Version 2

Summer 2017 Membership Application

Member (Child) Information:

First Name: ________________Middle:______________Last:_____________________

Nickname:_____________________ DOB:______________ Age:____________

Gender: Male ______ Female ______ Race/Ethnicity__________________

Address:________________________________________________________________

City:_____________________State:_________________________Zip______________

General member description:

Eye color:__________________Height:_______________Weight:___________

Shirt size:_____________________Pants size:_____________Shoe size:___________

Any distinguishing markings:_____________________________________________

Why did you select the Boys & Girls Club?

______________________________________________________________________

How did you hear about the Club? DHS/DCS____ Family/Friend____ Facebook____

School_____ Juvenile Court System_____ Website_____ Newspaper/Media_____

Other________________________________

Parent/Legal Guardian:

Name: ________________________________________________________________

Address: ______________________City:________________State:______Zip:________

Home Phone: ______________Work Phone:________________Cell:________________

Relationship to Child:________________________Email: ________________________

Employer: __________________________________Occupation:__________________

The above information is complete: Staff Initials___________

2

Medical Information:

Primary Physician: ___________________________Office Telephone: (___)_________

Permission for treatment by doctor? ________Yes _______No

Medical Insurance information:

Do you have Medical Insurance? Yes______ No________

Medicaid____ TNCare___ TNKids___ Other health or accident insurance? _________

Insurance Carrier: _______________________________________________________

Policy #_______________________Group #_____________________________

Are all required shots up to date and on file at the child’s school? _____Yes _____No

Any operations, serious injuries, or chronic illness? _____Yes _____No

If yes, please specify:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Please list any/all known allergies: _____________________________________

_________________________________________________________________

List allergy medications used: _______________________________________________

Does your child require an EpiPen or inhaler?____Yes____No If yes, you agree to provide one to the Club to keep on premises at all times, in case your child

needs it.

If your child has any known physical, mental, or social difficulties or other information

which may affect participation and/or for which special accommodations are needed,

please attach a Physician’s statement which identifies the condition and gives the

Physician’s special instructions for your child’s care.

List all daily medications: ____________________________________________

List any medications that member must be given while at the Club and dosage

instructions (when to be administered, how much, with/without food, etc.):

_____________________________________________________________________

Can your child swim? Check one: _____Yes ______No ______Unknown All children will be required to pass a swim test for Club staff before being allowed to swim on

Club field trips.

The above information is complete: Staff Initials___________

3

Household information

Number of Adults in Household:_______________

Number of Youth in Household, including member: __________

Household Size (total the above two numbers):____________

Who lives with member? Check all that apply. ____Mom ____Dad ____Step Mom

____Step Dad _____ Grandparent _____Foster Parent _____Legal Guardian _____Other

Is there a household member over the age of 65? ____yes _____ no

Is there a household member that is disabled or handicapped? _____yes ____no

Are you currently participating in any federal or state government programs? Please

check all that apply:

_____TANF _____SSI _____Food Stamps _____Free/Reduced Lunch

_____Families First ____Transitional Child Care

If yes, recertification date? ______________

TANF#__________________

How many adults in the household are currently employed? ________

Unemployed/Laid Off? _______________

In School?__________________

Earner #1’s Occupation: ___________________

Place of Employment:_____________________

Earner #2’s Occupation: ____________________

Place of Employment:______________________

Earner #3’s Occupation:_____________________

Place of Employment:_______________________

Annual Total Household Income Level: (This information is required for grants and other funding sources and scholarship purposes.)

