Member Registration Application
OFFICE USE ONLY Date Entered in Computer ___ /__ _/___ Data Staff Initials _________ KidTrax #__________ Date start if after 8/16/2018_____________ Weekly fee_______________ Registration fee paid_______
Boys & Girls Club of Brazoria County Member Registration Form 2018-2019 Please complete this application, initial and sign page 3. Paychecks for 1 month, child support, & other income sources must be turned for a reduction in payments or fee will be the full amount. Member (Child) Last Name
First Name
Middle Initial
Home Street Address
Home/Cell Phone #
-) State
City
Zip
TX Birth Date
/
Age
/
Gender (circle)
M
Grade
F
Social Security-Needed for grant purposes regardless of income. If you do NOT want to give the number it must be shown to a staff member for verification. Staff member: Initial box after verifying Social Security. Ethnicity (Choose one) Hispanic/Latino or Other
Race (Choose one or more, regardless of ethnicity)
American Indian/Alaska Native Asian Black/African American Native Hawaiian/Other Pacific Islander White Site-please select SFA, 7351 SFA Rd, Jones Creek 77541 Brannen, 802 That Way, Lake Jackson 77566 Fleming, 431 West 4th, Freeport 77541 Griffith, 101 Lexington, Clute 77531 Ney, 308 Winding Way, Lake Jackson 77566 Ogg, 208 Lazy Lane, Clute 77531 Polk, 600 Audubon Woods, Richwood 77531 Rancho Isabella, 100 Corral Loop, Angleton 77515 Roberts, 110 Cedar, Lake Jackson 77566 Southside, 1200 Park Lane, Angleton 77515 Sweeny Jr High, 800 Elm, Sweeny 77480 Westside, 1001 W Mulberry, Angleton 77515 Member receives: (check one)
Beutel, 101 Nasturtium, Lake Jackson 77566 Clute, 421 East Main, Clute 77531 Frontier, 5200 Airline, Angleton 77515 Lanier, 522 M Ave B, Freeport 77541 Northside, 1000 Ridgecrest, Angleton 77515 Passmore, 600 Kost, Alvin 77511 Rasco, 94 Lake Road, Lake Jackson 77566 Red Duke, 2900 County Rd 59, Manvel, 77578 Savanah Lakes, 5151 Savanah Pkwy, Rosharon, 77583 Sweeny, 709 Sycamore, Sweeny 77480 Velasco, 401 N Gulf Blvd, Freeport 77541
Free Lunch
Circle all programs your family receives:
AFDC
Reduced Price Lunch SSDI
SSI
Food Stamps
Annual HOUSEHOLD income including child support: (circle) Below $12,000 Gross income, child support & other assistance Number living in household? ____________ (including adults) $30,000-34,999
None
Child support
Other assistance
$12,000-19,999
$20,000-24,999
$25,000-29,999
$35,000-39,999
$40,000-44,999
$45,000 & over
Child Primary Language if other than English: Child lives with: (circle one)
Both parents
Single parent mother Single parent father
Foster care
Guardian Other_______
Is there any medical reason why my child shall not participate in certain physical activities? No Yes, please explain
List anything else (allergies, medications or special needs) that the staff should know about your child. IF NONE PLEASE CIRCLE
Dr.
Phone:
: N/A
Address:
**Parent or Guardian is responsible for notifying staff of any changes** List ALL children from your household attending any BGCBC Program: Member Last Name
First Name
Age
Grade
Member Name ________________________________________________ Parent/Guardian 1 Last Name
First Name
Cell Phone
Address if different from child. N/A if not. Place of Employment Educational Level (circle one)
Work Phone
Relationship
Occupation
No high school diploma
Parent/Guardian 2 Last Name
High School
GED
Some college/certification
First Name
Cell Phone
Bachelor
Master
Work Phone
Doctorate
Relationship
Address if different from child. N/A if not. Place of Employment Educational Level (circle one)
Occupation No high school diploma
High School
GED
Email 1
Some college/certification
Bachelor
Master
Doctorate
Email 2
In the event of an emergency, parent/guardians will be contacted first. List 2 other adults to be contacted if parents cannot be reached.
