THE BOYS & GIRLS CLUB OF WASHINGTON COUNTY
Great Futures Start Here!
Application for ð After School 20____
ð Summer 20____
Our mission statement
The mission The Boys & Girls Club of Washington County is to enable all young people to reach their full potential as productive, caring and responsible citizens…to “Be Great”.
STAFF
Our full and part-time staff is composed of individuals who care about children. They are positive role models who are enthusiastic about their jobs with children, and who share their knowledge and professional experience with the children.
CLUB HOURS OF OPERATION SCHEDULE:
School Year Program: Monday-Friday, 3:00 p.m. to 6:00 p.m.
Summer Program: Monday-Friday, June 10, 2013 7:30 a.m. to 6:00 p.m.
The club will be closed a few days before the start of the summer program and the after school program for maintenance and staff training. Schedule will be announced as known.
Each year, you must renew the membership for your child(ren). Memberships are annual and expire after one year. Feel free to call and check the status of your application. Also, contact information needs to be current. Please update any changes of information. Please Note: New members are welcome at any time during either program. Just fill out an application and return.
CHECK IN:
When a child arrives at the club, they are required to sign in at the front desk. This is done by highlighting their name. Their attendance is maintained in order to keep a record of children who have entered the club.
PARENT SIGN OUT:
Parents/guardians are asked to pick their children up at the front of the Club. Every parent/guardian is required to sign their child out on the attendance sheet, which will be located at the front table. This ensures that we have a record of who has left the building and the time of their departure. A child may sign him/herself out to walk home at the end of the day, ONLY if his/her parent/guardian gives written permission on the “Walking Home Release” contained within this application.
GUEST PROCEDURE:
Children are allowed to bring a guest to the club. We have a form that needs filled out and signed by the parent/guardian of the guest before the child (guest) can enter the club facility. This form is available at the front desk, so please feel free to ask for one. Guests are required to follow the same policies as the regular members.
THE BOYS & GIRLS CLUB OF WASHINGTON COUNTY
MEDICATIONS:
The Boys & Girls Club will NOT be responsible for holding or dispensing any type of medications.
ILLNESSES:
If your child(ren) becomes ill while at the Club, the parent/guardian will be called. Depending on the seriousness of the illness, you may be asked to come and pick up your child. If it is not that serious, we may still call to let you know how your child is feeling. Any child with head lice will be brought to the front office and the parent/guardian will be called and asked to pick the child up immediately. If your child has a serious or chronic illness, such as asthma, diabetes, etc., please inform Sam Anderson, Executive Director.
Child(ren) Must Be Potty Trained to Attend the Boys & Girls Club
DISCIPLINE:
Please be sure to read and sign the attached copy of our discipline policy thoroughly. The rules of this policy are strictly enforced.
CLUB & ADMINISTRATIVE OFFICE CONTACT INFORMATION:
The Boys & Girls Club of Washington County
307 Lancaster Street, Suite 1
Marietta, OH 45750
Telephone #: (740) 373-4123
Fax # n/a
E-MAIL:
Sam Anderson, Director:
THINGS TO BRING:
· Educational Materials (Homework Assignments)
· Swim suit, towels, and sunscreen (Summer Program swim days)
· Money and/or Items requested for field trips
THINGS TO LEAVE AT HOME:
· Favorite toys or games
· CD players or tape player
· Beepers, cell phones, electronic game systems
· Large amounts of money, or valuable items
· Nail polish or make up
The Boys & Girls Club is NOT responsible for things that are lost or stolen, unless it is the unmistakable fault of one of our staff. We realize the children like to bring their toys, etc. to play with and to show to the other children, however, please make sure the things that you feel are valuable to them, emotionally or monetarily, stay at home.
