2017-2018 MEMBERSHIP INFORMATION
GARDINER CLUBHOUSE PROGRAMS
Middle School & High School
School Age Care (K-8th Grade)
Located at the Gardiner Clubhouse
Date of Birth
(Single Parent Household)
(2 Parent Household) *
1 Parent/1 Step Parent
City, State & Zip
Name of School
If yes, what level?
Race-Nationality of Member
Parent / Guardian Name
Same Address as Member?
If no, address
Parent/Guardian | City, State & Zip
If yes, what Branch?
Parent/ Guardian e-mail address
#2 Parent / Guardian Name
#2 Same Address as Member?
#2 If no, address
#2 Parent/Guardian | City, State & Zip
#2 Work Phone
#2 Parent/ Guardian e-mail address
HOUSEHOLD INFORMATION USED FOR GRANTS & BGCKV FUNDING
How many people are in Household?
EMERGENCY CONTACTS/ CASE WORKER / ONE ON ONE This is someone who can who can assume temporary care of your child if we cannot reach you.
Emergency Contact #1 Name
Emergency Contact #1 Relationship
Emergency Contact #1 Phone
Emergency Contact #2 Name
Emergency Contact #2 Relationship
Emergency Contact #2 Phone
Other People allowed to pick up Member
Reasons for Medications
Allergy Physical Restrictions
Medication Physical Restrictions:
Does this child receive any services?
If yes, what?
(IF MEDICATION IS NEEDED DURING CLUB HOURS WE MUST HAVE A MED FORM COMPLETED) NO CHILD MAY CARRY MEDICATION ON THEM NO MATTER WHAT PROGRAM THEY ARE ENROLLED IN
I give permission to the Boys & Girls Clubs of Kennebec Valley 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. That includes emergency transportation.
SURVEYS AND QUESTIONNAIRES
I, the parent/guardian of the minor child listed on this application, give permission for the Boys & Girls Clubs of Kennebec Valley 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 Kits surveys or other survey instruments.
SUMMER WEEK CHANGE
I understand that I am responsible to make payment for all weeks that I have checked even if my child does not attend. I have to make all changes by the last day of school.
I give my permission to the Boys & Girls Clubs of Kennebec Valley and my child’s School to exchange information (such as standard test scores, grades, MEDMSID’S and Free/Reduced status) 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 Clubs and in life. This release is valid for one year and may be revoked at any time by contacting the Boys & Girls Clubs of Kennebec Valley in writing.
My child has permission to use any/all age appropriate equipment such as roller blades, mountain bike, snow shoes, and cross country skis. Along with any other sports equipment while they are attending the Boys & Girls Clubs of Kennebec Valley.
MISCELLANEOUS HOVER OVER HELP TEXT (?) FOR MORE INFORMATION
I understand the BGCKV is not responsible for lost or stolen items.
I give permission for my child’s picture *
moving pictures, or any other graphic depiction or likeness, to be used by the Boys & Girls Clubs of Kennebec Valley and its activities.
I give the Boys & Girls Clubs of Kennebec Valley permission *
to take my child on scheduled field trips such as or including swimming and or wading activities.
I have read this form and completed it to my full potential. *
I have also read and understand the Boys & Girls Clubs of Kennebec Valley program handbook.
As stated in our handbook all payments *
As stated in our handbook all payments are due by 9:00 am every Friday to the Gardiner Clubhouse. This payment is for the upcoming week of service. Payments are processed on Friday.
If fees are not received on Friday services will not be available to you on Monday. Payments accepted are cash, ACH Debit Authorization or check or money order. We do not accept visa/debit cards. Checks or ACH returned non-sufficient funds (NSF) will be charged a $25.00 fee and must be paid by cash or money order within 5 business days. Personal checks will no longer be accepted after 2 NSF checks. Thank you for adhering to this policy. We appreciate your understanding of the need for payments to be made in full and on time.
MENTORING – SCHOOL AGE ONLY GRADES K-5
I understand that my school age child will participate in the OJP mentoring program onsite at the Club during the school year.
I understand that the staff of the Club will provide ongoing monitoring during mentors activities.
COMPUTER USE- TEEN CENTER ONLY
I have read the computer use policy which is located in the handbook. *
I agree to let my Teen Center child use the wireless internet at the Club for social and school purposes.
OPEN DOOR /CLOSED DOOR - TEEN CENTER ONLY Please choose one of the following
Closed Door Policy; *
After arrival at the Club, your child must remain at the Club unless picked up by a parent or guardian.
Open Door Policy; *
Members may arrive and depart from the Club on their own; however child must sign in and out. The Club will not be responsible once the child has signed out.
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 Clubs of Kennebec Valley, and The Boys & Girls Clubs of America, their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organization such as staff, directors or volunteers, from all liability, claims, demands, or causes of action for any and all loss, damage, injury and any claim of damages resulting from use of facilities owned or controlled by the above organization, or participation in activities of said organization either at or away from the Club.
Name / Sign
By Checking this box I agree to the terms of this form
ALL FORMS NEED TO BE RETURNED TO THE CLUB WITH 1ST WEEK PAYMENT TO COMPLETE MEMBER REGISTRATION
The Boys & Girls Clubs of Kennebec Valley
14 Pray St. Gardiner, ME 04345 Phone 207-582-8458