Emergency Contact-OTHER THAN PARENTS Phone
Address
ADULTS/FAMILY MEMBERS AUTHORIZED TO PICK-UP MEMBERS: To list additional adults authorized to pick up your child, use the boxes below. If no adults are listed below, ONLY THE PARENT / GUARDIAN WILL be able to pick up the student. Adult/family-other than parent
Phone
Relationship
Walking/Bike Riding Permission Leave blank if not applicable ____________________________________
_______________
___________________
Member Name (please print)
Grade
School Campus
I hereby give permission for my son/daughter to walk or bike ride from the BGCBC program. I understand that the BGCBC program is not responsible for my son/daughter after he/she leaves the premises.
Walking/Bike Destination (if different from home address): ___________________________ Day(s) member will walk/bike: Circle all that apply: M
T
W
Th
F
Everyday
___________________________
________________________________
_________
Parent’s Name (please print)
Parent Signature
Date
A designated time will be determined between the parents and site director, otherwise at 15 minutes before the site closes.
Parent / Guardian Permission/Releases For BGCBC Activities Please initial next to each statement _____ Photo Release: By signing this application I hereby grant permission for BGCBC to photograph my dependent child/ren for any legal purpose including fundraising, press releases or United Way materials. I do not expect, nor will I receive, any form of compensation for these photographs and furthermore waive any future rights to compensation for use of pictures of myself or my dependent child/ren. I also understand and agree that the photograph/s will remain the property of BGCBC and they shall retain all rights and privileges associated with ownership of these photographs. ______ Medical Treatment: I give permission to BGCBC to seek emergency medical treatment for my minor child if I cannot be reached. I will be responsible for any/all costs of medical attention and treatment. ______ School Information: I give my permission to BGCBC and AISD/AISD/BISD/SISD to exchange information regarding the minor child listed on this application including PEIMS and academic information. The purpose of the exchange is to help both organizations do a better job of helping the member be successful. This release is valid for one school year and may be revoked at any time by contacting BGCBC at 979-373-9668. ______ Surveys & Questionnaires: I, the parent/guardian of the minor child listed on this application, give my permission to BGCBC to survey my child about his or her Club experiences and behaviors, skills and attitudes using BGCA surveys or other survey instruments. ______ Technology: As a member of BGCBC your child may have access to the Internet. While precautions are being taken, it is possible that s/he may access inappropriate sites. BGCBC will have rules and consequences at the Club for such behavior; however, we will not be responsible for the consequences of such actions. ______ Miscellaneous: I understand BGCBC is not responsible for lost or stolen items. Parents and Club members are responsible for their own transportation to and from the Club. As a drop-in facility, we are not responsible for Club members’ whereabouts. ______ Outdoor playground equipment: Boys & Girls Club of Brazoria County will be using the public school and city parks’ outdoor playground equipment. By state law, they do not have to meet the licensing standards from the state that are required for licensed operations. If at any time, the staff at your child’s afterschool site finds any pieces of equipment unsafe or in disrepair; your child will not be allowed to play on the equipment until the equipment is repaired. The employees of the Boys & Girls Club of Brazoria County are aware of unsafe practices on the playground with children and take extra precautions to ensure your child’s safety. I understand that all necessary precautions are taken in regards to my child playing on outdoor playground equipment. ______ Acknowledgment: I have read the Parent Handbook, completed the application, understand the rules of all Boys & Girls Club of Brazoria County (BGCBC) programs and request my son/daughter be admitted into membership. I have explained the rules to my child and agree BGCBC will not be responsible for any accident to my child while on BGCBC premises or while engaged in any activities away from BGCBC. ______ Transportation: SISD members may be transported daily to and from Sweeny Elementary to their homes. ______ No refund: I understand that the registration fee and weekly fees are non-refundable. ______ Payments: For parent protection and the safety of staff no cash/check payments can be made on site. Weekly fees are paid on a bi-weekly basis and late fees will be invoiced. They may be paid online, via phoning the office or at the administrative office. ______ Withdrawal from the program: To officially withdraw from the program a parent MUST complete the withdrawal form found on the website, at the site or at the BGCBC office. Parents will continue to be invoiced and responsible for all payments until form is completed. There will be no refunds for withdrawing from the Club.
PLEASE TURN PAGE FOR PAYMENT INFORMATION AND PARENT SIGNATURE
*PLEASE READ CAREFULLY* Must be signed by Parent/Guardian for member participants 18 and under.
