Boys & Girls Club Registration

1Parent/Guardian Information

2Emergency Contacts (other than parents)

3Member Information

4Additional Required Information

5Positive Climate Philosophy & Procedures

6Permission and Release Form

Emergency Contacts (other than parents)
* Names listed are assumed to be authorized to pick up the child.
Emergency Contacts
First Name Last Name Phone
List anyone not allowed to pick up child by court order
First Name Last Name

A document is needed if there are any custody orders involving restrictions or limitations of when any parent or guardian is allowed to drop off or pick up.

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Member 1
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender*
Grade*
Member Cell Phone #
Ethnicity*
Race*
Other*
Living with*
Other*
Site Information
Club Location*
Current School*
Eastside Club hours are school dismissal until 6:45 p.m. for K-5 and school dismissal until 7:45 p.m. for 6 -12th M - F. Summer hours are M - F noon - 5:45 p.m.
Southside Club hours are school dismissal until 6:45 p.m. for K-5 and school dismissal until 7:45 p.m. for 6 -12th M -F. Summer hours are M - F noon - 5:45 p.m.
Roosevelt Club hours are school dismissal until 6:45 p.m. for K-5 and school dismissal until 7:45 p.m. for 6 -12th M - F. Summer hours are M - F noon - 5:45 p.m.
The Club's Storm Afterschool Program at Sauk Rapids Middle School is open Monday – Friday from 3:15 – 5:15 p.m. after school days only.
Select Grade*
Which group is your child in school?*
What do these terms mean?
Drop in Distance Learning Program (including Fridays):
- Members may arrive at the Club at any time to work on their homework, based on space availability each day.
- Members may not leave the Club and come back unless given prior approval by Club staff.
- All members need to be picked up or walk home in a timely manner to allow staff to thoroughly clean and sanitize all spaces & equipment.
Afterschool Drop in Club Programming:
- Members may arrive at the Club at any time, based on space availability each day.
- Members may not leave the Club and come back unless given prior approval by Club staff.
- All members need to be picked up or walk home in a timely manner to allow staff to thoroughly clean and sanitize all spaces & equipment.
Failure to follow Club expectations may result in loss of program registration
Medical Information
Health Clinic*
Health Clinic Phone*
Dental Clinic*
Dental Clinic Phone*
Insurance Company*
Policy Number*
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.
Describe any unusual health related conditions of the child
Does your child have any physical or mental disabilities, developmental delays or emotional/behavioral disorders that we should be aware of the help your child be successful in Club?*
Has your child experienced any emotional trauma?*
Note: If you answered yes to either of the above two questions, an intake questionnaire will be provided for you, to detail your child's specific needs to insure success for your child.
Is your child receiving any services through Special Education?*
Member 1
Price:
- Add Another Member
Member 2
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender*
Grade*
Member Cell Phone #
Ethnicity*
Race*
Other*
Living with*
Other*
Site Information
Club Location*
Current School*
Eastside Club hours are school dismissal until 6:45 p.m. for K-5 and school dismissal until 7:45 p.m. for 6 -12th M-F during the 2020-21 school year. Summer hours are M - F noon - 5:45 p.m.
Southside Club hours are school dismissal until 6:45 p.m. for K-5 and school dismissal until 7:45 p.m. for 6 -12th M-F during the 2020-21 school year. Summer hours are M - F noon - 5:45 p.m.
Roosevelt Club hours are school dismissal until 6:45 p.m. for K-5 and school dismissal until 7:45 p.m. for 6 -12th M-F during the 2020-21 school year. Summer hours are M - F noon - 5:45 p.m.
The Club's Storm Afterschool Program at Sauk Rapids Middle School is open Monday – Friday from 3:15 – 5:15 p.m. after school days only.
Select Grade*
Which group is your child in school?*
What do these terms mean?
Drop in Distance Learning Program (including Fridays):
- Members may arrive at the Club at any time to work on their homework, based on space availability each day.
- Members may not leave the Club and come back unless given prior approval by Club staff.
- All members need to be picked up or walk home in a timely manner to allow staff to thoroughly clean and sanitize all spaces & equipment.
Afterschool Drop in Club Programming:
- Members may arrive at the Club at any time, based on space availability each day.
- Members may not leave the Club and come back unless given prior approval by Club staff.
- All members need to be picked up or walk home in a timely manner to allow staff to thoroughly clean and sanitize all spaces & equipment.
Failure to follow Club expectations may result in loss of program registration
Medical Information
Health Clinic*
Health Clinic Phone*
Dental Clinic*
Dental Clinic Phone*
Insurance Company*
Policy Number*
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.
Describe any unusual health related conditions of the child
Does your child have any physical or mental disabilities, developmental delays or emotional/behavioral disorders that we should be aware of the help your child be successful in Club?*
Has your child experienced any emotional trauma?*
