Test membership application form

Which Club Location will your child be attending?*

Member Info

Members

Name	Gender	Race	Ethnicity	DOB	Address	School	Teacher	Grade	Does your child have any allergies that we need to be aware of?	Allergies:	Does your child have any other medical conditions that we need to be aware of?	Medical Conditions:	Does you child have allergies that require an Epipen?	Actions

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Contact Info

Primary Contact

Name*

First Last

Relationship to Child*

Parent/Guardian*

Address*

Street Address City ZIP Code

Email*

Cell Phone*

Home Phone

Work Phone

Employer*

Enter "N/A" if unemployed.

Secondary Contact

Name*

First Last

Relationship to Child*

Parent/Guardian*

Address*

Street Address City ZIP Code

Email*

Cell Phone*

Home Phone

Work Phone

Employer

Enter "N/A" if unemployed.

Emergency Contact

Name*

First Last

Relationship to Child*

Parent/Guardian*

Email*

Cell Phone*

Home Phone

Work Phone

Medical Info

Doctor name:*

If your child/children don't have a regular physician, enter "none."

Doctor phone:

Permission for treatment by doctor/hospital?*

Yes
No

Do you have health &/or accident insurance?*

Yes
No

Do you have Medicaid?

Yes
No

Medicaid Policy Number

Insurance Carrier

Insurance Carrier Phone Number

Insurance Policy Number

Insurance Group Number

Is your child/children a member of one of these CCO's?

CCO: Coordinated Care Organizer

Household Info

Member(s) live with:*

Single Parent Household?*

Number of members in household:*

Number of children under age 18:*

If none, enter "0"

Is a member of the household 65 years old or older?*

Is a parent or guardian a member of the military?*

Is another language other than English spoken in your home?*

No

If yes, enter preferred language above.

Annual combined household income:*

Disclaimer

The Boys & Girls Clubs of the Rogue Valley has an Open Door Policy, which means that members must sign themselves in and out of the Club, using their individual Membership cards or Club Member ID Numbers. Members are allowed to leave the Club property when they please. The Club assumes no responsibility for members who choose not to come on a particular day or who choose to leave early. Club supervision only occurs within our facilities. If you want your child to remain at the Club at all times, please instruct your child not to leave. If your child does choose to leave the Club, please instruct your child whom they can leave with. Arrangements should also be made for your child’s transportation to and from the Club. If your child is allowed to walk home, we request written authorization from a parent/guardian stating so.

We have implemented the Safe Passage Policy for Club Members under the age of 11

Members under the age of 11 must be retrieved from the Club by a parent, guardian or another authorized adult
Members age 11 and older may escort other members of their household from the Club with written permission
Members that leave unescorted without written permission will face disciplinary actions up to and including suspension and termination of membership.

It is important to note that the Club is not a licensed day care facility. Once a member signs out for the day he/she cannot sign back in that same day, without prior permission from the Program Director or Executive Director. The Club is not responsible for members once they sign out. Members are not allowed on the Club’s property unless they are participating in Club activities. Members should not be dropped off prior to the opening of the Club, as the Club cannot be held responsible for the supervision of youth during those times.

As a Parent and/or Guardian of the Club member, you agree that the Boys & Girls Clubs of the Rogue Valley and the Boys & Girls Clubs of America shall not be held responsible or liable in the event of harm or injury during Club Activities, and also includes the member’s welfare and/or whereabouts. It is understood with your Childs Membership that if you file a complaint against Boys & Girls Clubs of the Rogue Valley and/or Boys & Girls Clubs of America you will pay for the applicable legal expenses on behalf of the organization(s).

Terms and Conditions

Please initial each item below to accept the membership terms.

Membership Fees*

I understand that membership fees are non-refundable as these help cover basic registration and insurance costs. If it becomes necessary for us to cancel a program before it begins, if your child becomes sick or injured before a program begins, or if your family must leave Southern Oregon before a program begins, we may refund the membership fee. Initial above for approval.

Permissions*

I hereby give permission for my child to be photographed, videotaped, and/or interviewed for use by the Boys & Girls Clubs of the Rogue Valley (BGCRV) and Boys & Girls Clubs of America (BGCA) in productions, marketing, training, services, and similar purposes (BGCRV Website, BGCRV Flickr, BGCRV Newsletter, BGCRV Facebook). I understand that my child will receive no compensation or consideration for the release. Initial above for approval.

Education Records*

I hereby give permission for BGCRV to have access to my child's teachers, grades, and/or report cards in conjunction with programs related to education and case management. Initial above for approval.

Pick Up Arrangements*

I agree that if my son or daughter needs to be picked up due to illness, injury, or suspension, I will pick up my child or arrange to have him/her picked up within 1 (one) hour. Initial above for approval.

