Member Information

* Child's Name:
*Gender:
* Date of Birth:
* Age:
* Address:
Address 2:
* City:
* State:
* Zip:
* Phone Number:
* Ethnicity:
* School:
* Grade:
Household Annual Income:
My child qualifies for free/reduced lunchMy child receives SSI, is under court-ordered supervision, is in foster care and/or receives services through the Dept. of Mental HealthMy child has a functional challenge according to medical evidence and requires special attention
Are there other siblings in the household? (list names/grade)
* Member lives with:
Parent/Guardian is employed with Boys & Girls ClubParent/Guardian is employed with Partnering School DistrictMember has a parent serving in the military
Military Branch:
Military Status:
** Ask about military discount

Contact Information

Primary Contact

* Name:
* Relationship to Child:
* Address:
Address 2:
* City:
* State:
* Zip:
* Phone Number:
Email:
* Employer:

Secondary Contact

Name:
Relationship to Child:
Address:
Address 2:
City:
State:
Zip:
Phone Number:
Email:
Employer:

Missouri Department of Health and Human Services Child Care Enrollment Form

Facility Provider Name:Boys & Girls Clubs of West Central Missouri
Admission Date:
Discharge Date:
Child's Name:
Gender:
Date of Birth:
Address:
Address 2:
City:
State:
Zip:

Identifying Information

Mother/Guardian
* Name:
* Address:
* Home Phone:
* Cell Phone:
Email:
* Employer/School Attend:
* Work/School Schedule:
* Employer/School Address:
* Work Phone:
Father/Guardian
* Name:
* Address:
* Home Phone:
* Cell Phone:
Email:
* Employer/School Attend:
* Work/School Schedule:
* Employer/School Address:
* Work Phone:

Emergency Contact & Persons Authorized to Take Child from Facility (Other Than Parent) - At Least One Emergency Contact Is Required

* Name:
* Relationship to Child:
* Address:
* Phone Number:
 
Name:
Relationship to Child:
Address:
Phone Number:

Comments on Child's Development

Personal development, behavior, patterns, habits and individual needs:

Authorization for Emergency Medical Care

Physician or Clinic
* Name:
* Phone:
Preferred Hospital
* Name:
* Phone:

Acknowledgements





I doI do not
... give my permission for field trips/excursions. I understand I will be notified in advance when they are planned.

I doI do not
... give my permission for the facility to transport my child.

Child & Adult Care Food Program

Child's Projected Attendance Schedule

Check which days and times your child will usually attend Boys & Girls Club:
Mondays: 3 to 6:30 PMTuesdays: 3 to 6:30 PMWednesdays: 3 to 6:30 PMThursdays: 3 to 6:30 PMFridays: 3 to 6:30 PM

Write any comments, changes or variations in usual attendance in this section, including shift changes:

Check the meals your child is usually given at this facility:

Afternoon SnackLunch (Summer Program Only)

Check the holidays your child is in care at this facility:

New Years Day (January) BGC Closed
Martin Luther King Jr. Day (February)
Presidents Day (February)
Easter (March/April)
Memorial Day (May) BGC Closed
Independence Day (July) BGC Closed
Labor Day (September) BGC Closed
Columbus Day (October)
Veterans Day (November)
Election Day (November)
Thanksgiving (November) BGC Closed
Christmas (December) BGC Closed

Parent's Health Statement For School-Age Child

Child's Name:
Date of Birth:
Check One:
My child is in good health, is able to participate in group care, has no special health or medical requirements.My child is able to participate but has special health or medical requirements. Please list any allergies, special medical conditions including chronic health programs (such as asthma, seizures), behavioral issues, special needs, etc.
Comments:

Marketing/Photography Release

I doI do not
... grant Boys & Girls Clubs of West Central Missouri the right to interview, use quotes, take photos and videos of my child. I also grant Boys & Girls Club the right to edit, use and reuse said products for nonprofit purposes, including use in print media and on the Club’s social media pages. I also hereby release the Boys & Girls Club and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.
Child's Name:
Grade:

Program Participation Consent Form

Boys & Girls Club provides programs that promote positive behaviors, health, well-being and personal success. With these protective factors, young people have the tools to overcome the many challenges they face today. All programs are tailored to specific age groups.
My child has permission to attend:
SMART Moves – a nationally acclaimed prevention program aimed at educating youth about the dangers of tobacco, alcohol and drug useSMART Girls – health, fitness, prevention/education an self-esteem enhancement program for girls 8 to 14Passport to Manhood – educates and encourages males on their journey to manhood while promoting positive values, responsible behavior and healthy attitudes and lifestyles, for boys 8 to 14Meth SMART – designed to help youth understand how to achieve life goals without succumbing to the threat of drugs, particularly meth.
Child's Name:
Age:

Member Success Agreement

Parent/Guardian Electronic Signature

Name:
Signature Date:
By entering your full name and date into the fields above, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement.