MIKMAQ NATION

MI'KMAQ NATION
BOYS & GIRLS CLUB OF MI'KMAQ NATION
MI'KMAQ NATION YOUTH PROGRAM
56 MI'CMAC DRIVE
PRESQUE ISLE MAINE 04769
BOYS & GIRLS CLUBS OF MI'KMAQ NATION
Name: YOUTH

First NameMiddle InitialLast Name
Gender
D.O.B:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #:
Format: (000) 000-0000.
Alternate Phone #:
Format: (000) 000-0000.
School Name:
Grade:
Ethnicity:
Tribal Affliliation: (if any)
Can your Child Swim?
Eligible for Free School Lunch?
Known Allergies: (environmental, medicinal, or food)
Medical Issues:
Medications: (name, dosage, frequency, reason, side effect)
Does Child use EpiPen?
Does Child use Insulin?:
Does Child use an Inhaler?
Is Child in Foster Care?
# of Adults in Household:
# of Children in Household:
Name: PARENT/CAREGIVER

First NameMiddle InitialLast Name
Phone #:
Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name:

First NameMiddle InitialLast Name
Phone #:
Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name: OTHER CONTACTS
Phone #:
Format: (000) 000-0000.
Relationship:
Eligible to pickup?
Name:
Phone #:
Format: (000) 000-0000.
Relationship:
Eligible to pickup?

MIKMAQ NATION
BOYS & GIRLS CLUB OF MIKMAQ NATION
MIKMAQ NATION YOUTH PROGRAM
56 MICMAC DRIVE
PRESQUE ISLE MAINE 04769
Parental/Guardian Acknowledgement & Agreement
Please read and sign below showing that you understand the following:
- I understand that the BGC of Mi'kmaq Nation- Mi'kmaq Nation Youth Program claims no responsibility for injuries or illness which my child may sustain as a result of his/her participation in any Club activities, sports, programs, the use of equipment, exercise or other activities.
- I give permission to the BGC of Mi'kmaq Nation- Mi'kmaq Nation Youth Program to contact my child's school and/or teachers for the purposes benefitting my child in connection to homework and schoolwork. I give permission for the BGC of Mi'kmaq Nation- Mi'kmaq Youth Program to receive a copy of my child's school report card each quarter of the school year.
- I give permission for the BGC of Mi'kmaq Nation- Mi'kmaq Youth Program to conduct surveys with my child regarding the program and/or my child's participation in activities. Survey results will be kept confidential.
- I give permission to the BGC of Mi'kmaq Nation- Mi'kmaq Nation Youth Program, without limitation or obligation, to use photographs, video footage, or tape recordings which may include my child's face or voice for the purposes of promoting or interpreting Club programs.
- My child's belongings are his/her sole responsibility when they are at the Club and the Club is not responsible for my child's articles that become misplaced or disappear. This includes, but is not limited to: clothing, backpacks, school supplies, electronics, toys and games.
- I give my child permission to utilize the programs basic internet services.
- I give my child permission to watch PG rated movies chosen by the BGC of Mi'kmaq Nation Mi'kmaq Nation Youth Program.
- I hereby give my consent to allow the BGC of Mi'kmaq Nation- Mi'kmaq Nation Youth Program or the school to which my child is attending, to mutually share information about my child with the BGC of Mi'kmaq Nation- Mi'kmaq Nation Youth Program for the purpose of creating individualized academic plans, tracking school progress and academic performance that will be used to enhance my child's performance in school. I also understand that all information shared between the Boys and Girls Club of Mi'kmaq Nation- Mi'kmaq Nation Youth Program, or my child's school will be kept strictly confidential and will NOT be used for any other reason.
Mentoring Program
Would you like your child to be matched with a Mentor?
Please note that all mentors go through a background check and receive proper training to deal with a variety of different situations that are likely to occur during a Mentor/Mentee session. All sessions are overseen by a BGC of Mi'kmaq Nation-Mi'kmaq Youth Program professional.
Check all that applies:
The Boys & Girls Club of Mi'kmaq Nation- Mi'kmaq Nation Youth Program are not responsible, or liable in the event of harm or injury occurring to your child. It is agreed that the parent/guardian will not hold the Boys & Girls Club of Mi'kmaq Nation- Mi'kmaq Nation Youth Program responsible for the welfare or whereabouts of the child. If parents or guardian does file a complaint against the Boys & Girls Club of Mi'kmaq Nation-Mi'kmaq Nation Youth Program, the parent/guardian agrees to pay for the Boys & Girls Club of Mi'kmaq Nation- Mi'kmaq Nation Youth Programs legal fees.
The BGC of Mi'kmaq Nation- Mi'kmaq Youth Program are FREE Learning Center Programs for students that offers a variety of stimulating activities to promote school success and personal well-being in a safe environment. Active attendance and engagement are essential to the students' and program's success.
Non-discrimination Notification
The BGC of Mi'kmaq Nation and Mi'kmaq Nation Youth Program does not discriminate against any persons on the basis of sex (including transgender status, gender nonconforming, and gender identity), marital status, sexual orientation, race, religion, ethnicity, national origin, age, color, pregnancy, disability, military status, or genetic information.
Print Parent/Guardian Name
Parent/Guardian Signature
Date

