Program Registration Form

Parent/Guardian (child lives with)

Mailing Address

Email Address

Cell Phone

Employer

Work Phone

Position

Other Parent/ Guardian

Mailing Address (If different)

Email Address

Cell Phone

Employer

Position

If Other please specify:

Is either parent in the military?

Branch

Status:

Active Guard Reserve

Child First name

Child Middle name

Child Last name

Child Birthdate

Gender

Female Male

School

Insurance Company Name:

Insurance Policy Number

Insurance Policy Group Number

PROOF OF INCOME (This information will be kept in strict confidence and is important because it helps us to identify member who qualify for services including scholarships & free eye care. It also makes the Boys & Girls Club eligible to receive federal grant funding. you must verify your family income by providing 1 of the following: Income tax return, last 2 months of paycheck stubs, and any other income documentation - i.e. statement of unemployment benefits, social security benefit letter, public assistance, benefits letter and foster providers)

Please upload proof of income:

Number of people in your household:

Does your child have any medical problems or allergies?

Yes No

If yes, Please explain:

Does Your child have special needs?

Yes No

If so, Please explain:

Emergency Contact person:

Relationship to Child

Cell phone:

Other phone:

Authorized to pick up?

Yes No

Emergency Contact person:

Relationship to Child

Cell phone:

Other phone:

Authorized to pick up?

Yes No

As a partner in your child's positive development, the Boys & girls Club of the Umpqua Valley is committed to provideing the best possible programming for your child. The following are expectations for parents/guardians of members of the club. By check marking each category to agree to the terms:

The Boys & Girls Club is a youth development program; not a child care facility. Our staff helps guide members through problem-solving and decision making. If you believe your child would be better suited to a child care environment, we are happy to provide information on child care options in the community.

Be sure that your child has his/her membership card every day. Scanning in and out of the club each day your child attends is required. The member's participation in most club activities is also dependent on having their card with them as they move from area to area. if your child comes without a membership card, they will have to manually sign in. Replacement membership cards can be purchased in the office for $2.00 each. Please

The Club operates with a "safe Passages" policy. For members under 6th grade, a parent, guardian, or other adult must come to the Greeter's desk to puck up his/her child. Members in 6th grade and up may leave the club unescorted with written permission from a parent/guardian adn a signed release of liability. No member will be allowed to return to the Club once they leave the premises for the day. It is the parent's responsibility to discuss the Safe Passages Policy with his/her child and ensure that he/she complies.

I understand that my child must attend a full day of school in order to attend the after school program

I understand that i am expected to pick up my child on time. The Club closes at 6:30pm during the school year and 5:30 during the summer. If your child is picked up late, you will be issued a warning notice. If you child is picked up late a second time, your child's membership may be suspended and a $50.00 late pick up fee will be assessed in order to reinstate the membership.

If my child is sick or injured or if he/she is suspended due to a discipline issue, I am required to pick up my child within 1 hour of notification by the Club.

I understand that any violation of Club rules by my child will result in disciplinary action as laid out in the member's Code of Conduct. I accept that the Club has the right to take the disciplinary action necessary.

I understand that the program schedule and availability is subject to change due to changing guidelines.

Parents, guardians or family members who exhibit behavior or language that is offensive and/or inappropriate or engage in physical/verbal abuse or threat of harm to any staff, volunteer or member will be subject to removal from the facility.

I waive any claims against the Boys & Girls Club , board, staff or volunteers except claims arising from gross negligence or willful acts of the board or its agents that may arise from participation in Club activities.

I give Permission for the Club to use photographs and/or videos in which my child appears for publicity or programming purposes.

Yes No

Permission will be required for my child to be transported to any off-site activities accompanied by leadership staff. I understand that reasonable measures will be taken to safeguard the health and safety of all participants. I will encourage my child's positive participation in Club programs and will adhere to all Club policies. I understand taht failure to abide by these rules could result in suspension of my child's membership.

By clicking this box Parent AND Member agrees to the following Code of Conduct: RESPECT YOURSELF: 1. Be honest 2. Let staff know if others treat you with disrespect. 3. Show good Sportsmanship 4.Use appropriate language 5.Encourage others and model respect, fairness, kindness and trust. 6.Follow Club Dress Code. RESPECT OTHERS: 1.Say only good things about others. 2.Resolve conflict peacefully and with words. 3.Treat others the way you like to be treated 4.Encourage others and show good sportsmanship 5.Be respectful of others members' property 6. Honor differences RESPECT THE CLUB: 1.Be respectful of Boys & Girls Club Staff. 2.Be respectful of Boys & Girls Club building and equiptment

FOR PARENTS & GUARDIANS

Assumption of the Rise and Waiver of Liability Relating to Coronavirus/COVID-19 By selecting this section you are agreeing that The novel coronavirus COVID-19 has been declared a worldwide pandemic by the World health organization. COVID-19 is extremely contagious and is believed to spread mainly from person to person contact. As a result, federal, state, and local governments and location , prohibited the congregation of groups of people. Boys & Girls Club for the Umpqua Valley ("Club") has put in place preventative measures to reduce the spread of COVID-19; however, the club cannot guarantee that you or your child(ren) will not become infected with COVID-19 Further, attending the club could increase your risk and your child(ren)'s risk of contracting COVID-19

MEMBERSHIP ACKNOWLEDGEMENT

By selecting the following you acknowledge the following HEALTH & SAFETY PROCEDURES: The top priority of the Boys & Girls Club of the Umpqua Valley is to safely serve all children and youth in its care. Our staff members will work with families to understand special needs of children seeking accommodation and to identify potential modifications within our ability to safely serve all children attending The Club during the COVID-19 health Crisis. it's important that every parent cooperate fully with the Health & Emergency procedures of the organization. Our regulations are designed to protect the well-being of all members. In a local, regional, or national health emergency, the Governor of Oregon, The Oregon Health Authority, Oregon Department of Education, and Oregon Early Childhood Learning Departments have required The Club to modify its regular procedures by adding more rigor, regulations, and restrictions to ensure our ability to safely operate our facilities and programs. Processes require additional screening, parental acknowledgement of health and wellness, provision of documentation, and verification of compliance with organizational standards prior to admission to program or services, and modified operation hours. All process implementation is done in accordance with modified organizational policy, and at adherence to local, state and federal laws and ordinances.

MEMBERSHIP

By accepting the following you agree that The Boys & girls Club of the umpqua Valley's school Year Program provides membership to youth entering grades 1-12, regardless of race, color, religion, gender, or national origin. Priority will be given on a first come first served basis with limited sports available per grade level. BGCUV reserves the right to refuse or terminate the membership of a participant for any failure to comply with policies and procedures set forth by the organization which allows for the safe operation of its facilities and programs. Children must be able to follow all staff directions at all times. BGCUV reserves the right to refuse service during this health crisis to any member that poses a risk to themselves or any other children or requires supervision that would detract from the staff to safely run programming.