Note: If you answered yes to either of the above two questions, an intake questionnaire will be provided for you, to detail your child's specific needs to insure success for your child.
Is your child receiving any services through Special Education?*
Member 2
Price:
- Add Another Member
Member 3
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender*
Grade*
Member Cell Phone #
Ethnicity*
Race*
Other*
Living with*
Other*
Site Information
Club Location*
Current School*
Eastside Club hours are school dismissal until 6:45 p.m. for K-5 and school dismissal until 7:45 p.m. for 6 -12th M-F during the 2020-21 school year. Summer hours are M - F noon - 5:45 p.m.
Southside Club hours are school dismissal until 6:45 p.m. for K-5 and school dismissal until 7:45 p.m. for 6 -12th M-F during the 2020-21 school year. Summer hours are M - F noon - 5:45 p.m.
Roosevelt Club hours are school dismissal until 6:45 p.m. for K-5 and school dismissal until 7:45 p.m. for 6 -12th M-F during the 2020-21 school year. Summer hours are M - F noon - 5:45 p.m.
The Club's Storm Afterschool Program at Sauk Rapids Middle School is open Monday – Friday from 3:15 – 5:15 p.m. after school days only.
Select Grade*
Which group is your child in school?*
What do these terms mean?
Drop in Distance Learning Program (including Fridays):
- Members may arrive at the Club at any time to work on their homework, based on space availability each day.
- Members may not leave the Club and come back unless given prior approval by Club staff.
- All members need to be picked up or walk home in a timely manner to allow staff to thoroughly clean and sanitize all spaces & equipment.
Afterschool Drop in Club Programming:
- Members may arrive at the Club at any time, based on space availability each day.
- Members may not leave the Club and come back unless given prior approval by Club staff.
- All members need to be picked up or walk home in a timely manner to allow staff to thoroughly clean and sanitize all spaces & equipment.
Failure to follow Club expectations may result in loss of program registration
Medical Information
Health Clinic*
Health Clinic Phone*
Dental Clinic*
Dental Clinic Phone*
Insurance Company*
Policy Number*
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.
Describe any unusual health related conditions of the child
Does your child have any physical or mental disabilities, developmental delays or emotional/behavioral disorders that we should be aware of the help your child be successful in Club?*
Has your child experienced any emotional trauma?*
Note: If you answered yes to either of the above two questions, an intake questionnaire will be provided for you, to detail your child's specific needs to insure success for your child.
Is your child receiving any services through Special Education?*
Member 3
Price:
- Add Another Member
Member 4
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender*
Grade*
Member Cell Phone #
Ethnicity*
Race*
Other*
Living with*
Other*
Site Information
Club Location*
Current School*
Eastside Club hours are school dismissal until 6:45 p.m. for K-5 and school dismissal until 7:45 p.m. for 6 -12th M-F during the 2020-21 school year. Summer hours are M - F noon - 5:45 p.m.
Southside Club hours are school dismissal until 6:45 p.m. for K-5 and school dismissal until 7:45 p.m. for 6 -12th M-F during the 2020-21 school year. Summer hours are M - F noon - 5:45 p.m.
Roosevelt Club hours are school dismissal until 6:45 p.m. for K-5 and school dismissal until 7:45 p.m. for 6 -12th M-F during the 2020-21 school year. Summer hours are M - F noon - 5:45 p.m.
The Club's Storm Afterschool Program at Sauk Rapids Middle School is open Monday – Friday from 3:15 – 5:15 p.m. after school days only.
Select Grade*
Which group is your child in school?*
What do these terms mean?
Drop in Distance Learning Program (including Fridays):
- Members may arrive at the Club at any time to work on their homework, based on space availability each day.
- Members may not leave the Club and come back unless given prior approval by Club staff.
- All members need to be picked up or walk home in a timely manner to allow staff to thoroughly clean and sanitize all spaces & equipment.
Afterschool Drop in Club Programming:
- Members may arrive at the Club at any time, based on space availability each day.
- Members may not leave the Club and come back unless given prior approval by Club staff.
- All members need to be picked up or walk home in a timely manner to allow staff to thoroughly clean and sanitize all spaces & equipment.
Failure to follow Club expectations may result in loss of program registration
Medical Information
Health Clinic*
Health Clinic Phone*
Dental Clinic*
Dental Clinic Phone*
Insurance Company*
Policy Number*
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.
Describe any unusual health related conditions of the child
Does your child have any physical or mental disabilities, developmental delays or emotional/behavioral disorders that we should be aware of the help your child be successful in Club?*
Has your child experienced any emotional trauma?*
Note: If you answered yes to either of the above two questions, an intake questionnaire will be provided for you, to detail your child's specific needs to insure success for your child.
Is your child receiving any services through Special Education?*
Member 4
Price:
Where did you learn about us?
- Advertisement
- Family/Friend Referral
- School
- Website
- Other
If other, please describe