Personal Property*

I understand that the Club, it's employees and agents, shall not be responsible for any losses of personal property. Initial above for approval.

Program Evaluations*

I hereby grant consent for my child to participate in surveys, mentoring programs or other program evaluation mechanisms instituted by BGCRV or BGCA. I understand all results will be strictly confidential. Initial above for approval.

BGCRV Activities*

Member may participate in all BGCRV activities in or adjacent to the Club building, including and not limited to field trips, rock climbing walls, educational programs and transportation to and from activities and field trips. This Membership Application serves as a blanket permission slip for all programs, activities and field trips. I am aware of the inherent risks of Club activities and will ensure my child is fully prepared to participate. I release the Club from all liability and I will take full responsibility from any and all accidents and injuries which may be sustained by my child. If my child becomes ill or injured and I cannot be reached immediately, I give my release and permission for my child to be treated by a medical facility. Initial above for approval.

Parent Involvement*

I may be asked to join Boys & Girls Clubs Parent Committee and would like to have more information about it. Initial above for approval.

Policies

Please initial each item below to accept the membership terms.

Policies*

Boys & Girls Clubs of the Rogue Valley (BGCRV) has an OPEN DOOR POLICY. Members are allowed to leave the Club property when they please. The Club assumes no responsibility for members who choose not to come on a particular day or who chooses to leave early. Club supervision only occurs within our building. If you want your child to remain in the Club at all times, please instruct him/her not to leave. If your child chooses to leave the Club, please instruct your child whom they can leave with. Arrangements should also be made for your child's transportation to and from the club, unless s/he is allowed to walk. Initial above for approval.

Lice Policy*

Boys & Girls Clubs of the Rogue Valley does routine Lice Checks. I understand that my child will need to be picked up immediately if he/she has lice.

Bathroom Policy*

Boys & Girls Clubs of the Rogue Valley has a Bathroom Policy in place for the safety of all Club Members. I understand that if my child is caught in the bathroom without a pass, he/she will be suspended for a minimum of three days.

Liability Release*

As a parent and/or guardian of the applying member(s), I agree that the Boys & Girls Clubs of the Rogue Valley (BGCRV) and the Boys & Girls Clubs of America (BGCA) shall not be held responsible or liable in the event of harm or injury to the applying member(s). This also includes the applying member's welfare and/or whereabouts. If I file a complaint against BGCRV or BGCA, I agree to pay for the applicable legal expenses on behalf of BGCRV or BGCA. Initial above for approval.

Member Approval*

I hereby grant permission for my child(ren) to become a member of BGCRV. I certify that I am the child's parent and/or guardian and have full power, right, and authority to enter into this release on behalf of the child and understand all applicable terms, conditions, and provisions. Initial above for approval.

Mandatory Reporting Agency*

I understand that BGCRV is a mandatory reporting Agency. Initial above for approval.

Code Of Conduct

The mission of the Boys & Girls Clubs of the Rogue Valley is to provide a safe, positive and fun place for all kids helping them to build self-esteem and develop skills necessary to make right choices and become responsible and productive citizens. In order to provide such programs and activities for youth, we need the support of the Parents/Guardians and Club Members.

Parent Agreement

It is important for parents to understand that the Club and its activities are for the benefit of children and that parents are required to conduct themselves in a manner consistent with creating a positive experience. As a Parent/Guardian of a child participating in the programs, you are responsible for your behavior as well as the conduct of your child(ren), guests and other family members.

I will RESPECT the Club and the Club Staff

I will work with the staff to make the Club a positive and safe environment for all kids
I will discuss incidents involving my child(ren) with the Club Staff in a timely manner and work with them towards resolution
I will take responsibility for my child’s actions
I will not smoke on Club property
I will use appropriate language in Club facilities or Club activities
I will show good sportsmanship during all Club activities
I will pick up my child before the Club closes at 6:30 pm. If my child is under the age of 11, I will pick up my child by coming inside the Club to the membership desk and requesting my child. I will not request my child to be released for pick up in the parking area.

I have read and fully agree to abide by this Code of Conduct. I agree to discuss this information with my child and I understand that it is my responsibility to share this information with my spouse and other parents/guardians.

Parent/Guardian Signature*

Date*

Membership Fees

Total

Price: $0.00

Member Info

Contact Info

Primary Contact

Secondary Contact

Emergency Contact

Medical Info

Household Info

Disclaimer

Terms and Conditions

Policies

Code Of Conduct

Parent Agreement

Membership Fees

When school's out, the Clubs are in.

Member Info

Club Member Agreement