* 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
* Name:
* Relationship to Child:
* Address:
Address 2:
* City:
* State:
* Zip:
* Phone Number:
Email:
* Employer:
Name:
Relationship to Child:
Address:
Address 2:
City:
State:
Zip:
Phone Number:
Email:
Employer:
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:
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:
* Name:
* Relationship to Child:
* Address:
* Phone Number:
Name:
Relationship to Child:
Address:
Phone Number:
Personal development, behavior, patterns, habits and individual needs:
Physician or Clinic
* Name:
* Phone:
Preferred Hospital
* Name:
* Phone:
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
Afternoon SnackLunch (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:
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.
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:
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:
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.