Embed Size (px)
Citation preview
What is the Boys & Girls Club and what does my membership mean? The Boys & Girls Club 1-5 Grade Unit and The Boys & Girls Club Teen Center is a membership organization that is a drop-in recreational program and facility. It is not a licensed childcare or a fee-based program. Completing a Boys & Girls Club application and submitting payment for dues, does not guarantee membership to the Boys & Girls Club. The Boys & Girls Club may also require meetings or additional information prior to acceptance as a member to ensure the Club has the capability, facilities and professionals to meet the needs of the youth requesting membership. Once membership is accepted, the expectation for families and youth to maintain membership is that Club rules and guidelines are followed. In addition, if a child’s needs change or new information is disclosed, the Boys & Girls Club will review its capabilities, facilities and professionals at that time to ensure it can meet the needs of the youth currently enrolled.
Club Programming & Spaces: The Boys & Girls Club focuses on three priority areas of programming: Academic Success, Healthy Lifestyles and Character & Leadership. Grades 1-5 will be in shared spaces, with 4 & 5 graders having some separate social areas at times. Grades 6-12 are in shared spaces, with 6-8 and 9-12 graders having their own social and homework areas at times.
How much does it cost to be a member at the Club? The 2020 Club membership due is $25, with the purpose to ensure all youth can afford to come to the Club. However, it costs the Club over $1,050 a year for each member, therefore we highly encourage families to support the Club beyond the membership due, if able, by filling out the donation form on the last page of the application.
When are you open and how old do you have to be to attend the Club? o School Year:
o 1-5 Grade- M. T. Th. F: Afterschool – 9 PM; W.: Afterschool - 8 PM; and Sat.: Sign up available at front desko 6-12 Grade – M. - Th.: Afterschool – 7 PM, F: Afterschool – 10 PM, Sat: Sign up available at front desko Early dismissals: Afterschool – 6:00 PM
o Summer:o 1-5: 7:30 AM – 6:00 PM; 6-12: M. T. W. TH.: 7:30 AM -6:00 PM & Friday: 12:00 PM - 9:00 PM
o Snow Day & No School Day:o 1-5: 7:30 AM – 6:00 PM; 6-12: 7:30 AM – 6:00 PM
o Club Closed: Major holidays and transitions between summer and school year sessions, notice will be provided to parentsin advance. The Club will close one day every month for Club in-service (see attached schedule). This keeps our staff welltrained, the Club safe, the building clean and makes it possible for us to be open year round.
o Grades Served: ECE: Age 3 through Kindergarten & Traditional Sites: First day of summer after Kindergarten through Grade12. If your child repeats K or did JK they must wait until the summer before they enter grade 1.
Do I need to fill out the entire application? The application needs to be fully completed to be considered for membership, don’t forget:
o Youth & Parent Signatures: Make sure your child has signed and the guardian has signedo Salary Section: This is used for grants and securing resources to keep dues as low as possibleo Parent Email & Two Emergency Contacts: This helps the Club stay in contact with you, newsletters and in emergencies
Parent/Guardian Orientation Requirements: Orientation Time: Every Monday at 5:15 pm for 1-5 Grade and Tuesday at 5:15 for 6-12 Grade It is a Boys & Girls Club membership requirement that all youth and a guardian attend orientation prior to joining the Club at each stage: before ECE program, again before 1-5 grade and again in 6-12 grade. All youth are unable to attend the Club as a member until the orientation is attended by youth and guardian, even if guardian and a sibling have previously attended.
Emergencies, Questions & Concerns: o Chelsea Lang, Executive Director, 605-692-3333 or 605-692-6666. [email protected] Matt Sass, Elementary Director, 605-692-3333, [email protected] Erinn Thomas, Teen Director, 605-692-6666, [email protected] Lindsie Bell, Chief Operations Officer, 605-692-3333, [email protected] Tim Lease, Chief Executive Officer, 605-692-3333, [email protected]
Brookings6-12 Grade | 2020
Expires 12/31/2020
BE GREAT!
Brookings 2020 In-Service Calendar
Club Closed:
School Year: January 24
February 28
March 20
April 24
September 25
October 23
November 20
Summer: June 19
July 17
Important Dates The Club will be closed on the dates below for Club in-service.
