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Club Membership Information

How to Register for Club Programs

Registration forms for all Club programs are available in the front office, or you may download the member registration form to complete. Forms need to be filled out in full to complete the registration process. Information that appears on the form is important to Club programming and funding.

Depending upon the program for which you wish to register your child—early childhood, school age, teen center, or summer camps—there are different procedures for completing your registration since in some programs there are waiting lists. Contact the Club for opening and program availabilities. Please see the discussion under each of these programs for how you should proceed with your registration.

Please download the Club Handbook and review it before submitting your registration form.

Please do not mail or fax any registration forms. All forms must have original signatures.

As indicated on the Registration Form, a first week’s payment is required to be submitted with the final completed form in order to activate the application. The current payment amount is indicated under each program. Page 6 of the Handbook discusses our payment policies. Resident fees apply to children living in Chelsea, Gardiner, Pittston, Randolph, Richmond, and West Gardiner. Nonresident fees apply to all other towns.

2017-2018 MEMBERSHIP INFORMATION
GARDINER CLUBHOUSE PROGRAMS
INFANT TODDLER EARLY PRESCHOOL PRESCHOOL
BEFORE CARE AFTER CARE BEFORE & AFTER CARE
Teen Center & CLC Teen Center
CHELSEA CLUBHOUSE
Before School After School Before & After School Other Clubs Activities
SUMMER PROGRAMS
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8

MEMBERS INFORMATION
Participant Lives
Mother Only Father Only

Guardian Foster Care
Yes No
African-American Native American Asian Hispanic Caucasian/White Multi-Racial Other



HOUSEHOLD INFORMATION USED FOR GRANTS & BGCKV FUNDING
SSDI Food Stamps SSI TANF School Lunch Free School Lunch Reduced Day Care Voucher
$0-$18,000 $18,001-$24,000 $24,001-$26,000 $26,001-$28,000 $28,001-$41,500 Over $41,501

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.

MEDICAL INFORMATION
Food Medications Enviroment
At Home At Club Both
(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
RELEASE INFORMATION
Yes No

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.

Yes No

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.

Yes No

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.

Yes No

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.

Yes No

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

Yes No
Yes No

moving pictures, or any other graphic depiction or likeness, to be used by the Boys & Girls Clubs of Kennebec Valley and its activities.

Yes No

to take my child on scheduled field trips such as or including swimming and or wading activities.

Yes No

I have also read and understand the Boys & Girls Clubs of Kennebec Valley program handbook.

PAYMENT POLICY
Yes No

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
Yes No
Yes No
COMPUTER USE- TEEN CENTER ONLY
Yes No

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
Yes No

After arrival at the Club, your child must remain at the Club unless picked up by a parent or guardian.

Yes No

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.
By Checking this box I agree to the terms of this form
I agree
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

14 Pray Street, Gardiner ME 04345

Phone 207-582-8458 | Fax 207-582-7902

               
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