PAYMENT POLICY Payments are bi-weekly and due every other Friday beginning August 31st. Please refer to the Welcome PacketPayment Schedule, Parent Handbook or the website for payment due dates. If payment is not received by the Friday following the due date the child may NOT attend until payment is received or arrangements are made.
Example:
Payment is due September 14th for the following 2 weeks.
$10 late fee will be added per child, if payment is not received by midnight, Monday, September 17th.
Child CANNOT attend programming after Friday, September 21st If payment has not been received. Site Directors will be given a list on Monday, September 24th if your child CANNOT attend programming.
If you are unable to make payment, please call the office at 979-373-9668 to make arrangements.
Once the payment has been made, our office will notify the site director that payment has been received and your child(ren) will able to attend.
I hereby give permission for the participant listed in this application to take part in BGCBC activities, which may include off-site events, academic assistance, continuing education, and recreational programs. If a medical emergency arises, program staff will take all steps necessary to ensure the safety of the participant and will call, if necessary, a public emergency vehicle for transport to an emergency facility. I understand that I will be responsible for any transportation charges and medical expenses incurred. I further give my consent to the school district and BGCBC to share the participant’s member records with each other for purposes of providing educational support and assistance. In addition, I understand that school district and/or BGCBC will use participant records to evaluate individual progress and improvement, as well as to evaluate the impact of the program on member achievement and to obtain continued funding for the program. I understand that BGCBC is a non-profit organization and must rely on funding for operations to come from many sources including but not limited to parent weekly fees (paid on a monthly basis), grants, fundraising, etc. To sustain operation of this site adequate registration is required. If it becomes necessary to close this location a 2 week notice will be provided to parents to allow ample time to find other afterschool arrangements. I hereby certify that I have read and do understand the above information and all information on this application is true and accurate:
Print Name __________________________ Signature_________________________________ Date _______________________ Application may be scanned and emailed to [email protected]; faxed to 979-373-9667; or at the office-202 West 1St Street, Freeport.
STAFF USE ONLY-INCIDENT REPORT Please use the chart below, including late pick-up, accidents, phone calls, behavior issues, etc.
Date
Time
Incident
Staff signature
Parent signature if needed
Boys & Girls Club of Brazoria County Member Registration Form 2018-2019 Please complete this application, initial and sign page 3. Paychecks for 1 month, child support, & other income sources must be turned for a reduction in payments or fee will be the full amount. Member (Child) Last Name
First Name
Middle Initial
Home Street Address
Home/Cell Phone #
-) State
City
Zip
TX Birth Date
/
Age
/
Gender (circle)
M
Grade
F
Social Security-Needed for grant purposes regardless of income. If you do NOT want to give the number it must be shown to a staff member for verification. Staff member: Initial box after verifying Social Security. Ethnicity (Choose one) Hispanic/Latino or Other
Race (Choose one or more, regardless of ethnicity)
American Indian/Alaska Native Asian Black/African American Native Hawaiian/Other Pacific Islander White Site-please select SFA, 7351 SFA Rd, Jones Creek 77541 Brannen, 802 That Way, Lake Jackson 77566 Fleming, 431 West 4th, Freeport 77541 Griffith, 101 Lexington, Clute 77531 Ney, 308 Winding Way, Lake Jackson 77566 Ogg, 208 Lazy Lane, Clute 77531 Polk, 600 Audubon Woods, Richwood 77531 Rancho Isabella, 100 Corral Loop, Angleton 77515 Roberts, 110 Cedar, Lake Jackson 77566 Southside, 1200 Park Lane, Angleton 77515 Sweeny Jr High, 800 Elm, Sweeny 77480 Westside, 1001 W Mulberry, Angleton 77515 Member receives: (check one)
Beutel, 101 Nasturtium, Lake Jackson 77566 Clute, 421 East Main, Clute 77531 Frontier, 5200 Airline, Angleton 77515 Lanier, 522 M Ave B, Freeport 77541 Northside, 1000 Ridgecrest, Angleton 77515 Passmore, 600 Kost, Alvin 77511 Rasco, 94 Lake Road, Lake Jackson 77566 Red Duke, 2900 County Rd 59, Manvel, 77578 Savanah Lakes, 5151 Savanah Pkwy, Rosharon, 77583 Sweeny, 709 Sycamore, Sweeny 77480 Velasco, 401 N Gulf Blvd, Freeport 77541
Free Lunch
Circle all programs your family receives:
AFDC
Reduced Price Lunch SSDI
SSI
Food Stamps
Annual HOUSEHOLD income including child support: (circle) Below $12,000 Gross income, child support & other assistance Number living in household? ____________ (including adults) $30,000-34,999
None
Child support
Other assistance
$12,000-19,999
$20,000-24,999
$25,000-29,999
$35,000-39,999
$40,000-44,999
$45,000 & over
Child Primary Language if other than English: Child lives with: (circle one)
Both parents
Single parent mother Single parent father
Foster care
Guardian Other_______
Is there any medical reason why my child shall not participate in certain physical activities? No Yes, please explain
List anything else (allergies, medications or special needs) that the staff should know about your child. IF NONE PLEASE CIRCLE
Dr.