This keeps our staff well trained, the Club safe, the building clean and makes it possible for us to be open year round.
The Boys & Girls Club may have other, both expected and unexpected, closed dates for holidays, events, etc. The dates above are only highlighting our Club in-service days.
1
2020 Expires 12/31/2020
1910 12th St. S., Brookings SD 57006 Tel 605-692-6666 Fax 605-692-9199
www.greatfuturessd.org
BROOKINGS TEEN CENTER MEMBERSHIP APPLICATION
OFFICE USE ONLY
Membership Number: Orientation Date: Payment Type: Cash Check #__________
New Member / Renewal: Card Printed Date: Receipt #:
Entered By: Date: Photo Taken Date: Accepted By: Date:
Expiration Date: 12/31/2020 Welcome Email Date: Location Accepted:
Youth First Name:__________________________________Youth Last Name:_______________________________ Member’s Sibling(s):
Name Age Full/Half/Step Name Age Full/Half/Step
______________________________________________ _____________________________________________
______________________________________________ _____________________________________________
Circle the Appropriate 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 (Primary Club Contact):___________________________________________________ Gender: M F
Address: _____________________________________ City: ____________________ State: _____ Zip: _________
Home Phone: _____________________ Cell Phone: _____________________ Work Phone: _____________________
Email (at least one email is required to be on file): _______________________________________________________________
Place of Employment: ______________________________________________________________________________ □ If single parent, please check this box
Parent/Guardian:__________________________________________________________________ Gender: M F
□ Check this box if home address is same as above
Address: _____________________________________ City: ____________________ State: _____ Zip: _________
Home Phone: _____________________ Cell Phone: _____________________ Work Phone: _____________________
Email: ___________________________________________________________________________________________
Place of Employment: ______________________________________________________________________________
2
Youth Information:
First Name:__________________________ Middle: _________________________ Last: _______________________
Age:__________________ Date of Birth: _____________________ Gender (circle): M F
Ethnicity (circle): Number in Household: __________________
African American Asian
Caucasian Hispanic
Multi-Racial Native American ____________________(Tribe)
Native Hawaiian/Pacific Islander Other OPTIONAL:
E-mail Address of 6th-12th Grade Youth (to help youth stay informed of Club events):_____________________________________________
Teen Cell Phone Number (parents will be notified before the Club calls a youth): ________________________________________________
Academic information: School:__________________________________________Grade:___________ School Year: ________________ Anticipated Graduation Year:____________ Teacher____________________________________________ Is your child on an Individualized Education Plan or 504? ___Yes ___No Does your child have a specific academic need? ___Yes ___No If yes, please explain: _________________________________________________________________________________________________ _________________________________________________________________________________________________
Medical Information: Does your child have asthma? ___Yes ___No Do they use/carry an inhaler? ___Yes ___No ___N/A
Does your child have an allergy? ___Yes ___No If yes, please list allergy and associated symptoms: Allergy_________________________________________ Symptom(s):__________________________________________ Allergy_________________________________________ Symptom(s):__________________________________________
Does your child have other medical conditions or diagnoses? ___Yes ___No If yes, please explain: _________________________________________________________________________________________________
_________________________________________________________________________________________________ The Boys & Girls Club is a drop-in recreational facility, not a licensed daycare facility, and is not responsible for or allowed to dispense, store and/or oversee medication of any kind, including all non-prescription medications. Parents/Guardians are able to come to and sign in to the Boys & Girls Club and administer medication to their child. The Boys & Girls Club can follow its incident and accident policies and procedures, including:
• Support your child through a team effort • Call 911 in case of an emergency situation • Follow normal incident/behavior protocol, if needed, as outlined through Boys & Girls Club of the Northern Plains, Inc. policy
By signing my name below, I certify that I have read, understand and agree to the above.
