* Child's Name:

* Date of Birth:

* Address:

* City:

* Zip:

* Ethnicity:—Please choose an option—African-AmericanAsianCaucasianHispanicNative AmericanMulti-RacialOther

My child will attend the Club Site located in Sedalia Housing Authority (Saline Site).

Household Annual Income:

My child has allergies

Please list/explain

* Member lives with:—Please choose an option—Both ParentsMother OnlyFather OnlyAunt/UncleGrandparentGuardian/Other

* Name:

* Address:

* City:

* Zip:

Email:

Name:

Address:

City:

Zip:

Email:

Facility Provider Name:Boys & Girls Clubs of West Central Missouri

Discharge Date:

Gender:

Address:

City:

Zip:

Mother/Guardian (If this does not apply please type NA in boxes)

* Name:

* Home Phone:

Email:

* Work/School Schedule:

* Work Phone:

Father/Guardian (if this does not apply please type NA in boxes)

* Name:

* Home Phone:

Email:

* Work/School Schedule:

* Work Phone:

* Name:

* Address:

Name:

Address:

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

I understand that I will be notified at once in case of an emergency with my child and I will make arrangements for medical care of my child with the physician or hospital of my choice. If I cannot be reached to make necessary arrangements or in a critical emergency requiring medical care, I authorize Boys & Girls Clubs of West Central Missouri to contact the following:

Physician or Clinic

* Name:

* Phone:

Preferred Hospital

* Name:

* Phone:

I have received a copy of this facility's policies pertaining to the admission, care and discharge of children.
I have been informed that a copy of the licensing rules for child care homes or the licensing rules for group child care homes and centers is available at this facility for review.
The provider and I have agreed on a plan for continuing communication regarding my child’s development, behavior and individual needs.
When my child is ill, I understand and agree that s/he may not be accepted for care or remain in care.
I understand that before the first day of attendance by my child, I will provide proof of completed age-appropriate immunizations or exemption from immunizations.

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.

I have been notified that I may request notice at initial enrollment or any time there after whether there are children currently enrolled in or attending the facility for whom an immunization exemption has been filed.

Check which days and times your child will usually attend Boys & Girls Club:
Mondays: 6:30 AM to 5:30 PMTuesdays: 6:30 AM to 5:30 PMWednesdays: 6:30 AM to 5:30 PMThursdays: 6:30 AM to 5:30 PMFridays: 6:30 AM to 5:30 PM

Afternoon SnackBreakfast (Summer Program Only)Lunch (Summer Program Only)

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

Child's Name:

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.

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:

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:

* I have read and agree to the Member Success Statement

* I have read the completed application, understand the rules of the Club’s Parent/Member Handbook, and request that my child be admitted as a member into the Boys & Girls Clubs of West Central Missouri. I have explained the rules to my child and will be responsible for any damages caused by his/her actions. I agree to hold harmless the Boys & Girls Club, or any representative thereof, for injuries or accidents in connection with the Club’s activities, and authorize the Club to administer first aid in case of an accident. I also give the Club permission to authorize and obtain emergency treatment if needed. I understand the Club does not assume responsibility for my child if he/she leaves the Club at any time during the hours of operation, with or without permission. I give consent to my child’s school for the release of grades and/or MAP/EOC scores, attendance and disciplinary records, and immunization records to the Club. I further acknowledge that I have the legal authority, custody and control of my child and warrant that I also have the legal right to make these acknowledgements and agreements on behalf of my child. I understand any dues and/or fees paid are non-refundable and are valued at the beginning of the school year and good through the end of summer.

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.