MEMBERSHIP APPLICATION
The Boys & Girls Club of Washington County
307 Lancaster Street, Suite 1, Marietta, Oh 45750
CLUB MEMBER INFORMATIONFirst Name: / MI / Last Name:
Nickname: / DOB:
Gender (circle one): M F / Ethnicity:
Street Address:
City: / State: / Zip:
Home Phone #: / e-mail:
Cell: / Other contact #
General information
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: / Religion:
SCHOOL INFORMATION
Current Teacher:
School: / Grade: / Fee Level:
Enrollment in other groups
Boy Scouts or Girl Scouts: / School Club: / YMCA Sports / Church Group: / Other:
Reasons for joining other group: / Fun: / Learning: / Sports: / Other:
MEMBERSHIP APPLICATION
Page 2
Physical descriptionEye Color: / Hair Color: / Skin Color/Features:
Height: / Weight:
Medical information:
Doctor’s Name: / Doctor’s Phone #:
Date of Last Exam: / Permission for treatment by Doctor/Hospital: YES NO
Special Needs/Health Issues: YES NO / If yes, explain:
Medications: YES NO / If yes, explain:
Date Medical Information Received:
insurance information
Medicaid: YES NO / Does your family have health and/or accident insurance: YES NO
Insurance Carrier: / Policy # / Group #
Date health insurance information received:
NOT NEEDED IF ENROLLED IN OHIO OR WEST VIRGINIA SCHOOLS
shotsHepatitis / MMR / HIB / Polio / DTP / Chicken Pox
1st Shot
2nd Shot
3rd Shot
4th Shot
5th Shot
MEMBERSHIP APPLICATION
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Household information sheetNOTE: This information is collected for Grant writing purposes ONLY
Member lives with: / Mom / Step Mom / Dad / Step Dad / Grandparent / Other
Housing Development YES NO / If yes, what is the name:
Annual Income Level:
$0 – 5,000 / $30,001 - $35,000 / $60,001 - $65,000
$5,001 - $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, 0000 / $85,001 - $90,000+
Number in household:
(circle the best answer)
Is there a member of the household who is 65 years or older: / YES NO
Is there a member of the household who is disabled: / YES NO
Current single parent: / YES NO
Current head of the household is: / MALE FEMALE
MEMBERSHIP APPLICATION
Page 4
DISCLAIMERThe Boys & Girls Club of Washington County, its employees, and representatives exercise policies and procedures in an effort to maintain a reasonably safe, and protected environment for Club Members. If a Club Member is harmed or injured as a result of said Member disregarding Club policy, or as a result of another Member disregarding policy, the parent/guardian of the injured Member agrees not to hold The Boys & Girls Club of Washington County liable in any form.
The Boys & Girls Club of Washington County is not responsible for the welfare or whereabouts of Club Members before they arrive at the Club (307 Lancaster Street, Suite 1, Marietta, OH 45750), or after Members have signed out of The Club.
Parent/Guardian Signature
Club Member Signature
FOR OFFICE USE ONLY / Membership #
Entry Date: / Expiration Date: / Status:
Type: / New/Renewal Member: / Processed by:
Washington County’s POSITIVE Place for Kids
THE BOYS & GIRLS CLUB OF WASHINGTON COUNTY
COMPUTER POLICY
The Boys & Girls Club of Washington County (BGCWC) computer network/internet access is available to members to enhance their educational experience and enable members to become literate in an increasingly technological world. The BGCWC network has been established for educational purposes limited to classroom activities, career development, and independent scholastic research on appropriate subjects.
The purpose of these guidelines is to foster the appropriate use of that network and the internet. The following guidelines apply to All users whenever they access the BGCWC network connection.
YOUR RIGHTS
· BGCWC’s network is considered a limited forum, similar to a school newspaper and therefore the Club reserves the right to regulate that forum for valid educational reasons.
· The network may be treated like school lockers. Administrators and staff may review files and communications to maintain system integrity and insure that members are using the system responsibly. Users should not expect that files will be private.