$0-$5,000_____ $20,001 - $25,000_____ $40,001. - $45,000______

$5,001 - $10,000_____ $25,001 - $30,000_____ $45,001 - $50,000 ______

$10,001 - $15,000_____ $30,001 - $35,000_____ $50,001 - $55,000______

$15,001 - $20,000_____ $35,001 - $40,000_____ $55,001 - $60,000______

$60,001- 70,000_______

$70,001 and up ________

Member’s School Information:

School attending for 2017-2018:__________________ Grade level for 2017-2018:_____

Summer Program Hours Required: 7:30am-5pm (Regular)_____ OR

6am-6pm (Extended)_____

The above information is complete: Staff Initials___________

4

Disclaimers: I acknowledge that my and child’s named above participation in the activities, functions, sponsored events and other programs associated with Boys & Girls Clubs of Maury County, (the “Activity”) may require me and child named above to perform physical exercise or other physical Activity that have the potential for bodily injury, death, or property loss. With an understanding of the Activities I have volunteered for and for the Activity the child named above participates in, I HEREBY ASSUME FOR MYSELF AND THE CHILD NAMED ABOVE ALL RISKS RELATED TO OUR PARTICIPATION AS A VOLUNTEER AND PARTICIPANT IN ANY ACTIVITY IN WHICH WE PARTICIPATE. _______ (parent/guardian initials) I agree to the rules set forth by the Club for the safety of the children in attendance. I also agree to allow my child to participate in scheduled activities and to be transported to and from the Club facility to locations indicated by the Club as field trips (prior notification of field trips will be provided). _______ (parent/guardian initials) While at the Club, I understand that proper attire for my child, suitable for the public and for organized activities at the Club, is required. _______ (parent/guardian initials) I authorize the Club to administer first aid that may include sunscreen, antibiotic Neosporin based ointment, bee sting ointment (or the generic of each) in case of injury, and/or seek emergency medical attention as deemed necessary including transporting my child to a medical facility until I and/or another guardian is contacted and available. I understand that Boys & Girls Clubs of Maury County has a secondary accident policy for accident and or injury. However, in the case of an accident, I understand that the parent and/or guardian is the primary responsible party. _______ (parent/guardian initials) I understand that the cost for the 2017 Summer Program is $75 per child per week for care during the regular hours of 7:30am-5pm, or $95 per child per week for care during the extended hours of 6am-6pm. I understand that the cost of enrollment for the 2017 Summer program also includes a one-time registration fee of $30, which will be added to the aforementioned fees, depending on which program hours I select (Regular or Extended). I understand that financial assistance is available upon request, and that, if I am requesting financial assistance, I will need to provide proof of income for review in an appointment with Club staff. I agree to pay the above stated fees each week unless or until approved in writing for financial assistance. I understand that missing payments can result in a late fee charge and ultimately dismissal from the program if the problem continues. _______ (parent/guardian initials) I have read and understand the above disclaimers and agree, as parent and/or guardian, to comply with the policies of the Boys & Girls Clubs of Maury County.

Parent/Guardian Signature_______________________________ Date_____/______/_____

The above information is complete: Staff Initials___________

5

Dispensing Medication Permission and Release

Your signature below authorizes Boys & Girls Clubs of Maury County to administer any and all medication required during the hours your child is at the Club. You also agree to bring medication in the proper prescription bottle with proper dose on label. Instructions must be indicated in writing by a parent or physician, and staff must be physically shown the proper procedure to dispense the medication. Although you as a parent have shown a staff member how to dispense the medication, your signature states that you understand that the staff member required to dispense this medication is not licensed in the medical field and is only required to follow the written and demonstrated instructions. In the event the medication changes or directions change, new written instructions and a physical demonstration of administration procedures must be provided. I also understand that the staff at Boys & Girls Clubs of Maury County may only dispense the medications according to the instructions provided. Therefore, if the medication dosage or instructions change, I acknowledge that it is my responsibility to immediately notify Boys & Girls Clubs of Maury County of any medication changes. I hereby indemnify and release Boys & Girls Clubs of Maury County of any liability relating to the dispensing of medication.

_________________________________________ _______________________________ Print Name of Parent Parent’s Signature

_________________________________________ Date

Parent/Guardian initials indicating staff have been shown how to dispense medication___

Staff Initials____

6

Member Confidentiality Agreement and Release of Information

Boys & Girls Clubs of Maury County will maintain all member files in a confidential manner.

