The following information is required for membership at the Boys & Girls Club. This information will not be used individually but grouped for fundraising and grant writing. All information is held strictly confidential.
* Names listed are assumed to be authorized to pick up the child.
The questions below are designed to help us understand and work effectively with your child. You are not required to answer these questions; however, the lack of this information may affect our ability to work with your child.
I agree to abide by the terms and conditions of the Boys & Girls Club Parent Handbook (a copy of which I have received) governing the enrollment of the child named on this Membership Application/Emergency form. I understand that payment of club program fees is made on the first day of the week that child(ren) attend(s). I agree to abide by the terms and conditions of the Boys & Girls Clubs/KIDSTOP fee policies.
I agree to permit the child named above to participate in walking trips, field trips or other activities sponsored by The Boys & Girls Club. This permission is given with the understanding that transportation, if needed, will be provided by private vehicles driven by Boys & Girls Club staff members or volunteers, school buses and/or public transportation. I also understand that the children will be under Boys & Girls Club supervision throughout the duration of any field trip.
Knowing there is a certain amount of risk involved in even the simplest of childrens games, sports and activities, I give my permission for my child to participate in Club activities and programs. I accept responsibility in the unlikely event that an accident might take place. I hereby certify that I carry health and/or accident insurance for my child and that I am solely responsible for the cost of health care for my child, even as a result of my childs participation in Club programs or activities.
I further certify that my child is covered by medical insurance as listed on the above Membership/Emergency form. I understand that insurance coverage is required in order for my child to participate in Club programs and that I am solely responsible to provide such coverage. I understand that I am solely responsible for any consequences of my failure to provide adequate insurance coverage. I agree to abide by all of the rules of the Boys & Girls Clubs of Central Minnesota pertaining to the health and safety of the members and to inform the Club immediately of any changes in my childs health, health care insurance or medical provider. I also agree to inform the Boys & Girls Clubs of Central Minnesota immediately if my child contracts a serious communicable disease.
I agree that the Boys & Girls Clubs of Central Minnesota, its employees (both paid and volunteer), Board of Directors and affiliated agencies, shall not be liable for any claims, demands, actions or causes of action, whatsoever for any injury caused to me or to my child as a result of my childs involvement in Boys & Girls Club programs or activities.
I hereby expressly forever relieve and discharge said Boys & Girls Clubs of Central Minnesota from all acts of negligence on the part of the Boys & Girls Clubs of Central Minnesota, its employees (both paid and volunteer), the corporation, its servants, agents, officers, shareholders and affiliated agencies.
I give my consent to any exchange of information between my childs Boys & Girls Club/KIDSTOP staff and school professional staff whenever it would be beneficial to my child.
In case of serious accident of illness to my child or in the event that the injury/illness involves my childs mouth or teeth, I hereby authorize the staff of the Boys & Girls Clubs of Central Minnesota, my childs physician, dentist and those individuals named on the above Membership/Emergency form to give any necessary treatment to my child. You may call the doctor and/or ambulance if necessary at my exclusive expense. I agree that I am solely responsible for updating medical information to the Boys & Girls Clubs of Central Minnesota.
The Boys & Girls Clubs of Central Minnesota is taking part in an annual survey that will be used to track the well being of members in Boys & Girls Clubs nationally. Our Club is one of a group of Clubs across the country participating in the survey that asks how members feel about the activities and time they spend in Boys & Girls Club programs, education plans, and involvement in community service and work.
Additionally, the survey asks about the attitudes and health behaviors of members, including questions about nutrition and physical activity. Members will not put their names on the survey. No site or member will ever be mentioned by name in a report of the results.
We would like all members at our sites to take part in the survey, but the survey is voluntary. Survey participants can skip any questions they do not wish to answer.
If you would like to see the survey, a copy is available upon request. Please contact the program manger or unit director. You may review the survey during regular hours.
If you do NOT want your child to take part in the survey, we have a form for you to sign. The form is available from you program manger or unit director.
If you have any questions about the survey, please contact the Boys & Girls Clubs of Central Minnesota at (320) 252-7616.
Please agree to the above by entering your name and relationship to the new member(s).
Your child may not attend the Boys & Girls Club until the registration fee has been received. If you need information about our scholarship programs or county child care assistance, please call us immediately at 252-7616.
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