MonthDayYear
Date

MIKMAQ NATION
BOYS & GIRLS CLUB OF MIKMAQ NATION
MIKMAQ NATION YOUTH PROGRAM
56 MICMAC DRIVE
PRESQUE ISLE MAINE 04769
BOYS & GIRLS CLUBS
OF BORDER TOWNS
Membership Acknowledgement & Agreement
- I understand that the possession of weapons, including, knives and firearms, are cause for immediate dismissal.
- I understand that the BGC of Mi'kmaq Nation- Mi'kmaq Nation Youth Program have a warning/behavior system. For more information please contact staff during scheduled hours (refer to monthly activities calendar).
- Swearing and vulgar language will not be tolerated and will be dealt with through our disciplinary standards.
- All homework should be completed before any computer time or participating in activities.
- Youth must always stay with staff. They are not allowed to wander around the building without supervision.
- Respect each other and the BGC of Mi'kmaq Nation- Mi'kmaq Nation Youth Program staff and equipment.
- Zero Tolerance Policy- ANY BULLYING BEHAVIORS (This will be defined as any behaviors that affect the immediate or long-term safety, health or welfare of another person) WILL BE DEALT WITH ON AN INDIVIDUAL BASIS, PARENTS WILL BE NOTIFIED IMMEDIATELY UPON ANY CONCERN OF BULLYING AND A DISCIPLINARY PLAN WILL BE PUT INTO PLACE.
- I understand that physical contact is not allowed while at the Club. This does include between siblings.
- I understand that if I don't attend school, I am not allowed to participate in youth programs for that day.
- I understand that food will be eaten at the tables in the designated eating areas.
- We believe in teaching our youth responsibility and are expected to pick up after themselves.
- Youth are not allowed to come and go from Club. Once a youth signs out for the day, that means they are not able to return until the next day(exceptions for appointments can be made with supervisory approval).
Disciplinary Procedures:
The Boys & Girls Club of Mi'kmaq Nation- Mi'kmaq Nation Youth Program, takes a proactive approach to dealing with disciplinary situations. The program has developments and consequence based approach (opposed to punishment based) to dealing with behavioral issues. Restorative justice and a love and logic approach will be utilized when it is deemed necessary and parents will be notified of any plans in place that need behavioral support. Any safety concerns for youth will be dealt with using a team approach and parents will be included in the team.
By signing below, you understand the Boys & Girls Club of Mi'kmaq Nation- Mi'kmaq Nation Youth Programs Rules & Membership Acknowledgement & Agreement
Print Parent/Guardian Name
Parent/Guardian Signature
Date