Pertinent information may be shared professionally with a Boys & Girls Club staff member, a

Tennessee Department of Human Services Case Manager (if legal investigation has been

initiated), or the Maury County Public School System. Files for all programs funded in whole or in

part by the Tennessee Department of Education are available for monitoring and subject to audit

by the Tennessee Department of Education. Communication of individual member information

to persons or agencies other than those listed above will require express written approval from

the member’s parent or legal guardian.

I agree to the release of information to persons or agencies as listed above. I understand that any

release of information to persons or agencies other than those mentioned above will require my

written approval.

_________________________________________ _______________________________ Print Name of Parent Parent’s Signature

_________________________________________ Date

7

Authorization for Marketing and Public Relations Purposes

I, the undersigned, hereby authorize the taking of photographs, videotape or audiotape,

and/or the taking of other testimonial information from me or a minor for whom I am a

guardian, for marketing and public relations purposes by Boys & Girls Clubs of Maury

County, or for use by the news media. I understand and agree that I am not entitled to any

compensation or other benefit, now or at any time in the future, for the use of such

photograph/videotape/audiotape and/or testimonial information by Boys & Girls Clubs of

Maury County.

Based on the foregoing, I do hereby release Boys & Girls Clubs of Maury County, its Board

of Directors, employees, agents, and any other representatives, from any and all liability

related to, or arising from, the use of such photograph/videotape/audiotape and/or

testimonial information described above by Boys & Girls Clubs of Maury County at any

time.

By signing, I acknowledge that I have read the foregoing and have had all my questions

answered to my complete satisfaction. I understand the nature of the consent that I am

granting, and agree to be bound by the terms of this Authorization.

Parent/Guardian Printed Name:

Signature: Date:

________ (Staff initials)

8

Survey Consent Form

As a grant-funded agency, the Club is occasionally required to collect some information

from members to report on the effectiveness of our programs. Therefore, a few times a

year we will be administering surveys to members that ask how members feel about the

activities and time they spend at the Club, education plans, and involvement in

community service and work. Survey participants can skip any questions they do not

wish to answer and may stop participating in the surveys at any point without penalty. If

you would like to see copies of the surveys, they are available at the Club upon request.

This information is kept strictly confidential, like all member records, and will only be

used to report grant outcomes for the Club as a whole, with no member names or

identifying information.

This information is very helpful to the Boys & Girls Club. It allows us to evaluate the

effectiveness of our programs, so that we can continue to improve the services we offer to

your child. It also helps the Club secure grants to implement new programs that will help

your child reach their academic, character, and healthy lifestyle goals.

Please sign below granting permission for your child to complete surveys at the Club

during the summer of 2017. Your signature indicates you have read and understand the

information herein.

_______________________________ ______________________________

(Print Name of Parent) (Parent Signature)

_______________________________

(Date)

________ (Staff initials)

9

Student Academic Release Form

The purpose of the Federal Education Rights and Privacy Act of 1974 is to protect the

privacy of information concerning individual students by placing restrictions on the

disclosure of information contained in a student’s education records. In order for Maury

County Public Schools to release education records, a signed authorization must be on file.

Your signature below states that you are filing this release with Boys & Girls Clubs of

Maury County, to allow them access to your child’s academic records through the school

system’s iNow Parent Portal. Boys & Girls Clubs of Maury County will use these records

for academic success tracking and grant reporting purposes. Access to Parent Portal allows

Boys & Girls Clubs to know your child’s weekly progress, and increases the effectiveness

of the Academic Case Management Program by allowing Club tutors and staff members to

identify your child’s specific academic needs and any area in which he/she may be

struggling. Allowing access to your child’s information in Parent Portal ensures that you,

your child, and the Club are applying the necessary energy and effort to meet your child’s

specific and targeted academic needs.

“I hereby authorize Maury County Public Schools to release my child’s academic records

to Boys & Girls Clubs of Maury County. This information will be released with my full

consent. I understand this release authorization remains in effect for the 2017-2018

academic year.”