Phone:
: N/A
Address:
**Parent or Guardian is responsible for notifying staff of any changes** List ALL children from your household attending any BGCBC Program: Member Last Name
First Name
Age
Grade
Member Name ________________________________________________ Parent/Guardian 1 Last Name
First Name
Cell Phone
Address if different from child. N/A if not. Place of Employment Educational Level (circle one)
Work Phone
Relationship
Occupation
No high school diploma
Parent/Guardian 2 Last Name
High School
GED
Some college/certification
First Name
Cell Phone
Bachelor
Master
Work Phone
Doctorate
Relationship
Address if different from child. N/A if not. Place of Employment Educational Level (circle one)
Occupation No high school diploma
High School
GED
Email 1
Some college/certification
Bachelor
Master
Doctorate
Email 2
In the event of an emergency, parent/guardians will be contacted first. List 2 other adults to be contacted if parents cannot be reached.
Emergency Contact-OTHER THAN PARENTS Phone
Address
ADULTS/FAMILY MEMBERS AUTHORIZED TO PICK-UP MEMBERS: To list additional adults authorized to pick up your child, use the boxes below. If no adults are listed below, ONLY THE PARENT / GUARDIAN WILL be able to pick up the student. Adult/family-other than parent
Phone
Relationship
Walking/Bike Riding Permission Leave blank if not applicable ____________________________________
_______________
___________________
Member Name (please print)
Grade
School Campus
I hereby give permission for my son/daughter to walk or bike ride from the BGCBC program. I understand that the BGCBC program is not responsible for my son/daughter after he/she leaves the premises.
Walking/Bike Destination (if different from home address): ___________________________ Day(s) member will walk/bike: Circle all that apply: M
T
W
Th
F
Everyday
___________________________
________________________________
_________
Parent’s Name (please print)
Parent Signature
Date
A designated time will be determined between the parents and site director, otherwise at 15 minutes before the site closes.
Parent / Guardian Permission/Releases For BGCBC Activities Please initial next to each statement _____ Photo Release: By signing this application I hereby grant permission for BGCBC to photograph my dependent child/ren for any legal purpose including fundraising, press releases or United Way materials. I do not expect, nor will I receive, any form of compensation for these photographs and furthermore waive any future rights to compensation for use of pictures of myself or my dependent child/ren. I also understand and agree that the photograph/s will remain the property of BGCBC and they shall retain all rights and privileges associated with ownership of these photographs. ______ Medical Treatment: I give permission to BGCBC to seek emergency medical treatment for my minor child if I cannot be reached. I will be responsible for any/all costs of medical attention and treatment. ______ School Information: I give my permission to BGCBC and AISD/AISD/BISD/SISD to exchange information regarding the minor child listed on this application including PEIMS and academic information. The purpose of the exchange is to help both organizations do a better job of helping the member be successful. This release is valid for one school year and may be revoked at any time by contacting BGCBC at 979-373-9668. ______ Surveys & Questionnaires: I, the parent/guardian of the minor child listed on this application, give my permission to BGCBC to survey my child about his or her Club experiences and behaviors, skills and attitudes using BGCA surveys or other survey instruments. ______ Technology: As a member of BGCBC your child may have access to the Internet. While precautions are being taken, it is possible that s/he may access inappropriate sites. BGCBC will have rules and consequences at the Club for such behavior; however, we will not be responsible for the consequences of such actions. ______ Miscellaneous: I understand BGCBC is not responsible for lost or stolen items. Parents and Club members are responsible for their own transportation to and from the Club. As a drop-in facility, we are not responsible for Club members’ whereabouts. ______ Outdoor playground equipment: Boys & Girls Club of Brazoria County will be using the public school and city parks’ outdoor playground equipment. By state law, they do not have to meet the licensing standards from the state that are required for licensed operations. If at any time, the staff at your child’s afterschool site finds any pieces of equipment unsafe or in disrepair; your child will