Teen Membership Application Checklist

TEEN MEMBERSHIP APPLICATION CHECKLIST

(All information must be submitted with your application; INCOMPLETE applications will not be accepted!) Child must be between 6-18 years of age.

Child’s Name: ______Age: ______

Site: ______Grade:_____

____ Completed Membership Application (ALL lines on application must be filled out!)

____ Signed Membership Orientation (Handbook)

____ Immunization Records

____ Physical Form

____ Birth Certificate

____ 2 emergency contacts other than the parents

____ Registration Fee $25

____ Fee = $2/day; $5 Fridays

____ Free or reduced lunch status letter from school.

Staff person completing application: ______Date: ______

Boys & Girls Clubs of Waynesboro, Staunton & Augusta County

2016-2017 Membership Application

Please fill out COMPLETELY!

Unit Name: ______

First Name: ______Middle: ______Last: ______

Nickname: ______

Gender: ___M ___F Ethnicity: ______DOB: ______Age: ______

Address: ______City: ______State: ______Zip: ______Phone: ______Fax: ______

School Information:

Current Teacher: ______

School: ______Grade: _____ Lunch: Free Reduced Non-Needy

Medical Information:

Doctor Name: ______Doctor Phone: ______

Date of Last Medical Exam: ______*PLEASE PROVIDE A COPY OF CHILD’S IMMUNIZATION RECORD AND PHYSICAL EXAM

Permission for Treatment by Doctor/Hospital: ____Yes ____No Medicaid: ____Yes ____No

Does your family have health and/or accident insurance: ____Yes ____No

Insurance Carrier: ______Insurance Phone: ______

Policy #: ______Group#: ______

Date Health Info Received: ______

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

Medications: ___Yes ___No If Yes, explain: ______

Date Medical Info Received: ______

PARENTAL INFORMATION (Mother/ Step-Mother)

Name: ______
Person Authorized to Pickup Member: Y or N
Occupation: ______
Address H: ______
Employer: ______
Address W: ______
Phone: ______Type: ______
Phone: ______Type: ______
Phone: ______Type: ______
Email: ______/

PARENTAL INFORMATION (Father/Step-Father)

Name: ______
Person Authorized to Pickup Member: Y or N
Occupation: ______
Address H: ______
Employer: ______
Address W: ______
Phone: ______Type: ______
Phone: ______Type: ______
Phone: ______Type: ______
Email: ______

EMERGENCY CONTACT

Relationship to Member: ______
Person Authorized to Pickup Member: Y or N
Name: ______
Occupation: ______
Address H: ______
Employer: ______
Address W: ______
Phone: ______Type: ______
Phone: ______Type: ______
Phone: ______Type: ______
Email: ______/

EMERGENCY CONTACT

Relationship to Member: ______
Person Authorized to Pickup Member: Y or N
Name: ______
Occupation: ______
Address H: ______
Employer: ______
Address W: ______
Phone: ______Type: ______
Phone: ______Type: ______
Phone: ______Type: ______
Email: ______

General:

Birth Certificate on File: ____Yes ____No Birth City: ______Birth State/Country: ______

Member/Contacts Understood Signed Insurance Disclaimer and Permission Statement: ____Yes ____No

Member has permission to be used in public relations materials: ____Yes ____No

Member may participate in all Club activities in or adjacent to the club building: ____Yes ____No

Club Member Since: ______

Household:

NOTE: This information is important for the Club to help with grant funding. These funds help offset operating costs and keep overall costs as low as possible.

Member lives with: ____Mom ____Step Mom ____Dad ____Step Dad ____Grandparent

____Foster parent(s) ____Other: ______

Annual Household
Income
Level: / $0 - $5000 _____ / $30,001 - $35,000 _____ / $60,001 - $65,000 _____
$5001 - $10,000 _____ / $35,001 - $40,000 _____ / $65,001 - $70,000 _____
$10,001 - $15,000 _____ / $40,001 - $45,000 _____ / $70,001 - $75,000 _____
$15,001 - $20,000 _____ / $45,001 - $50,000 _____ / $75,001 - $80,000 _____
$20,001 - $25,000 _____ / $50,001 - $55,000 _____ / $80,001 - $85,000 _____
$25,001 - $30,000 _____ / $55,001 - $60,000 _____ / $85,001 - $90,000+ _____

Number in Household (to include member): ______

Number under 18 years old: ______

Is there a Member of the Household 65 years old or Older: ____Yes ____No

Is there a Member of the Household Handicapped: ____Yes ____No

Current Head of Household: ____Female ____Male ____Both

Current Single Parent: ____Yes ____No

Person(s) Authorized to Pick-up Member

Physical:

Eye Color: ______Hair Color: ______Skin Color/Features: ______

Height: ______Weight: ______

Do this child belong to other groups:

___ Boys Scouts or Girl Scouts ___ School Club ___ YMCA or YWCA ___ Church Group

___ Other: ______Previous School/Daycare Center

Reason(s) for joining: ____ Fun ____ Learning ____ Sports ____ Other: ______

PLEASE READ THE FOLLOWING REGUALTIONS WITH YOUR CHILD. YOUR SIGNATURE ON THE APPLICATION FORM INDICATES THAT BOTH YOU AND YOUR CHILD HAVE RECEIVEDA COPY OF THE PARENT/GUARDIAN(S) MANUAL, THE DISCIPLINE POLICIES AND CLUB PROPERTY REGULATIONS.

