Boys & Girls Clubs of Greater Flint
A safe place to learn, grow and have fun!

Membership Application

 

Membership Application

 
 
Club Member Information
Birthdate *
Birthdate
Race/Ethnicity *
Address *
Address
Cell Phone *
Cell Phone
Home Phone *
Home Phone
Pick-Up Information
Emergency Contact *
Emergency Contact
(someone who does not live with member)
Emergency Contact Phone Number *
Emergency Contact Phone Number
Authorized to Pick-Up Member #1 *
Authorized to Pick-Up Member #1
Authorized to Pick-Up Member #1 Phone Number *
Authorized to Pick-Up Member #1 Phone Number
Authorized to Pick-Up Member #2 *
Authorized to Pick-Up Member #2
Authorized to Pick-Up Member #2 Phone Number *
Authorized to Pick-Up Member #2 Phone Number
Family History
Mother
Mother
Mother's Phone Number
Mother's Phone Number
Father
Father
Father's Phone Number
Father's Phone Number
Guardian
Guardian
(if different from mother or father)
Guardian's Phone Number
Guardian's Phone Number
Medical Information
Doctor *
Doctor
Doctor's Phone Number *
Doctor's Phone Number
Confidential Information
The following information is necessary for our records and the funding our organization receives. The answers you provide are confidential. Your cooperation in providing this information is both appreciated and necessary.
All Services Household is Currently Recieving *
Club Rules
CLUB RULES: Respect Yourself | Respect Others | Respect the Staff | Respect the Club PEACE OPTIONS: Apologize | Compromise | Get Help | Walk Away I understand that all food and drinks are to be consumed in the cafeteria only. Gum is not permitted in the Club. I understand that my child must wear adequate footwear to participate in sports, fitness, and recreation programs. This includes the gymnasium, Fitness Center, and playground/field space. I understand that my child must wear appropriate attire when participating in the activities of BGCGF. I understand the organization is not responsible for any lost, stolen, or damaged property, and that my child is responsible for checking in any purse, backpack, gym bag, jacket, and/or coat into the Coat Room and they are not permitted to walk around the building with these items. I understand that when my child is absent from school due to illness or disciplinary action of any kind, he/she may not attend the program on those days as it represents a health/safety risk to others. I understand that the BGCGF does not dispense medication to youth. I understand that medication my child needs during program time must be checked into the Main Office in the original prescription bottle and I must complete a Medication Agreement. I understand that my child must be picked up before or at the time the program ends. I understand that I am subject to a Late Fee Policy, in the event that my child is not picked up within the proper time frame. I understand in the event that no approved contact of my child is available, it is the policy of the organization to involve the local authorities. I understand it is the policy of the organization to exhaust every measure to reach me or the emergency contacts listed on this application in the event that my child is not picked up on time. I authorize the Boys & Girls Clubs of Greater Flint to seek emergency medical treatment for the minor child listed on this application if I cannot be reached and/or if life threatening injuries are apparent. I understand that I will be responsible for any/all costs of medical attention and treatment. The Club will not be responsible for any accident to the child while on the premises or while engaged in any off site activity with the organization. I understand that my child’s membership standing or program participation is based upon their ability to obey the rules of the Club, its officials, staff members, volunteers, members, facility, and program. Membership may be suspended or terminated at any time for misbehavior without a refund. I understand I, the parent/guardian of the minor child listed on this membership application, for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever discharge the Boys & Girls Clubs of Greater Flint (BGCGF, Club), and Boys & Girls Clubs of America, their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organizations such as staff, directors, or volunteers, from all liability, claims, demands, or causes of action for any and all loss, damage, injury or death and any claim of damages resulting from use of facilities owned or controlled by the above organizations, or participation in activities of said organizations, either at or away from the Club. I have read the completed application and this form, understand the rules, regulations, policies, and expectations of the Boys & Girls Clubs of Greater Flint, and have properly communicated and reviewed them with my child. I request that the minor child listed on this application be admitted into membership at the Boys & Girls Clubs of Greater Flint.
Read & Sign