_______________________________ ______________________________

(Child’s Name) (Name of School)

_______________________________ ______________________________

(Print Name of Parent) (Parent Signature)

_______________________________

(Date)

10

EMERGENCY CONTACTS

Member Name:_______________________________________________

Please list any and all contacts that may be called in your absence.

These contacts should be able to pick up your child and/or authorize

medical attention.

PRIMARY CONTACT

Name:___________________________

Relationship to Member:___________

Address:_________________________

City:________________State:________

Zip:____________

Home Telephone:__________________

Employer:________________________

Business Telephone:________________

Cell Telephone:____________________

Name:___________________________

Relationship to Member:___________

Address:_________________________

City:________________State:________

Zip:____________

Home Telephone:__________________

Employer:________________________

Business Telephone:________________

Cell Telephone:____________________

Name:___________________________

Relationship to Member:___________

Address:_________________________

City:________________State:________

Zip:____________

Home Telephone:__________________

Employer:________________________

Business Telephone:________________

Cell Telephone:____________________

PRIMARY CONTACT

Name:___________________________

Relationship to Member:___________

Address:_________________________

City:________________State:________

Zip:____________

Home Telephone:__________________

Employer:________________________

Business Telephone:________________

Cell Telephone:____________________

Name:___________________________

Relationship to Member:___________

Address:_________________________

City:________________State:________

Zip:____________

Home Telephone:__________________

Employer:________________________

Business Telephone:________________

Cell Telephone:____________________

Name:__________________________

Relationship to Member:___________

Address:_________________________

City:________________State:________

Zip:_____________

Home Telephone:__________________

Employer:________________________

Business Telephone:________________

Cell Telephone:____________________

The above information is complete: staff initials ___________

11

Transportation Plan ALERT

Member:___________________________________________________

The following people DO NOT have my permission to pick up my child in my

absence.

Boys & Girls Clubs will not, under any circumstances, allow your child to

leave the premises with any individuals you have named on this page.

1. Name__________________________

Relationship to Member:__________

Address:_________________________

City:________________State:________

Home Telephone:__________________

Employer:________________________

Business Telephone:________________

Cell Telephone:____________________

2. Name: _________________________

Relationship to Member:___________

Address: _________________________

City:_______________State:________

Home Telephone:__________________

Employer:________________________

Business Telephone:________________

Cell Telephone:____________________

3. Name:_________________________

Relationship to Member:___________

Address:_________________________

City:________________State:________

Home Telephone:__________________

Employer:________________________

Business Telephone:________________

Cell Telephone:____________________

4. Name:_________________________

Relationship to Member:___________

Address:_________________________

City:________________State:________

Home Telephone:__________________

Employer:________________________

Business Telephone:________________

Cell Telephone:____________________

The above information is complete: staff initials___________

12

Special Requirements

In an effort to provide the quality services and programs that each child deserves, we have

included a special requirements check list which will allow us to know more about any special

needs your child may have and what we can do to help assist in positively impacting your child

at a deeper level.

Please check all that apply to your child:

[ ] Aggressive Behavior

[ ] Exposure to Gangs in Community

[ ] Exposure to violence in community

[ ] Discipline problems at school

[ ] Single Parent Home

[ ] Hearing Impaired

[ ] Speech/Language Impairment

[ ] English as second language

[ ] Exposure to drugs/alcohol in community

[ ] Anger

[ ] ADHD/Hyperactivity

[ ] Bipolar Disorder

[ ] Autism

[ ] Depression

[ ] Displays low self-esteem

[ ] Displays hopelessness/lack of future aspirations

[ ] Developmentally Delayed

[ ] Family member(s) involved in prison system

[ ] Poor grades/risk for failure

[ ] Victim of violent crime

[ ] Gifted

[ ] Special Ed/Individualized Education Plan (IEP)

[ ] Handicapped/Physical Disability

[ ] Needs Glasses

Additional Comments/Concerns:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________