving my child.
Please type your name to confirm you have read and agree to these statements*

HOUSEHOLD INFORMATION
Check all that apply:
This child lives with:*

MotherFatherGrandmotherGrandfatherOther
Does this child live in a Winder Housing Authority property?*

YesNo
How many people live in the household?*
Number of brothers/step-brothers: *
Number of sisters/step-sisters: *

INDIVIDUALS AUTHORIZED FOR PICK-UP
Please list individuals who are authorized to pick up your child from the Boys & Girls Club of Winder-Barrow County. Should this information change, please inform a member of the Club's administrative staff.

*ID is required before Club members will be released
Name, relation to youth, and phone number(s):
Name, relation to youth, and phone number(s):
Name, relation to youth, and phone number(s):

AUTHORIZATION TO RELEASE SCHOOL RECORDS
I, as parent/guardian of the child named in this form, hereby authorize the Administration and/or Teachers at the school in which my child in enrolled to release to the authorized individuals of the Boys & Girls Club of Winder-Barrow County limited school records to include Grades, Test Scores, copies of Report Cards/Progress Reports and Attendance Information to include School Suspension. It is understood that the Boys & Girls Club of Winder-Barrow County or any of its representatives will not release this information to a third party. Furthermore, it is understood that once obtained, this information will be kept in strict confidence and will be used only to assess academic strengths and weaknesses in order to provide assistance where needed at the Boys & Girls Club.
Please type your name to confirm you have read and agree to these statements*

CONFIRMATION
I, as parent/guardian of the child for whom this membership application is being completed, hereby give my child permission to join the Boys & Girls Club as a member. I also give my child permission to participate in all programs offered at and sponsored by the Boys & Girls Club, including programs and activities that will take place away from the immediate Boys & Girls Club facilities. I understand that the Boys & Girls Club has an "open door" policy, which means children are free to leave the Boys & Girls Club at any time. I agree that the Boys & Girls Club will not be responsible for the welfare of my child once he/she leaves the Boys & Girls Club premises. I, individually and on behalf of my child, agree to hold harmless, protect, indemnify, release, and discharge the Boys & Girls Club and the Georgia Department of Human Services from all claims, demands, action, causes of action, damages, or liability associated with all Boys & Girls Club activities, and I, individually and on behalf of my child, agree not to sue, make a claim against, or prosecute the Boys & Girls Club or the Georgia Department of Human Services in any fashion as a result of injury to me or to my child (or the consequences of any injury to me or to my child). I further acknowledge and agree, individually and on behalf of my child, that the terms of this release apply whether any act or omission to act which results in injury or death to me or my child occurred as a result of the conduct on the part of the Boys & Girls Club and/or the Georgia Department of Human Services, the conduct of a third party, my conduct, or the conduct of my child. I, individually and on behalf of my child, expressly waive any claim for injury or damages which I and/or my child may have against the Boys & Girls Club and/or the Georgia Department of Human Services, whether because of negligence or otherwise, which arises by reason of any Boys & Girls Club activities organized by the Boys & Girls Club or by reason of any act or omission to act on the part of any employee of the Boys & Girls Club.

As the parent/guardian, I agree that the Boys & Girls Club will not be responsible for any accident to my child while on the Boys & Girls Club premises or while engaged in any of its activities away from the Boys & Girls Club.

I UNDERSTAND THAT PARTICIPATION IN THE BOYS & GIRLS CLUB OF WINDER-BARROW COUNTY IS A PRIVILEGE, AND THE CLUB IS NOT OBLIGATED TO PROVIDE CARE FOR CHILDREN WHO ARE UNWILLING TO COOPERATE WITH CLUB STAFF AND VOLUNTEERS.

I give permission for my child's picture, motion pictures, or any other graphic depiction or likeness, either live or video tape, to be used by the Boys & Girls Club and/or its agents to include the Georgia Department of Human Services and/or the media in promotion of the Boys & Girls Club and/or the Georgia Department of Human Services and its activities.
BY SUBMITTING THIS FORM, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Please type your name to confirm submission of this online form*
Date*

MonthDayYear
Please complete Part B of the 2022-2023 Teen After-School Program Registration Application. Both forms must be completed for your child's application to be considered.
Should be Empty:

2022-2023 Teen After-School Program Registration Form

CHILD'S INFORMATION

PARENT/GUARDIAN/CAREGIVER INFORMATION

EMERGENCY CONTACT INFORMATION

MEDICAL INFORMATION

HOUSEHOLD INFORMATION

INDIVIDUALS AUTHORIZED FOR PICK-UP

AUTHORIZATION TO RELEASE SCHOOL RECORDS

CONFIRMATION