Open Door Policy: I understand that the Boys & Girls Clubs of Greater Flint has an open door policy, and members are free to enter and leave the building. I understand it is my responsibility as the parent/guardian to instruct my child as to when and with whom they may leave the facility. Parents and guardians of Club members are responsible for their own transportation to and from the program. I also understand the Club is not, nor does it claim to be, a licensed day care provider. I understand that the program is a drop-in facility, and the organization is not responsible for Club members’ whereabouts. School Information: I authorize the Boys & Girls Clubs of Greater Flint, my child’s school, and the school district, listed on this application to exchange information regarding the minor child listed on this application. I understand the purpose of this exchange is to enrich my child’s learning experience and help them succeed academically. I am authorizing the Boys & Girls Clubs of Greater Flint to have access to my child’s grade reports, attendance records, and behavioral history from my child’s teacher, principal, and/or school administration. This release is valid for the duration of my child’s active membership (one calendar year) and may be revoked at any time by contacting the Boys & Girls Clubs of Greater Flint in writing. Photo/Video/Media Release: As the parent/guardian of the minor child listed on this application, I hereby grant permission to the BGCGF, its agents and assigns, to use above named child’s photo or video, and likeness for the purpose of promotion by BGCGF for all forms of media and manners, for the following, but not limited to: news releases, photographs, videos, audio, website, marketing, advertising, trade, promotion, exhibition, for an indefinite period of time. I give unrestricted permission for images, videos, and recordings of the child listed on this application to be used in print, video, digital and internet media. I agree that these images and/or voice recordings may be used for a variety of purposes and that these images may be used without further notification. I further acknowledge that I will not be compensated for these uses and the BGCGF owns all rights to the images, videos, and recordings, and to any derivative works created from them. I hereby release BGCGF and its agents and assigns from any claims that may arise from these uses, including and without limitation of claims of defamation or invasion of privacy, or of infringement of moral rights or rights of publicity or copyright. If there are security issues with the public release of my child’s image engaged in BGCGF, I understand that I must speak with the CEO. Data Collection & Sharing: I give my permission to the BGCGF to collect information via online or written surveys, questionnaires, interviews, and focus groups from the minor child listed on this application. Any and all information received will be kept and strictly confidential. Data gathered through these means will be summarized in the aggregate and will exclude all references to any individual responses. The aggregated results of these analyses may be shared with Club staff, Boys & Girls Clubs of America (BGCA), funders, and other community stakeholders to evidence program effectiveness and/or Club impact on our members. I understand that the BGCGF may share information about the minor child listed on this application with the Boys & Girls Clubs of America for research purposes and/or to evaluate the program’s effectiveness. Information that will be disclosed to Boys & Girls Clubs of America may include the information provided on this membership application, information provided by the minor child’s school or school district, and other information collected by BGCGF including data collected via surveys or questionnaires. All information provided to BGCGF will be kept confidential. Educational Services Assessments: I understand in an effort to enrich my child’s academic success and educational experience in the Club, free literacy and/or math testing is available as part of my child’s membership at BGCGF. As such, I authorize the BGCGF to pre-test and post-test my child using accredited literacy and math assessments to determine their educational needs are being adequately met. I understand that the scores of these assessments will be available to me upon my request to the Tutoring Center. This release is valid for the duration of my child’s active membership with the BGCGF (one calendar year) and may be revoked at any time by contacting the BGCGF in writing. Technology: I understand that as a member of the BGCGF, my child will have access to the Internet. While BGCGF takes precautions, it is possible my child may access inappropriate sites and/or material. BGCGF will have rules and consequences at the Club for such behavior. Cell phones and electronics are not allowed at the Club for Cadets (ages 7 to 9) or Juniors (ages 10 to 12), in an effort for them to minimize screen time and engage in the planned activities at the BGCGF. Teenagers (ages 13 to 17) are permitted to use cell phones in the Teen Room during approved program times. Teenagers must adhere to the rules and policies of the organization when engaging in technology use in the building. I understand there may be consequences for my child in the event of inappropriate use of technology. Youth Development Program: I understand the Boys & Girls Clubs of Greater Flint has a mission to inspire and enable all young people, especially those who need us most, to reach their full potential as productive, responsible, caring citizens. I understand that in the course of serving my child and fulfilling the mission, BGCGF staff and/or volunteers may develop a mentoring and professional relationship with my child. I understand it is the policy of the organization for every adult to complete and pass a state and federal background check. I understand it is the policy of the organization for this relationship to be constrained to official BGCGF activities and events.
Club Member *
Club Member
Club Member Signature *
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
Parent or Guardian *
Parent or Guardian
Parent or Guardian Signature *
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
Today's Date *
Today's Date