UNACCEPTABLE USES
Personal Safety
· You WILL NOT post personal contact information about yourself or other people on the BGCWC network. Personal contact information includes, but is not limited to: home, school, or work addresses and/or telephone numbers.
· You WILL NOT meet with someone, whom you have met online while on the BGCWC network. You WILL NOT arrange, or agree to meet with anyone whom you have met online.
· You WILL immediately tell the Program Director or any other staff member or adult volunteer about any message that you receive over the network that is inappropriate or that makes you feel uncomfortable.
Illegal Activities
· You will not use the BGCWC network for commercial purposes, unless you are a staff member, given specific permission to do so. This means you may not offer, provide, or purchase products or services through this network.
· You will not use the BGCWC network for political lobbying, but you may use the system to communicate with elected representatives and to express your opinion on political issues.
· You will not use the BGCWC network to engage in any illegal act, including but not limited to arranging for the purchase or sale of drugs or alcohol, engaging in criminal activity, or threatening the safety of another person.
COMPUTER POLICY – 2
System Security
· You are responsible for your individual user account and should take all reasonable precautions to prevent others from being able to use your account. Under no conditions should you provide your password to another person.
· You will not attempt to gain unauthorized access to the BGCWC network or to any other computer system through the BGCWC network. This includes attempting to log on through another person’s account or accessing another person’s files. These actions are illegal, even if only for the purposes of “browsing.”
· You will immediately notify a staff member or volunteer if you have identified or witnessed a possible security problem. Do not go looking for security problems, because this may be construed as an illegal attempt to gain access.
· You will not make deliberate attempts to disrupt the computer system or destroy data by spreading computer viruses.
Inappropriate Language
· Restrictions against inappropriate language apply to public messages, private messages, and material posted on Web pages.
· You will not use obscene, profane, lewd, vulgar, rude, inflammatory, threatening, or disrespectful forms of communication. This applies to verbal and written language, diagrams, photographs, representations, videos or any other form of communication.
· You will not post information that could cause damage or a danger of disruption.
· You will not engage in personal attacks, including prejudicial or discriminatory attacks.
· You will not harass another person. Harassment is persistently acting in a manner that distresses or annoys another person. If you are told by a person to stop sending him or her messages, you must stop.
· You will not knowingly post false or defamatory information about a person or organization.
Respect for Privacy
· You will not re-post a message that was sent to you privately without permission from the person who sent you the message.
· You will not post private information about another person.
COMPUTER POLICY – 3
Plagiarism and Copyright Infringement
· You will not take someone else’s work and claim it for your own. Plagiarism is taking the ideas or writings of others and presenting them as if they were your own.
· You will respect the rights of copyright owners. Copyright infringement occurs when you reproduce a work that is protected by a copyright without authorization. If a work contains language that specifies appropriate use of that work, you should follow the expressed requirements. Copyright law can be very confusing. If you have any question, you should as a staff member.
Access to Inappropriate Material
· You will not use the BGCWC network to access material that is profane or obscene (pornographic), that advocates illegal acts, or that advocates violence or discrimination toward other people (hate literature).
· If you mistakenly access inappropriate information, you should immediately tell the program director or a staff member. This will protect you against a claim that you have intentionally violated this policy.
DISCIPLINARY ACTION
Members, who violate guidelines listed in this computer policy, may be denied future internet and/or network privileges for a defined period of time. Members may also be subject to other disciplinary procedures as set forth by the Program director and Staff Members.
RELEASE SIGNATURE
As a parent, staff member, or guardian, I have read the Boys & Girls Club of Washington County’s computer policy. I understand that access to BGCWC’s network and internet are designed for educational purposes and that BGCWC has taken available precautions to educate members on appropriate educational materials; however, it is understood that no matter how much supervision and monitoring that BGCWC offers, there will always be the possibility of my child coming into contact with inappropriate material, and I will not hold The Boys & Girls Club of Washington County responsible for materials acquired on the network.