MEMBER INFORMATION
2020 BOYS & GIRLS CLUB OF BUENA PARK MEMBERSHIP
*****************************************************************
MEMBER INFORMATION
1. Member’s Name First: Middle: Last: G
ender: M / F Birth Date: / / Age: School: Grade: NEW MEMBER Y / N
Address:
City:
State:
Zip:
Health Issues/Allergies: YES / NO If yes, List Medications:
2. Member’s Name First: Middle: Last: G
ender: M / F Birth Date: / / Age: School: Grade: NEW MEMBER Y / N
Address:
City:
State:
Zip:
Health Issues/Allergies: YES / NO If yes, List Medications:
3. Member’s Name First: Middle: Last: G
ender: M / F Birth Date: / / Age: School: Grade: NEW MEMBER Y / N
A ddress:
City:
State:
Zip:
Health Issues/Allergies: YES / NO If yes, List Medications:
ETHNICITY (need to mark yes or no)
Hispanic/ Latino: NO YES, ( if marked yes please circle one of the following)
Mexican / Chicano Puerto Rican Cuban Other Hispanic/Latino
RACE (check all that apply)
White/Caucasian Black/African American Asian
American Indian/ Alaskan Native
Native Hawaiian/Other Pacific Islander
Other/Multi-Cultural
Name: Address: | Name: Address: |
Employer: Home # Cell # Work # E-Mail Address | Employer: Home # Cell # Work # E-Mail Address |
Emergency Contact (other than parent/guardian): Name: Cell # Work # Relationship to Member:
Emergency Contact (other than parent/guardian): Name: Cell # Work # Relationship to Member:
The information that follows is necessary for our records and the funds that our organization receives. Information given to us is confidential. Cooperation in giving us this information is appreciated and necessary.
Annual Household Income (including any child support): $ Occupants in Household: Housing status: Own Renting Homeless Other:
Does this member live with their: Mom Step Mom Dad Step Dad Grandparent Other: Current Head of Household: Male / Female / Both
Number of Brothers: Ages: Number of Sisters: Ages: Does any person in your household have a disability? YES/NO (if yes please describe) :
Is English the primary language spoken at home? YES/NO If not, please list primary language:
MEMBERSHIP WILL NOT BE PROCESSED UNTIL PARENT/GUARDIAN HAS SIGNED THIS PORTION:
1. I have read the completed application, understand the rules of the Boys & Girls Club of Buena Park and request that my child be admitted into membership.
2. I understand my child’s membership standing is based on his/her ability to obey the rules of the Club, its officials, and staff members. Membership may be suspended or canceled at any time for not following the Club's policies and procedures.
3. The Boys & Girls Club of Buena Park is for youth ages 6-18. A birth certificate must be provided for all new members that are age 6. Members that are 18 years of age must be currently enrolled in high school to attend the Club.
4. I understand that the Boys & Girls Club of Buena Park has a $3 daily fee during the school year for all members not in the Transportation Program, $10 daily fee during the summer program, and that all balances must be paid at the end of each week or your account will incur a $10 late charge. Balances must be paid in full in order for membership to remain active/valid. Unpaid balances will result in a suspension of membership until balance has been paid.
5. I understand that the Boys & Girls Clubs of Buena Park has an “OPEN DOOR POLICY.” This means that members are free to enter and leave the club. It is the parent’s or legal guardian’s responsibility to note on membership application whether or not their child can leave the Club.
6. Custody issues/payment responsibilities: The Club holds the parent that enrolls their child in our program responsible for any and all fees, regardless of “split or shared” costs involving custody issues.
7. I understand that my child must be picked up on or before closing time. The Boys & Girls Club of Buena Park closes at 6p.m. The Club will contact the Buena Park Police Dept. for any child left at the Club 30 minutes after closing. The Police will take the child into custody until the parent arrives. Being late can/will result in canceled membership.
