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

    Please list/explain

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

    * Name:

    * Address:

    * Home Phone:

    * Cell Phone:

    Email:

    * Employer/School Attend:

    * Work/School Schedule:

    * Employer/School Address:

    * Work Phone:

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

    * 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: 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

    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 SnackBreakfast (Summer Program Only)Lunch (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 a special food, health or medical requirement. Please list at food allergies, special medical conditions including chronic health problems (asthma, seizures, etc.) 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:

    Permission To Leave

    This permission is solely for the purpose of allowing your child to sign his or herself out of the program, with no adult supervision, and allow them to leave the facility on their own.

    No, I do not give my child permission to leave Boys & Girls Club on their ownYes, I give my child permission to leave Boys & Girls Club on their own

    [group permission-to-leave-conditionals]

    Comments:

    [/group]

    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 use. Additionally, definitions of safe and unsafe contact with strangers are addressed with children along with team and character building exercises. Focusing on males and females ranging from the age 6-14, each program is tailored to the age of participants.Journeys: Paths to Adulthood - is a program built to give young people the space, support and tools they need to navigate the journey of adolescence as they grow to emerge as strong, healthy young adults. This program will help youth develop self-esteem, emotional expression and coping strategies as tools to support them during adolescence. This program is intended for young people ages 10-14.Too Good For Drugs - is a prevention education and character development program that equips youth to make healthy choices as they make the journey to reaching their goals and avoiding substance use and aggressive behavior so they can be positive, healthy, happy kids. This program is for youth K-12 and tailored to the age of participants.

    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.