2014/15 SY Membership Enrollment Form

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1 Member s Name: For Office Use Only BGC # Location: WG BC BTC Amount Rec d Payment Type: Check/Money Order # Accepted By: Start Date: Date entered into membership database Scholarship? Scholarship Amount Photo Release: Allergies: Open Door: 2014/15 SY Membership Enrollment Form Child s First Name: Mid dle: Last Name: Address: City : Zip: Home Phone: DOB: Gender: Male Female Age: Grade: School: PS Password Ethnicity Household Income For School Based Clubs Only: African American Caucasian $0-$9,999 Before & After School Hispanic/Latino Multi-Racial $10,000-$19,999 Before School Asian/Pacific Other $20,000-$29,999 After School Native Hawaiian/Pacific Islander $30,000-$39,999 Early Release Days Only American Indian/Alaska Native $40,000 & up Summer Program Only Physician s Name: Physician s Phone : Permission for treatment by Doctor/Hospital? Yes No Is your child currently on medication? Yes No If yes, please list: List any Food Allergies: List Serious Health Problems/Allergies: List Physical Activities Your Child Cannot Participate in: List special needs/assistance your child may need to be successful in our program: Release of Child/Emergency Contact Information Mother/Guardian Name: Place of Employment: Occupation: Home Phone: Cell Phone: Father/Guardian: Place of Employment: Occupation: Home Phone: Cell Phone: Additional Contacts Name: Relationship: Cell Phone: Name: Relationship: Cell Phone: Is there anyone NOT authorized to pick up your child?

2 Check all those living in current household Household Information Mother Father Step-Mom Step-Dad Grandparent(s) Other: Total number of people living in household: Head of Household: Female Male Single Parent: Yes No School Lunch Program: Free Reduced Ineligible Is parent/guardian a member of military? TERMS & CONDITIONS: Please initial that you have read each paragraph. Parent Handbook: I have received a copy of the Boys & Girls Clubs of Greater Gaston handbook and agree to abide by the policies in the Parent Handbook, and that failure to do so can result in membership termination. Club Rules & Code of Conduct: I agree to review the Club rules and Code of Conduct and consequences with my child. I under- stand that membership can be suspended or revoked should behavior warrant such action. Payment: We accept check or money order only; no cash. Please keep record of payments, we do not provide annual statements. There are no refunds for membership fees or registration. Late Fees: I will adhere to the program hours. I understand that I will be charged a late fee for not picking my child up at the designated closing time. Please refer to the Parent Handbook for more information. I understand membership may be suspended until payment is made. I understand that repeated offenses can result in termination of membership. Photo Release: I give permission for my child to be photographed and/or videotaped for promotional materials: School Release Information: I understand that as a partner of the Gaston County School Board, the Boys & Girls Clubs of Greater Gaston will obtain academic information to better serve my child s academic needs. I give permission for the Boys & Girls Clubs of Greater Gaston to access my child's academic school records: Medical Care: In the event the Boys & Girls Clubs of Greater Gaston is unable to reach me, or is on a field trip out of town, when my child has been injured or needs medical attention/treatment, I authorize the Boys & Girls Clubs of Greater Gaston to obtain medical or hospital care on an emergency basis, and I will be financially responsible for such care. Internet Usage: The Boys & Girls Clubs of Greater Gaston has computer labs for member use.. Use of the internet is a privilege, not a right of membership. There are internet sites that members are prohibited from using. A list of these sites is available in the computer lab and is updated on a weekly basis as necessary.

3 CODE OF CONDUCT 1. This is my home away from home, I will treat it with respect, and I will keep it clean. 2. I will respect my fellow club members. I will respect and obey the staff and volunteers. 4. Our game room and equipment will be used with respect 5. My conduct shows what kind of person I am. (a) I will not run in my club (running is only allowed in the gym). (b) I will not us profanity or have inappropriate conversations in my club. (c) I will not fight in my club. (d) I will not use Personal electronics in my Club. BGCGG is not responsible for lost or stolen items. (e) I will not hang in the hallways or stairways in my club. (f) I will not bully or cyberbully in my club. (g) I will only eat and drink in designated areas (h) I will wear proper clothing in my club. a. Girls: No halter or tube tops. Shirts must cover belly with arms raised. Spaghetti straps may only be work on K-4 grade girls. Shorts and skirts must be finger-tip length. If shorter, leggings must be worn. Bathing suits must be 1 piece. b. Boys: No sagging. Shorts and pants must be worn around waist. (i) I will not take part in, or allow horseplay in my club. Consequences: 1. Verbal Warning 2. Removal from activity (writing sentences) 3. Phone call home 4. Suspension 5. Expulsion Behaviors which may result in immediate dismissal include but are not limited to: 1. Any action that could threaten or pose a direct threat to the physical/emotional safety of the child, other children or staff 2. Fighting 3. Possession of weapon of any kind 4. Vandalism or destruction of Boys and Girls Clubs Of Greater Gaston Property or property of others 5. Sexual misconduct 6. Possession of or use of alcohol or tobacco products 7. Running away 8. Biting I have read, understand, and agree with the policies as stated in this document and have discussed the expectations of behavior with my child. Parent/Guardian Signature: Print Parent/Guardian Name Members Signature: Print Members Name

4 TRANSPORTATION WAIVER FORM I hereby request and give permission for the Boys & Girls Clubs of Greater Gaston to pick up my child, at (school) School and transport him/her to the Boys & Girls Clubs of Greater Gaston during their after school program. This form will also cover any fieldtrips the Club may take to transport my child. The undersigned hereby releases and discharges the Boys & Girls Clubs of Greater Gaston, its staff, volunteers, and any other transportation the Club uses, from any claims or liability, present or future In return for my child being transported daily to the Boys & Girls Clubs of Greater Gaston, I am aware that the following procedures must be adhered to: (1) My child is a member, in good standing, of the Boys & Girls Clubs of Greater Gaston (2) The Waiver Form has been signed and is on file at the Boys & Girls Club of Greater Gaston (3) That if there are less than 4 children riding in a month from that school, pick up may cease I understand that my child must obey and conduct him/herself in a safe and proper manner while being transported by the Boys & Girls Clubs of Greater Gaston. Failure to do so may/will automatically eliminate him/her from future pick up services by the Boys & Girls Clubs of Greater Gaston. PARENT SIGNATURE DATE

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