8. The Boys & Girls Club of Buena Park has my consent to administer any treatment (including but not limited to: x-ray, examination, anesthetic, medical, surgical or dental diagnosis and any hospital care) that are considered necessary in the best judgment of the attending medical or emergency personnel. This consent is given prior to any such medical treatment, but is given to provide authority and power on the part of the Boys & Girls Club of Buena Park in the exercise of their best judgment upon the advice of any such medical or emergency personnel. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Boys & Girls Club of Buena Park to summon any and all professional emergency personnel to attend, transport, and treat the participant and to issue consent for any x-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur.
9. I knowingly waive any claim against, or right to sue, the Boys & Girls Club of Buena Park, its agents, officers, employees, and Boys & Girls Clubs of America for any injury, accident, illness, or death occurring during or by reason of your child’s participation in our program, and further waive any possible allegation or claim of liability of the Boys & Girls Club of Buena Park. I have carefully read this form and fully understand its contents, and by signing below, agree to this full and complete release of liability.
Parent’s Signature: Date:
MEMBERSHIP #1: #2: , #3 DATE PAID: RECEIPT#:
STAFF: GROUP: CUSTOM FIELD:
PARENT AGREEMENT
Please read the following and initial each one when finished. | PARENT’S INITIALS |
1) The Boys & Girls Club of Buena Park closes at 6pm. Being late will not be tolerated and will be cause for removal from the program without a refund. | |
2) All balances must be paid in full by the end of each week in order for child to remain in the program. Payments not received by the end of the day on Friday will incur a $10 late charge for every week the account remains delinquent. In addition, there is a $25 fee for all returned checks. | |
3) Parents must come into the Club to sign out their children. Members may not wait in the parking lot. When picking up members, parents must check in at the front desk so a staff member can page your child. For safety reasons parents are not allowed into the program areas to look for their child. | |
4) Toys & electronic devices of any kind are not allowed at the Club. The Boys & Girls Club of Buena Park is not responsible for lost, stolen, or damaged items brought to the Club. | |
5) The Boys & Girls Club of Buena Park has a ZERO TOLERANCE policy concerning any form of fighting or any verbal “Bullying”. This includes all forms of physical contact. These actions will result in an immediate suspension along with possible removal from the program. | |
6) Any equipment found to be damaged or broken through negligence of a Club member must be paid for by the parent. | |
7) Only children with current membership are allowed in the Club. Changes to address or any phone numbers must be updated on your membership form as soon as possible. | |
8) There is a separate registration fee when signing up for our Summer Program. | |
I GIVE MY CHILD PERMISSION TO LEAVE THE BOYS & GIRLS CLUB OF BUENA PARK ON THEIR OWN FOR LUNCH OR ANY OTHER REASON KNOWING THAT THE CLUB IS NO LONGER RESPONSIBLE FOR THEM ONCE THEY HAVE LEFT THE BUILDING. | YES/NO |
I GIVE MY CHILD PERMISSION TO USE THE INTERNET AT THE BOYS & GIRLS CLUB OF BUENA PARK. CLUB STAFF USE STRICT GUIDELINES REGARDING WHAT SITES CAN BE VIEWED. | YES/NO |
I hereby grant to the Boys & Girls Club of Buena Park the right to photograph my dependent and use the photo and or other digital reproduction of him/her for publication processes, whether by print or electronic publishing via the Internet. | YES/NO |
Parents are expected to set a positive and professional example in their behavior while at the Club. The following rules of conduct need to be adhered to while in the building or on Club property:
1. Parents will show respect and courtesy to Staff, members, and other parents at all times.
2. Parents are not to approach or address any child other than their own. If there is an issue involving another child, the parent needs to bring the matter to the Program Director’s attention to be handled appropriately.
3. Parents will not create any type of negative disturbance in front of members. All matters of concern will be taken care of behind closed doors.
4. There will be no foul or derogatory language of any kind.
5. Parents will use caution when entering and exiting the parking lot.
Any behavior unbecoming of a Parent will result in the permanent removal from the Club’s property and if need be, reported to the Buena Park Police Department.
Please make sure you have read the above in detail. Sign and date below stating you understand the above rules and policies.
Parent’s Name
Parent’s Signature
Date