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Additional Required Information
Boys & Girls Club receives federal funding from sources that require some additional information from families. Please download the attached fillable form(s), complete the required information and attach your completed form below. Thank you for your cooperation! If you have difficulty attaching the completed form(s), you may email the attachments to club@bgcmn.org.
Please download this form and attach it to the field below when complete. Community Development Block Grant Client Information Form (PDF)
Please download this form and complete it for em>each student. Attach the form(s) to the field below when complete. 21st Century Community Learning Centra Grant Program Parent/Guardian Consent Form (PDF)
Files*
Drop files here or

Accepted file types: pdf, Max. file size: 50 MB.

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Positive Climate Philosophy & Procedures
As a youth development agency, the Boys & Girls Clubs of Central Minnesota focuses on reward and reinforcement of positive behavior.

If your child is involved in a conflict or unsafe situation with another member or staff, or has violated Boys & Girls Club rules, they will be approached in the following progressive manner:
- Expectations, Rules and Consequences
  - Staff will teach expectations, rules and consequences for behavior and post these in their program areas.
- Verbal redirection / coaching:
  - Staff will use verbal redirection with youth when needed.
  - Staff will use proactive language when dealing with youth exhibiting unacceptable behavior.
- Take A Break Space
  - Youth may be asked to apologize or take a break from an area or activity. Examples of language used may include “let’s take a break” or “how about we take some time to cool off.
  - In the “take a break” space, youth will have intentional time to reflect on what they did and how they may do things differently next time.
  - In the “take a break” space, youth will have other calming tools that they can use to help regulate their emotions before returning back to the group.
- Meeting with a Site Manager and documentation of the incident.
- If the behavior continues or requires more serious intervention, your child will meet with the Site Manager.
- They will be asked, “Tell me what happened?” / “What part are you responsible for?”
- Members will be given the opportunity to discuss other possible choices and what they would likely choose to do in the future.
- The staff will work with the member to create a plan to return to the activity.
- The staff will document the intervention and have information available to share with parents/guardians.
- A call home and/or short-term suspension:
  - If the issue cannot be resolved in a meeting, or if it continues to occur, a call home may be made to discuss the conflict with you.
  - At the discretion of the Site Manager, a decision may be made to suspend your child from programming for one to five days, or limit the amount of time your child can be in the program.
- A long-term suspension or revocation of membership:
  - If continued intervention does not resolve the issue, or the behavior is so severe that it puts your child, other members or staff in danger, the Site Manager, Director of Clubs/KIDSTOP and/or VP of Operations may decide to suspend your child’s membership long-term or revoke their membership until the behavior can be resolved to a degree that it no longer endangers your child, other members or staff.
SUSPENSION / TERMINATION OF MEMBERSHIP:

The Boys & Girls Club seeks to make our programs a positive experience for your child, including coaching them through behavioral challenges and emotion control. If Club leadership feels that long-term suspension or termination of membership is the best option for your child, they will contact you to set up a meeting. Suspension or termination of membership may be considered for the following non-exhaustive list:
- Violent behavior that endangers your child, other members, staff or volunteers.
- Unsafe behavior, such as running from program.
- Disrespectful behavior.
- Continuous vulgar or abusive language that emotionally harms other members, staff or volunteers.
- Not complying with rules that exist to keep your child and other members safe.
- Bringing a weapon or an item that could be construed as a weapon, or threatening to bring a weapon to the program, or onto Club or school property.
- Continuous bullying or cyber-bullying that emotionally or physically hurts other members.
- Sexual harassment of other members, staff or volunteers.
- Theft or damage of another member’s property, staff property or Club property.
- Bringing illegal substances or alcohol into the program.
- Attending the program while under the influence of an illegal drug or alcohol.
- Any other reason deemed to be emotionally or physically dangerous to your child, other members, staff or volunteers.
After each suspension, your child and you must meet with Club leadership to discuss a re-entry plan to allow the member to attend programming. Developing a behavior plan allows you and your child to be an active participant in the success of your child’s experience.

If your child continues to exhibit the behaviors listed above, despite guidance and coaching from staff, termination of their membership may be sought in order to keep the program a safe and affirming place for all of its members.