Parent Name Date
3
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 you marked yes, the Department of Defense has partnered with us so your membership fee can be waived if you fill out the appropriate form. Ask the front desk for this form when turning in this membership. Are you willing to volunteer at the Club? ____ Yes ____ No Qualify for Free Lunch: ____ Yes ____ No Qualify for Reduced Lunch: ____ Yes ____ No
Additional Emergency Contacts (in addition to Parents/Guardians): *MUST HAVE AT LEAST 2 CONTACTS*
First Name:______________Last Name:_______________
Phone Number: __________________________________
City, State: ______________________________________
Relation to the Child: ______________________________
Please write below if someone is NOT ALLOWED TO PICK UP MEMBER
(If a biological parent, legal documentation must be provided) Name: ___________________________________________ Relationship to Member: _____________________________ Does this contact live in the Member’s household? Yes [ ] No [ ] (If not, please fill in address below) City/State/Zip: _____________________________________ Brief description of individual __________________________ _________________________________________________ _______________________________________________________
First Name:______________Last Name:_______________
Phone Number: __________________________________
City, State: ______________________________________
Relation to the Child: ______________________________
First Name:______________Last Name:_______________
Phone Number: __________________________________
City, State: ______________________________________
Relation to the Child: ______________________________
First Name:______________Last Name:_______________
Phone Number: __________________________________
City, State: ______________________________________
Relation to the Child: ______________________________
Please write below if someone is NOT ALLOWED TO PICK UP MEMBER
(If a biological parent, legal documentation must be provided) Name: ___________________________________________ Relationship to Member: _____________________________ Does this contact live in the Member’s household? Yes [ ] No [ ] (If not, please fill in address below) City/State/Zip: _____________________________________ Brief description of individual __________________________ _________________________________________________ _______________________________________________________
4
Teen Check-out Policy: Parents and guardians have the option to give their teen permission to leave the Club on a “Teen Pass.”
I. A teen pass allows the member 30 minutes to get to their destination and return back at the Club. II. Members going on a pass must walk or bike, not drive or ride in a vehicle. III. Teens must go in groups of two - four and at least one person in the group must have a cell phone with them. IV. Teens may only go on one pass per day. V. On the pass form, members must indicate where they are going and only go to that location. VI. If a teen breaks the Code of Conduct, or does not return within 30 minutes, they lose pass privileges for 5 days. VII. A second failure to follow pass rules results in that teen losing his or her pass privileges for the remainder of the
summer/school year.
Teen parents also have the option to allow their teen to leave the Club without an authorized adult picking them up only if they indicate this on their membership application. Parents can come into the Club and make changes to the privileges they grant on their youth’s membership form.
I. Approving this checkout option allows the teen to leave the building when and with whom they choose. II. However, if he or she returns to the Club later in that day, the Club will need parent/guardian verification that s/he can
return. a. If this is an ongoing need, for example if your youth has a sports practice or another camp, parents can notify the
Club ahead of time and pre-approve their teen’s reentry. III. However, if a teen checks out and parents do not notify the Club that s/he can return s/he will not be able to return
that day.
Permission Information 1. I give my permission to the Boys & Girls Club of the Northern Plains, Inc. and my child’s school 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 my child’s school or the Club in writing.
____ Yes ____ No ____________________________________________________________ Parent Signature
2. 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
3. I give permission for my teen to check-out on Club approved passes. A Club approved pass allows members to leave the Club, in groups of up to four kids, for 30 minutes without a Club staff member. ____ Yes ____ No _______ Initials
4. I give permission for my teen to check out of the Club for the day. By checking yes, I understand my teen cannot go back to the Club without parent permission. By checking no, my teen does not have permission to check out of the Club unless an authorized individual comes to pick them up. ____ Yes ____ No _______ Initials
5. I give permission for my teen to watch youtube.com videos. Video content and language will have to be appropriate for the Club or staff will take appropriate actions.
____ Yes ____ No _______ Initials
6. I give permission for my teen to use social media when the Club is implementing a program that involves the usage of social media. Teens
will use social media appropriately and will not use it to cyber bully or search for inappropriate material. ____ Yes ____ No ________ Initials
7. I give permission for my teen to watch PG13 movies. Even though some movies are rated PG13 they may still not be deemed appropriate by teen room staff and therefore not be shown.
