1126 Southland Lane, Brookings SD 57006

Tel 605-692-3333 Fax 605-692-9199

1st – 5th GRADEMEMBERSHIP APPLICATION

OFFICE USE ONLY

Membership #: ______Entry Date: ______Payment Type: ______

New/Renewal: ______Expiration Date: ______Receipt #: ______

Card Printed: ______Processed by: ______SDS ______

Orientation Date: ______Picture taken: ______

Youth Name:

First: ______Last: ______

Member’s Sibling(s):

NameAgeFull/Half/StepNameAgeFull/Half/Step

______

______

Please Mark the Appropriate Line regarding Annual Household Income (this is for grant purposes only)

____ 0-$37,700 ____ $37,701-$43,100 ____ $43,101-$48,500 ____$48,501-$53,850 ____$53,851-$58,200

____ $58,201-$62,500 ____$62,501-$66,800____$66,801-$71,000+

Parent/Guardian Information: Both parents/guardians information needs to be filled in below:

Parent/Guardian: ______

Address: ______Gender: ___M ___F

City: ______State: ______Zip: ______

Home Phone: ______Cell Phone: ______Work Phone: ______

Email: ______

Place of Employment: ______

Parent/Guardian:______

Home Phone: ______Cell Phone: ______Work Phone: ______

Email: ______

Place of Employment: ______

□Check this box if home address is same as above

□If single parent, please check this box

Address: ______Gender: ___M ___F

City: ______State: ______Zip: ______

Youth Information:

First Name: ______Middle: ______Last: ______

Date of Birth: ______

Gender: ___M ___F Ethnicity:African AmericanAsian Hispanic Multi-Racial

Number in Household: ______Native American: ______(Tribe)  Caucasian Native Hawaiian/Pacific Islander

School: ______Grade: ______School Year: ______

(2016-2017)

Academic information:

School:______Grade:______School Year:______(2016-2017)

Teacher______Is your child on IEP:______Yes ______No

Does your child have an academic need that you would like the Club to assist with, if so, please explain: ______

Medical Information:

Does your child have any medical conditions?(ADHD, Autism, Asthma, Allergies, etc) ___Yes ___No

If Yes, please explain: ______

Serious Health Problems: ___Yes ___No If Yes, explain: ______

______

Medications: ___Yes ___No If Yes, please explain: ______

ADDITONAL EMERGENCY CONTACTS in addition to Parents/Guardians

*MUST HAVE AT LEAST 2 CONTACTS*


Please check one item from each group below:

Single Parent: ____ Yes ____ No

Is the member a child of Military personnel and not living on a base? ____ Yes ____ No

If your child is between the ages of 14-18, has he/she had a part-time or seasonal work since the beginning of the year?
____ Yes ____ No

Are you willing to volunteer at the Club? ____ Yes ____ No

Qualify for Free Lunch: ____ Yes ____ NoQualify for Reduced Lunch: ____ Yes ____ No

Permission Information

  1. I give my permission to the Boys & Girls Club of Brookings and Brookings Community Schools to exchange information regarding the minor child listed on this application. The purpose of the exchange is to help both organizations do a better job of helping the student be successful in school, in the Boys & Girls Club and in life. This release is valid for one year and may be revoked at any time by contacting Brookings Community Schools or the Club in writing.

____ Yes ____ No______

Parent Signature

  1. I give permission for my child’s picture, moving pictures, or any other graphic depiction or likeness, to be used by the Boys & Girls Club and its activities.

____ Yes ____ No______Initials

RELEASE FORM

I, the parent/guardian of the minor child listed on this application, for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever discharge the Boys & Girls Club of Brookings Cooperation, and Boys & Girls Clubs of America, their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organizations such as staff, directors or volunteers, from all liability, claims, demands, or causes of action for any and all loss, damage, injury or death and any claim of damages resulting from use of facilities owned or controlled by the above organizations, or participation in activities of said organizations either at or away from the Club.

Medical Treatment

I give permission to the Boys & Girls Club of Brookings to seek emergency medical treatment for my minor child if I cannot be reached. I understand that Club employees cannot transport children to the hospital and that if a life threatening situation occurs, the AMBULANCE will be contacted first and then the PARENTS. I will be responsible for any/all costs of medical attention and treatment.

Surveys and Questionnaires

I, the parent/guardian of the minor child listed on this application, give permission for Boys & Girls Club of Brookingsto survey my child about his or her Club experience and behaviors, skills and attitudes using Boys & Girls Clubs of America’s Youth Development Outcome Measurement Tool Kit surveys or other survey instruments.

Restraining

I understand that when a youth is in a dangerous situation to themselves or others they will be removed from the situation.

Rec Program

I understand that the Boys & Girls Club is classified as a recreation program and not a licensed afterschool program. As a recreation program, the Boys & Girls Club does not maintain specific ratios within the program spaces. I also understand that the Boys & Girls Club cannot legally keep my child from leaving the Club. However, by having my child and myself sign below, I am entering into a contract with my child that states he/she will stay checked into the Club until a parent/guardian or other authorized adult picks them up. The Club will enforce this contract.

Miscellaneous

I understand that the Boys & Girls Club is not responsible for lost or stolen items. Any items placed in the lost and found will be discarded on the 15th of every month.

Late Fees

I understand that my child/children must be picked up by closing time each day. I understand that I will be charged $10.00 per child for every 15 minutes that my child/children remains at the club after closing time. Time is rounded up to next 15 minutes. For example:

1-14 minutes that child/children remain at the club after closing time = $10.00 per child

15-29 minutes that child/children remain at that club after closing time = $20.00 per child, etc

I have read the completed application and this form, understand the rules of the Boys & Girls Club and request that my child be admitted into membership.

I hereby give my permission for my child to become a member for the Boys & Girls Club of Brookings. I understand that the Club is Not Responsible for the time or manner in which he/she may arrive at or leave the Club, and that the Boys & Girls Club of Brookings and its property are not responsible for personal injury or loss of property.

Parent Signature: ______

Youth Signature: ______

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