Discovery Club Kids Preschool Program

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By signing up for Boys & Girls Club SMS texts, you consent to receive text messages, including weather-related closures, registration information and other important announcements from Twilio autodialer. Consent is not a condition of registration/purchase. Msg & data rates may apply. Msg frequency varies. Unsubscribe at any time by replying STOP. Privacy Policy: https://www.bgcmn.org/privacy-policy/ Terms: https://www.bgcmn.org/terms-of-use/

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Parent/Guardian 2

Name*

First Last

Relationship*

Other*

Primary Phone*

Phone Type*

Mobile

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Secondary Phone

Phone Type

Mobile

Landline

Sign up for Boys & Girls Club's SMS text messaging*

By signing up for Boys & Girls Club SMS texts, you consent to receive text messages, including weather-related closures, registration information and other important announcements from Twilio autodialer. Consent is not a condition of registration/purchase. Msg & data rates may apply. Msg frequency varies. Unsubscribe at any time by replying STOP. Privacy Policy: https://www.bgcmn.org/privacy-policy/ Terms: https://www.bgcmn.org/terms-of-use/

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Email*

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Employer*

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Are you enlisted in the military?*

Add Another Parent/Guardian

Parent/Guardian 3

Name*

First Last

Relationship*

Other*

Primary Phone*

Phone Type*

Mobile

Landline

Secondary Phone

Phone Type

Mobile

Landline

Sign up for Boys & Girls Club's SMS text messaging*

By signing up for Boys & Girls Club SMS texts, you consent to receive text messages, including weather-related closures, registration information and other important announcements from Twilio autodialer. Consent is not a condition of registration/purchase. Msg & data rates may apply. Msg frequency varies. Unsubscribe at any time by replying STOP. Privacy Policy: https://www.bgcmn.org/privacy-policy/ Terms: https://www.bgcmn.org/terms-of-use/

I agree to sign up for BGC text messaging

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Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County*

Employer*

Work Phone

Are you enlisted in the military?*

Add Another Parent/Guardian

Parent/Guardian 4

Name*

First Last

Relationship*

Other*

Primary Phone*

Phone Type*

Mobile

Landline

Secondary Phone

Phone Type

Mobile

Landline

Sign up for Boys & Girls Club's SMS text messaging*

By signing up for Boys & Girls Club SMS texts, you consent to receive text messages, including weather-related closures, registration information and other important announcements from Twilio autodialer. Consent is not a condition of registration/purchase. Msg & data rates may apply. Msg frequency varies. Unsubscribe at any time by replying STOP. Privacy Policy: https://www.bgcmn.org/privacy-policy/ Terms: https://www.bgcmn.org/terms-of-use/

I agree to sign up for BGC text messaging

I do not agree to sign up for BGC text messaging

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County*

Employer*

Work Phone

Are you enlisted in the military?*

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.

Number of people in your primary household*

Please enter a number greater than or equal to 0.

Select a range for Annual Primary Household Income*

Does your child receive free or reduced lunch?*

Health Clinic*

Health Clinic Phone

Dental Clinic*

Dental Clinic Phone

Insurance Company*

Insurance Policy Number

Emergency Contacts (other than parent/guardian)

* Please list an emergency contact of someone who is not a parent/guardian or someone living in the same residence. Names listed are assumed to be authorized to pick up the child.

Emergency Contacts*

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Last Name

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Positive Climate Philosophy & Procedures

As a youth development agency, the Boys & Girls Clubs of Central Minnesota (BGCMN) focuses on the reinforcement of positive behavior. The Club’s Expectations of Excellence will be posted in programs and staff will review them with members on a regular basis. If your child participates in a conflict or unsafe behavior, or has violated the posted BGCMN Expectations of Excellence, the situation will be addressed in the following manner:

Verbal redirection/coaching
- Staff will use proactive language when dealing with youth exhibiting unacceptable behavior.
- Staff will use verbal redirection with youth when needed.

Self-regulation/Co-regulation
- Youth may be given the opportunity to take a break from an area or activity to regulate themselves. Examples of language used may include “let’s take a break” or “how about we take some time to cool off.”
- While taking a break, youth will have time to intentionally reflect on the situation and how they may do things differently next time.
- Youth may be offered calming tools that they can use to help regulate their emotions before returning to the group.

Meeting with Site Management and documentation of the incident
- If the behavior requires more, your child will meet with Site Management.
- They will be asked questions like, “Can you tell me what happened?” / “What choice are you responsible for?”
- Members will be given the opportunity to discuss other possible choices and what they might do differently in the future.
- Documentation will be provided to the parent/guardian.

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.

Notification and/or short-term suspension
- If the issue cannot be resolved with the member, or if it continues to occur, a call may be made to discuss the issue with you.
- At the discretion of the Club, a decision may be made to suspend your child from programming or limit the amount of time your child can attend any BGCMN site.

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, staff, or volunteers in danger, BGCMN 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, staff, or volunteers.

SUSPENSION/TERMINATION OF MEMBERSHIP

The Boys & Girls Clubs of Central Minnesota seeks to do everything we can to make our programs a positive experience for your child, including coaching them through behavioral challenges. If BGCMN feels that long-term suspension or termination of membership is required, you will be contacted. Suspension or termination of membership may be considered if the following occur:

Violent behavior that endangers your child, other members, staff, or volunteers.
Unsafe behavior such as running from program.
Disrespectful behavior.
Vulgar or abusive language that harms other members, staff, or volunteers.
Not complying with behavior expectations 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 site, or onto Club or school property.
Bullying or cyber-bullying other members.
Sexual harassment of other members, staff, or volunteers.
Theft or damage of another member’s property, or BGCMN or school property.
Bringing tobacco, marijuana, THC, or illegal substances onto BGCMN or school property.
Attending the Club while under the influence of marijuana, THC, or illegal substances.
Other actions determined to be unsafe by BGCMN

BGCMN identifies positive behavior through our Expectations of Excellence: Respect yourself, others, & the Club; Keep your Club clean & safe; Carry out your commitment, Use appropriate language; Manners matter.

BGCMN identifies proactive language as language that positively directs our members to hold themselves accountable for their actions.

**I have read and understand the POSITIVE CLIMATE PHILOSOPHY & PROCEDURES.

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 (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 KIDSTART program fees is made on the first day of the month that child(ren) attend(s), unless signed up for Easy Pay. I agree to abide by the terms and conditions of the Boys & Girls Clubs/ KIDSTART 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 fieldtrip.

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 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 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/ KIDSTART 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, KIDSTOP and KIDSTART (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 Clubs 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.

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/ KIDSTART. Talk with your site program manager or unit director if you do NOT want your child to view PG rated videos.

National Youth Outcomes Initiative Survey

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 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 program manager 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 your program manager 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).

Name*

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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.

Do you receive county child care assistance or have you signed up for Easy Pay?*

Total

The registration fee for school year programming is $20.

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