____ Yes ____ No _______ Initials
5
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 the Northern Plains, Inc., 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 the Northern Plains, Inc. 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 the Northern Plains, Inc. to 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 of the Northern Plains, Inc. 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 understand it is a Boys & Girls Club membership requirement that all youth and a guardian attend orientation prior to joining the Club and at ______ the time of their first enrollment in the Club program in 1st -5th grade and again in 6th -12th grade. All youth are unable to attend the Club as Parent a member until the orientation is attended by youth and guardian, even if in the same family. I also understand that if I have completed Initials orientation in the past it is my responsibility to go to the Club website at www.greatfuturessd.org and read, review and follow the Boys &
Girls Club of the Northern Plains, Inc. parent handbook and listen to the recorded orientation. I hereby give my permission for my child to become a member for the Boys & Girls Club of the Northern Plains, Inc. 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 the Northern Plains, Inc. and its property are not responsible for personal injury or loss of property.
Parent Signature Date
Youth Signature (REQUIRED)
We highly recommend filling out and signing #1, #2, and if possible of #3 to optimize our collaboration and programming with the schools, communication on bussing situations, with families and to serve your youth best. You are able to select signing none, some or one if you wish.
AUTHORIZATION FOR RELEASE OF SCHOOL RECORDS AND/OR EXCHANGE OF WRITTEN AND/OR ORAL INFORMATION
1. Name of School: ________________________________________________________________________________
Student Name: Date of Birth: Grade:
______________________________________________________________________________________________
Date Requested: ___________________ Date Mailed: _____________________ Date Fixed: ___________________
2. Oral Exchange of student information between _____________________________________________________
(Professional outside Brookings School District) and staff from the Brookings school building noted on this form. This
exchange is authorized for 12 months beyond the authorized signature date listed below.
______________________________________________________________________________________________ Authorized Signature of Parent, Guardian or Eligible Student Date 3. Check one or both if applicable:
Records are requested FROM the following school District/Agency/Professional:
Attention: _____________________________________________________
District/Agency/Professional: _____________________________________________________
Address: _____________________________________________________
_____________________________________________________
Telephone: ______________________ Fax Number: ___________________
It is requested that records be sent TO the following school District/Agency/Professional:
Attention: _____________________________________________________
District/Agency/Professional: _____________________________________________________
Address: _____________________________________________________
_____________________________________________________
Telephone: ______________________ Fax Number: ___________________
In accordance with the Family Educational Rights and Privacy Act of 1974, as amended, enacted as Section 438 of the General Education Provisions Act, in effect April 11, 1988. I hereby give permission for the release of any and all confidential information, to include:
1. Transcript of grades 7. Special education records, such as
2. Grades at time of withdrawal a. current IEP
3. Birth Certificate b. education multi-disciplinary evaluations,
4. Attendance record psychological evaluations
5. Health and medical records (including c. socio/developmental reports
immunizations and sports physical) d. treatment records
6. Educational records
NOTE: We request that no permanent files be sent on the student named above. Send only copies of the information indicated. ______________________________________________________________________________________________ Authorized Signature of Parent, Guardian or Eligible Student Date
Boys & Girls Club of the Northern Plains, Inc.: 605-692-3333
Donation Options (You may donate to more than one category.) Annual Operating Campaign Endowment
Amount ($) Amount ($)
Payment Options Cash or Check Stock Crop Exchange
Credit Card EFT Deduction (Please attach voided check)
Name Telephone
Address
Employer Will Match My Gift? Yes No
Thank you. By contributing you help make a positive impact on the life of children in your community. The Boys & Girls Club is exempt from federal income tax under Section 501(C)(3) of the Internal Revenue Code and contributions are tax-deductible to the extent allowed by law
with tax ID of 73-1630215. No goods or services were provided in consideration of this contribution.
Parent/Guardian PledgeBoys & Girls Club of Brookings
Signature Date
Name on Card
Card #
exp. date 3-digit code on back
Amount per month ($) for month(s)
Name and address of financial institution
Checking or savings account #
Bank routing # (between |: |: on bottom left
Amount per month ($)
A Club membership dues are $25.00 a year with the purpose to make sure all kids can afford to come to the Club. However, it costs over $1,050 a year to fund each child coming to the Club so we highly encourage you,
if you are able, to support the Club and membership beyond the $25.00.