not be allowed to play on the equipment until the equipment is repaired. The employees of the Boys & Girls Club of Brazoria County are aware of unsafe practices on the playground with children and take extra precautions to ensure your child’s safety. I understand that all necessary precautions are taken in regards to my child playing on outdoor playground equipment. ______ Acknowledgment: I have read the Parent Handbook, completed the application, understand the rules of all Boys & Girls Club of Brazoria County (BGCBC) programs and request my son/daughter be admitted into membership. I have explained the rules to my child and agree BGCBC will not be responsible for any accident to my child while on BGCBC premises or while engaged in any activities away from BGCBC. ______ Transportation: SISD members may be transported daily to and from Sweeny Elementary to their homes. ______ No refund: I understand that the registration fee and weekly fees are non-refundable. ______ Payments: For parent protection and the safety of staff no cash/check payments can be made on site. Weekly fees are paid on a bi-weekly basis and late fees will be invoiced. They may be paid online, via phoning the office or at the administrative office. ______ Withdrawal from the program: To officially withdraw from the program a parent MUST complete the withdrawal form found on the website, at the site or at the BGCBC office. Parents will continue to be invoiced and responsible for all payments until form is completed. There will be no refunds for withdrawing from the Club.
PLEASE TURN PAGE FOR PAYMENT INFORMATION AND PARENT SIGNATURE
*PLEASE READ CAREFULLY* Must be signed by Parent/Guardian for member participants 18 and under.
PAYMENT POLICY Payments are bi-weekly and due every other Friday beginning August 31st. Please refer to the Welcome PacketPayment Schedule, Parent Handbook or the website for payment due dates. If payment is not received by the Friday following the due date the child may NOT attend until payment is received or arrangements are made.
Example:
Payment is due September 14th for the following 2 weeks.
$10 late fee will be added per child, if payment is not received by midnight, Monday, September 17th.
Child CANNOT attend programming after Friday, September 21st If payment has not been received. Site Directors will be given a list on Monday, September 24th if your child CANNOT attend programming.
If you are unable to make payment, please call the office at 979-373-9668 to make arrangements.
Once the payment has been made, our office will notify the site director that payment has been received and your child(ren) will able to attend.
I hereby give permission for the participant listed in this application to take part in BGCBC activities, which may include off-site events, academic assistance, continuing education, and recreational programs. If a medical emergency arises, program staff will take all steps necessary to ensure the safety of the participant and will call, if necessary, a public emergency vehicle for transport to an emergency facility. I understand that I will be responsible for any transportation charges and medical expenses incurred. I further give my consent to the school district and BGCBC to share the participant’s member records with each other for purposes of providing educational support and assistance. In addition, I understand that school district and/or BGCBC will use participant records to evaluate individual progress and improvement, as well as to evaluate the impact of the program on member achievement and to obtain continued funding for the program. I understand that BGCBC is a non-profit organization and must rely on funding for operations to come from many sources including but not limited to parent weekly fees (paid on a monthly basis), grants, fundraising, etc. To sustain operation of this site adequate registration is required. If it becomes necessary to close this location a 2 week notice will be provided to parents to allow ample time to find other afterschool arrangements. I hereby certify that I have read and do understand the above information and all information on this application is true and accurate:
Print Name __________________________ Signature_________________________________ Date _______________________ Application may be scanned and emailed to [email protected]; faxed to 979-373-9667; or at the office-202 West 1St Street, Freeport.
STAFF USE ONLY-INCIDENT REPORT Please use the chart below, including late pick-up, accidents, phone calls, behavior issues, etc.
Date
Time
Incident
Staff signature
Parent signature if needed