CLUB PROPERTY REGULATIONS

Please be aware that all grounds and all programs at Club locations and offsite activities are governed by Boys & Girls club policies. All staff, volunteers, youth and adults who come to the Club must follow the policies set by the Boys & Girls Club of Waynesboro, Staunton, & Augusta County. Please read them carefully and discuss them with your child or children. Smoking and possession of tobacco products on the premises is strictly prohibited. Violation of this policy will result in confiscation of the tobacco product and a 10-day suspension. No alcohol, drugs, drug paraphernalia, or weapons are allowed on the premises. Violation of this policy includes confiscation of item(s)/ charges pressed with Waynesboro or Staunton Police Departments, and a minimum of 30-day suspension.

1. I/we agree to comply with all published rules and regulations regarding the Club.
2. I/we agree to provide appropriate and acceptable medical information for my child and I am responsible for updating current contact information with the Club.
3. I/we agree to have my child picked up as soon as possible in the event of injury or sudden illness.
4. I/we agree to pay for any damages caused by my child to the building/ equipment used or owned by the Boys & Girls Club other than those clearly the result of an unavoidable accident.
5. I understand and agree that it is my responsibility to arrange for transportation of my child to the Club and that the Boys & Girls Club is not responsible for my child until he or she arrives at the Club.
6. I/we agree that my child may be transported on vehicles owned or rented by the Boys & Girls Club of Waynesboro, Staunton, & Augusta County and driven by Club staff and volunteers.
7. I/we agree that my child may accompany Boys & Girls Club staff and/or volunteers on short, local field trips either by walking or by vehicle without formal notification.
8. I give permission for the Boys & Girls Club to obtain pertinent information from/to schools, social service agencies, mental health providers and other related agencies concerning my child. I understand that this information will be used with discretion and as an aid in determining appropriate programs for my child and whether other service referrals are indicated.
9. I further grant permission for the information provided by myself, my child, the child’s family and other agencies to be shared with discretion to volunteers working with my child. I understand that volunteers are asked to hold this information in confidence.
10. If I do not pick-up my child by closing time, I agree to pay applicable fees ($1 per minute).
11. I/we agree to voluntarily withdraw my child from the Club if there are persistent disciplines ore other problems that cannot be resolved through reasonable efforts of the staff. I understand that the Boys & Girls Club’s staff reserves the right to ask for the immediate withdrawal of any member.
12. I/we authorize the Boys & Girls Club’s representatives to obtain immediate medical care and consents to the hospitalization of, the performance of necessary diagnostic test upon, the use of surgery on, and or the administration of drugs to, my child or ward if an emergency occurs when I or the listed emergency contact(s) can not be located. It is also understood that this agreement covers only those situations which are true emergencies and only when I no those emergency contact(s) listed cannot be reached. Otherwise, I expect to be notified immediately.

Please Initial

A) I/we will be responsible for payment of medical care expenses.

B) Medical treatments cost are covered by:

1) Private Insurance

2) Medicaid Insurance

3) Other:

4) No insurance

I promise to take care of my Club and its property. I understand the Club is not responsible for personal loss of property. If at any time I am asked to return my card, I understand no dues will be returned to me.

Member’s Signature: ______Date______

I hereby allow my child to join the Boys & Girls Club of Waynesboro, Staunton, & Augusta County and participate in its various activities including field trips. The Boys & Girls Club of Waynesboro, Staunton, & Augusta County and its property are not responsible for personal injury or loss of property. I hereby waive all rights to any future legal action(s) should one occur. I understand that my child will be governed by certain rules and regulations as part of the membership and that membership may be revoked at any time, without refund.

Parent’s Signature: ______Date______

FOR OFFICE USE ONLY Membership #: ______

Entry Date: ______Expiration Date: ______Status: ______

Type: ______New/Renewal Member: ______Processed by: ______

Waynesboro Public Schools

RELEASE OF INFORMATION FORM

Student Name: (please print) ______Date of Birth: ______

School Student currently attends: ______

If you have more than one child, please use the spaces provided below:

Student Name: (please print) ______Date of Birth: ______

School Student currently attends: ______

Student Name: (please print) ______Date of Birth: ______

School Student currently attends: ______