If Club leadership feels that termination of membership is the best option for your child, they will schedule a meeting with you and your child to discuss the concern. Club leadership has the final decision-making authority regarding termination of memberships.
*
- **I have read and understand the POSITIVE CLIMATE PHILOSOPHY & PROCEDURES.

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Permission and Release Form

Parent Handbook and Fee Payment Policy

I agree to abide by the terms and conditions of the Boys & Girls Club Parent Handbook: https://www.bgcmn.org/wp-content/uploads/2020/09/Parent-handbook-BGC-2020.docx governing the enrollment of the child named on this Membership Application/Emergency form. I understand that payment of KIDSTOP 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.

Field Trip Transportation and Supervision

I agree to permit the child(ren) named 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 school bus, public transportation or a Boys & Girls Club vehicle driven by an authorized driver. I also understand that the child(ren) will be under Boys & Girls Club supervision throughout the duration of the field trip.

Safety

Knowing there is a certain amount of risk involved in even the simplest of children’s 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 child’s participation in Club programs or activities.

Insurance Coverage

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 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 child’s 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 child’s 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.

Exchange Of Information

I give my consent to any exchange of information between my child’s Boys & Girls Club/ KIDSTOP staff and school professional staff whenever it would be beneficial to my child.

Authorization for Medical Care

In case of serious accident of illness to my child or in the event that the injury/illness involves my child’s mouth or teeth, I hereby authorize the staff of the Boys & Girls Clubs of Central Minnesota, my child’s 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.

I understand the implication of this Permission and Statement of Release. I certify that I am legally capable of executing this agreement, and that I have done so of my own free will on the date indicated below, on behalf of myself, my spouse, if not signed separately, and our child(ren) named above.

Media Consent

Boys & Girls Clubs of Central Minnesota, Boys & Girls Clubs of America, and KIDSTOP (collectively, “Boys & Girls Clubs”) may photograph or video record your child for marketing and promotional purposes, including but not limited to, use as stock photos on our website and social media pages. You give permission to Boys & Girls Clubs to photograph and/or video record your child for use in marketing and promotional materials. Your permission grants us the authority to publicize any photos/video recordings we may take of your child.

By participating in Boys & Girls Club services, you agree to the following:

I grant permission to Boys & Girls Clubs to photograph and/or video and audio record my child for marketing and promotional purposes and to publicize any photos/recordings of my child without additional notification. This grant remains in effect until revoked. The rights granted to Boys & Girls Clubs in this release include the perpetual, exclusive, and unencumbered right to use, edit, reproduce, distribute, publish, and otherwise exhibit the photos/recordings worldwide, in any and all forms of media. In addition, the rights granted to Boys & Girls Clubs in this release include the right to use the photo/recordings to publicize and advertise Boys & Girls and/or its services. No monetary compensation will be given for use of any photo/recording of my child. I agree to hold harmless and do hereby release the Boys & Girls Clubs and its past, current, or future directors, employees, agents, representatives, affiliates, successors, and assigns from any and all claims, demands, and causes of action associated with this release and, including without limitation, any claims for libel of violation of any rights of publicity or privacy which I many have by reason of this release.

Media Opt Out

You have a right to opt out of inclusion of photographs/recordings, but unless you complete this form: https://www.bgcmn.org/bgc-member-media-waiver, participation in Boys & Girls Club activities implies permission for the images taken at those events.

Movie Consent

I give consent to view any PG rated video shown at BGC/ KIDSTOP. Talk with your site manager if you do NOT want your child to view PG rated videos.

National Youth Outcomes Initiative Survey

The Boys & Girls Clubs of Central Minnesota participates 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 this 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 site manager. 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 your site manager.

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).
Name*
First Last
Relationship*
Other*
Name
This field is for validation purposes and should be left unchanged.

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Parent/Guardian

Parent/Guardian 2

Parent/Guardian 3

Parent/Guardian 4

Emergency Contacts (other than parents)

Member 1

Site Information

What do these terms mean?

Medical Information

Member 2

Site Information

What do these terms mean?

Medical Information

Member 3

Site Information

What do these terms mean?

Medical Information

Member 4

Site Information

What do these terms mean?

Medical Information

Additional Required Information

Positive Climate Philosophy & Procedures

SUSPENSION / TERMINATION OF MEMBERSHIP:

Permission and Release Form

Parent Handbook and Fee Payment Policy

Field Trip Transportation and Supervision

Safety

Insurance Coverage

Exchange Of Information

Authorization for Medical Care

Media Consent

By participating in Boys & Girls Club services, you agree to the following:

Media Opt Out

Movie Consent

National Youth Outcomes Initiative Survey

First Name	Last Name	Phone

First Name	Last Name