2019-2020 Membership Application

Program *
Member Name *
Member Name
Date of Birth *
Date of Birth
Member Phone
Member Phone
Address *
Address
Mailing Address (if different than above)
Mailing Address (if different than above)
Race/Ethnicity *
Physician
Physician
Physician Phone
Physician Phone
Primary Parent/Guradian Name *
Primary Parent/Guradian Name
Primary Parent/Guardian Address (if different than member)
Primary Parent/Guardian Address (if different than member)
Primary Parent/Guardian Cell Phone *
Primary Parent/Guardian Cell Phone
Primary Parent/Guardian Home Phone
Primary Parent/Guardian Home Phone
Primary Parent/Guardian Work Phone
Primary Parent/Guardian Work Phone
Secondary Parent/Guardian Name
Secondary Parent/Guardian Name
Secondary Parent/Guardian Address (if different than member)
Secondary Parent/Guardian Address (if different than member)
Secondary Parent/Guardian Cell Phone
Secondary Parent/Guardian Cell Phone
Secondary Parent/Guardian Home Phone
Secondary Parent/Guardian Home Phone
Secondary Parent/Guardian Work Phone
Secondary Parent/Guardian Work Phone
Emergency Contact/Authorized Pick Up #1 *
Emergency Contact/Authorized Pick Up #1
Emergency Contact/Authorized Pick Up #1 Cell Phone *
Emergency Contact/Authorized Pick Up #1 Cell Phone
Emergency Contact/Authorized Pick Up #1 Home Phone
Emergency Contact/Authorized Pick Up #1 Home Phone
Emergency Contact/Authorized Pick Up #1 Work Phone
Emergency Contact/Authorized Pick Up #1 Work Phone
Emergency Contact/Authorized Pick Up #2
Emergency Contact/Authorized Pick Up #2
Emergency Contact/Authorized Pick Up #2 Cell Phone
Emergency Contact/Authorized Pick Up #2 Cell Phone
Emergency Contact/Authorized Pick Up #2 Home Phone
Emergency Contact/Authorized Pick Up #2 Home Phone
Emergency Contact/Authorized Pick Up #2 Work Phone
Emergency Contact/Authorized Pick Up #2 Work Phone
Emergency Contact/Authorized Pick Up #3
Emergency Contact/Authorized Pick Up #3
Emergency Contact/Authorized Pick Up #3 Cell Phone
Emergency Contact/Authorized Pick Up #3 Cell Phone
Emergency Contact/Authorized Pick Up #3 Home Phone
Emergency Contact/Authorized Pick Up #3 Home Phone
Emergency Contact/Authorized Pick Up #3 Work Phone
Emergency Contact/Authorized Pick Up #3 Work Phone
Programs Used (check all that apply)
DISCLAIMER: *
I agree to abide by the rules and regulations of the Boys & Girls Club of El Dorado County Western Slope, and my child may participate in all supervised programs offered through the Club. I understand that membership is based upon mutual respect and consideration between members and staff. The staff of the Boys & Girls Club has my permission to obtain emergency medical care for my child should they be unable to reach me.
INDEMNIFICATION: *
Parent(s)/Guardian(s) agree to release and hold harmless the Club, its agents and employees, from ALL claims, damages, or other liabilities for injuries to their child, which are not the result of gross negligence by the Club, its agents or employees. Parent(s)/Guardian(s) also agree to pay the Club for any damages or loss by their child to the Club or Club property. The Club is not responsible for damages to or theft of personal property left on the Club grounds.
I grant the Boys & Girls Club of El Dorado County Western Slope my permission to obtain school records, transcripts, grade reports (report cards and progress reports), and all test results. I also grant Boys & Girls Club of El Dorado County Western Slope staff my permission to speak with teachers, counselors, and other school administrators at my child’s school in order to obtain and exchange information as part of the services provided by the Boys & Girls Club of El Dorado County Western Slope’s program.
1. Members must attend a minimum of three days per week to qualify and to maintain scholarship. 2. Members must pay Annual Membership fee of $25. 3. Members that do not attend a minimum of three days per week are not eligible for the fee waiver and the normal fee structure will apply.
I hereby give the Boys & Girls Club irrevocable right and permission to use photographs and videos taken of my child at the Club or during Club events to be used for promotional and advertising purposes. I waive all rights for compensation and liabilities. This section not applicable to the EDH Clubhouse. The EDH Clubhouse uses the EDHCSD’s photo release policy signed at time of program registration.
BRING YOUR OWN DEVICE POLICY: *
Personally owned devices are permitted for use during Club time for Club purposes and in approved locations only. Any inappropriate use of a personally owned device, as determined by Club staff, can lead to disciplinary action. Please see the full Bring Your Own Device policy located in the Member Handbook for more information.
CLUB HANDBOOK: *
For members attending the Boys & Girls Club program parents/guardians will receive a handbook at signup. Parent/Guardian & member agree to read and abide by the policies and procedures laid out in the BGCE Member Handbook.
Members are permitted to access the internet while on Club computers for Club purposes and during approved times only. Any inappropriate use or access of the internet, as outlined in the Club’s Internet Use policy and as determined by Club staff, can lead to disciplinary action, Please see the full Internet Use policy for more information. I give my child permission to access the internet while at the Club.
SMART Girls & Passport to Manhood are programs that educates members about healthy attitudes and lifestyles. Children in grades 2-12 may participate in this program. For more information, please see the Front Desk. I give my child permission to participate in the SMART Girls or Passport to Manhood program.
Mentoring is a program that pairs members one-on-one with specially trained staff. Mentoring will take place only at the Club facility. For more information, please see the Front Desk. I give my child permission to participate in BGCA’s Mentoring program.
Parent/Guardian Signature *
Parent/Guardian Signature
Please enter the name of the parent/guardian completing this form. By submitting this form you acknowledge that the information entered above is accurate and you have read and understand the parent/guardian agreement.