MonthDayYear
Date
Print Child Name
Child Signature
Date

MonthDayYear
Date

MI'KMAQ NATION
BOYS & GIRLS CLUB OF MI'KMAQ NATION
MI'KMAQ NATION YOUTH PROGRAM
56 MICMAC DRIVE
PRESQUE ISLE MAINE 04769
SAMHSA Project Parent/Guardian Informed Consent Form
Introduction:
The Mi'kmaq Nation provides Substance Abuse and Suicide Prevention programming. This document outlines the terms and conditions under which a parent or legal guardian grants permission for their child to participate in the SAMHSA Project.
I,
Parent/Caregiver
residing at
am the parent/legal guardian of
Youth
who is
Age
years of age and was born on

MonthDayYear
Date
I acknowledge, declare, and agree to the following:
- I understand that the Mi'kmaq SAMHSA Project claims no responsibility for injuries or illness which my child may sustain as a result of his/her participation in any project activities.
- I give permission for the Mi'kmaq SAMHSA Project to conduct surveys with my child regarding the project and/or my child's participation in activities. Survey results will be kept confidential.
- My child voluntarily agrees to participate in the Mi'kmaq SAMHSA Project.
- I have been fully informed of the nature, scope and demands of the SAMHSA Project.
- I give permission to the Mi'kmaq SAMHSA Project, without limitation to use photographs, video footage, or tape recordings which may include my child's face or voice for the purpose of promoting or interpreting the program.
By signing below, I declare that I completely understand and have fully informed myself of the terms and conditions of this "Parent/Guardian Informed Consent Form" by having read it, or having it read to me, before signing and I intend to be fully bound thereby.
Print Student Name
Signature of Student
Print Parent/Guardian Name
Signature of Parent/Guardian

MIKMAQ NATION
BOYS & GIRLS CLUB OF MIΚΜΛΟ NATION
MIKMAQ NATION YOUTH PROGRAM
56 MICMAC DRIVE
PRESQUE ISLE MAINE 04769

BOYS & GIRLS CLUBS
OF BORDER TOWNS
Van Rules & Expectations
Before the van arrives:
- Arrive at your van stop at least five minutes before scheduled pick up time.
- Remain at the van stop until picked up.
Expectations in the van:
- Follow the directions of the van driver.
- Walk to your seat and remain there.
- Sit still and stay in your seat while the van is moving.
- Talk quietly, so that the driver can hear traffic.
- Keep hands, head and items inside the van.
- Seatbelts must remain on at all times during transportation.
- Bullying, name calling, and shouting are not permitted. WE DO NOT ALLOW BULLYING OF ANY KIND!
Leaving the van:
- Stay buckled and in your seat until van comes to a full stop.
- Take your turn; no crowding in front of others.
- Have all the materials you need to take home with you.
Consequences for improper behavior in the vans:
- First, you will not be allowed on outings while at the club until you show that you can follow the rules.
- Second, you need to find another form of transportation to and from the club until you can show that you can follow the rules.
- Safety plans will be put into place with staff, students, and parents in order to minimize these behaviors.
- Parents will immediately be notified of all incidents.
The Parent/Guardian and Student are each asked to sign and return this statement below:
I am aware of and agree with the expectations of the Boys & Girls Club of Mi'kmaq Nation for transportation. I understand and agree with the regulations which are necessary in order to provide the safety and welfare of all children, and staff.
Parent/Guardian Signature:
Date:

MonthDayYear
Date
Student's Signature:
Date:

MonthDayYear
Date
Should be Empty:

MIKMAQ NATION

BOYS & GIRLS CLUB OF MIKMAQ NATION

MIKMAQ NATION YOUTH PROGRAM

Parental/Guardian Acknowledgement & Agreement

Mentoring Program

Non-discrimination Notification

Membership Acknowledgement & Agreement

Disciplinary Procedures:

SAMHSA Project Parent/Guardian Informed Consent Form

Introduction:

Income Verification Form

Van Rules & Expectations

Before the van arrives:

Expectations in the van:

Leaving the van:

Consequences for improper behavior in the vans: