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Greenwood Unit
Summer Camp Registration Application
FMI please call
361-853-2505
or email
cysassi@bgccb.org
summer_registration_forms.pdf
File Size:
3731 kb
File Type:
pdf
Download File
General Information:
*
Indicates required field
Boys & Girls Clubs of the Coastal Bend
Unit
*
Choose One
Greenwood Unit
London ISD Unit
Flour Bluff ISD Unit
Ingleside ISD Unit
Director's Name
*
Child's Full Name
*
First, Middle, Last
Child's Date of Birth (MM/DD/YYYY)
*
Child's Age
*
Child's Shirt Size
*
Choose One
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult 1x
Adult 2x
My child attends the following school
*
School Phone Number
*
Child's Grade
*
Child's Gender
*
Child's Social Security No.
*
Is the child a previous Club member?
*
Choose One
Yes
No
Date of Admission
*
Date of Withdrawal
*
Child's Home Address
*
Line 1
Line 2
City
State
Zip Code
Country
County
*
Name of Person Completing Form
*
First
Last
Relationship to Child
*
Child Lives With
*
Choose One
Both Parents
Mom
Dad
Guardian
Primary language spoken at home
*
Primary parent(s)/guardian(s)
please list name, telephone number, email address, address, and employer information below where you
may be reached while child is in care.
Parent 1/Guardian Name
*
First
Last
Parent 1/Guardian Telephone No.
*
Parent 1/Guardian Email Address
*
Parent 1/Guardian Employer
*
Parent 1/Guardian Employer's No.
*
Parent 1/Guardian Occupation
*
Parent 1/Guardian Address (if different from the child's)
*
Line 1
Line 2
City
State
Zip Code
Country
Parent 2/Guardian Name
*
First
Last
Parent 2/Guardian Telephone No.
*
Parent 2/Guardian Email Address
*
Parent 2/Guardian Employer
*
Parent 2/Guardian Employer's No.
*
Parent 2/Guardian Occupation
*
Parent 2/Guardian Address (if different from the child's)
*
Line 1
Line 2
City
State
Zip Code
Country
Give the name, phone number, address, and relationship of the responsible individual to call
in case of an emergency
if parents/guardian cannot be reached
#1 Emergency Contact Name
*
First
Last
#1 Emergency Contact Telephone No.
*
#1 Emergency Contacts Relationship to Child
*
#1 Emergency Contact Address
*
Line 1
Line 2
City
State
Zip Code
Country
#2 Emergency Contact Name
*
First
Last
#2 Emergency Contact Telephone No.
*
#2 Emergency Contacts Relationship to Child
*
#2 Emergency Contact Address
*
Line 1
Line 2
City
State
Zip Code
Country
I authorize the child care operation
to release
my child to leave the child care operation
ONLY
with the following persons. Please list name and telephone number of each.
Children will only be released to a parent, guardian, or a person designated below by the parent/guardian after verification of ID.
My child has permission to (check all that apply)
*
Walk to or from school or home
Ride a bus
Be released to the care of his/her sibling under 18 years old
None of the above, my child does NOT have permission to sign out on their own
Custody Documents on File
*
Select One
Yes
No
Documents must be submitted for individuals unauthorized to pickup child.
Upload Documents
*
Max file size: 20MB
Name
*
First
Last
Phone Number
*
If applicable, upload an image/school ID of the sibling under 18 years old authorized to pickup child(ren)
*
Max file size: 20MB
Name
*
First
Last
Phone Number
*
If applicable, upload an image/school ID of the sibling under 18 years old authorized to pickup child(ren)
*
Max file size: 20MB
Name
*
First
Last
Phone Number
*
If applicable, upload an image/school ID of the sibling under 18 years old authorized to pickup child(ren)
*
Max file size: 20MB
Consent Information:
1. Transportation
I understand that members are responsible for their own transportation to and from the Club. I give permission for my child to ride the Boys & Girls Clubs of the Coastal Bend's (BGCCB) bus/van transportation to and from school, home, and any other necessary travel for Club activities. I understand that all precautions will be taken for the safety of my child and I will not hold BGCCB, its officers, or volunteers responsible for any accident occurring during travel. I authorize the staff in charge to approve medical treatment for my child in the event of an emergency. I acknowledge by signing this form that my child will be eligible to ride the Boys & Girls Clubs vehicles but by not signing, they will not be able to be transported.
I authorize transportation service from my child's school to the Club for the current school year. I understand BGCCB reserves the right to remove my child from pick up service. I understand that to remain on the pick-up service, my child must attend 3 or more times a week.
I give consent for my child to be transported and supervised by the operation's employees: (check all that apply)
*
For emergency care
On field trips
To and from home
To and from school
My child does NOT have permission to use BGCCB transportation
Electronic Signature (Transportation Consent)
*
First
Last
Date (MM/DD/YYYY)
*
2. Field Trips
I authorize travel and the BGCCB to any field trip or outing that I sign my child up for during the SCHOOL YEAR AND/OR SUMMER PROGRAM. I understand that BGCCB reserves the right to remove my child from the van and/or field trip service.
Consent
*
Select One
I give consent for my child to participate in field trips
I do not give consent for my child to participate in field trips
Comments
*
3. Water Activities
I give consent for my child to use the Club pool (Greenwood Unit & Flour Bluff ISD Natatorium) and or participate in water activities. I understand and agree that the Club is not responsible for any bodily injuries incurred and suffered by my child on while in the pool or in the aquatic area or in connection with any activities at any of its facilities, or while engaged in any Club activities away from the Club.
I give consent for my child to participate in the following water actives (choose all that apply)
*
Water table play
Sprinkler
Splashing/wading pools
Swimming pools
Aquatic playground
None of the above, my child does NOT have permission to swim
Does your child know how to swim?
*
Yes, my child knows how to swim
No, my child does not know how to swim
4. Receipt of Written Operational Policies
CLICK HERE: Parent Handbook
I have received a copy of The Boys & Girls Clubs of the Coastal Bend Parent Handbook and I understand that l am responsible for reading the policies and practices described within it.
Electronic Signature (Receipt of Parent Handbook)
*
Date (MM/DD/YYYY)
*
5. Meals
I understand that the following meals will be served to my child while in care:
*
None
Breakfast
Morning snack
Lunch
Afternoon snack
Supper
Evening snack
6. Days and Times in Care
My child is normally in care on the following days and times:
Days of the Week
A.M.
P.M.
Monday
Monday AM
*
Monday PM
*
Tuesday
Tuesday AM
*
Tuesday PM
*
Wednesday
Wednesday AM
*
Wednesday PM
*
Thursday
Thursday AM
*
Thursday PM
*
Friday
Friday AM
*
Friday PM
*
Saturday
Saturday AM - N/A
Saturday PM - N/A
Sunday
Sunday AM - N/A
Sunday PM - NA
Authorization For Emergency Medical Attention:
In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:
Name of Physician
*
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Name of Emergency Care Facility
*
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Insurance Company
*
Policy #:
*
List any special needs that your child may have, such as environmental allergies, food intolerances, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, any medication prescribed for long-term continuous use, and any other information which caregivers should be aware of:
Comment
*
I give consent for the facility to secure any and all necessary emergency medical care for my child.
Electronic Signature (Authorization for Emergency Medical Attention)
*
First
Last
Date (MM/DD/YYYY)
*
COVID-19 Release Form
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization
. COVID-19 is extremely contagious
and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.
Boys & Girls Clubs of The Coastal Bend, Inc. (Club) has put in place preventative measures to reduce the spread of COVID-19; however, the Club
cannot guarantee
that you or your child(ren) will not become infected with COVID-19. Further,
attending the Club could
increase
your risk and your child(ren)’s risk of contracting COVID-19.
By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending the Club and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Club may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Club employees, volunteers, and program participants and their families.
I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the Club or participation in Club programming (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless the Club, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Club, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Club program.
Electronic Signature (COVID-19 Release Form)
*
Date (MM/DD/YYYY)
*
Demographics:
The following information is necessary for our records and the funding our organization receives. The answers you provide are completely confidential. Your cooperation in providing this information is both appreciated and necessary.
Boys & Girls Clubs of the Coastal Bend (BGCCB) does not discriminate based on political affiliation, race, color, national origin, sex, religious, creed, age, disability.
Household income
*
Choose One
$0-$10,000
$10,001-$20,000
$20,001-$30,000
$30,001-$40,000
$40,001-$50,000
$50,001-$62,999
$63,000 and up
Number of persons in household
*
Head of household
*
Choose One
Mom
Dad
Both
Other
Single Parent household
*
Choose One
Yes
No
Which of the following do you currently receive? (Choose all that apply)
*
Food Stamps
Foster Family Care
SSI, SSDI
Free or Reduced Lunch
TANF
Medicaid
Head Start/Early Head Start
Earned Income Tax Credit
None of the above
Number in household that are under 18
*
Number in household that are handicapped
*
Number in household that are over 65+
*
Does child live with
*
Choose One
Mother
Father
Both Parents
Non-family
Guardian
Foster family
Other
If other, please explain
*
Family housing
*
Choose One
Renting
Own
Temp
Public housing
Child's ethnicity
*
Choose One
Hispanic, Latino
White, Caucasian
Black, African American
Asian
Native Hawaiian/Pacific Islander
American Indian/Alaska Native
Bi-racial
Other, Unknown
Are you a militay parent/guardian?
*
Choose One
Yes
No
Do you live on a military base?
*
Choose One
Yes
No
What branch of military service:
*
Choose One
Navy
Army
Marines
Reserves
Retired
Coast Guard
Air Force
Air National Guard
DOD Civilian
Active Duty
Military Parent/Guardian Name
*
First
Last
Military Parent/Guardian Name
*
First
Last
Military Parent/Guardian Rank
*
Military Parent/Guardian Duty Station
*
Liability Release Form
I, the parent/guardian of the minor child listed on the application, for ourselves, our heirs, executors and administration, hereby release, waive, acquit and forever discharge the Boys & Girls Clubs of the Coastal Bend (BGCCB), and Boys & Girls Clubs of America, their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organizations such as staff, directors or volunteers, from all liability, claims, damages, or causes of action for any and all loss, damage, injury or death and any claim or damages resulting from use of facilities owned or controlled by the above organizations, or participation in activities of said organizations either at or away from the Club.
I understand and agree that the Club is not responsible or legally liable for any personal property losses, stolen or for any bodily injuries incurred and suffered by my child on any Club property or in connection with any activities at any of its facilities, or while engaged in any Club activities away from the Club. I understand and agree that the Club does not provide medical insurance for my child.
I, also grant permission to managing personnel or other representatives of the Club to authorize and obtain medical care from any licensed physician, hospital or medical clinic should my child become ill or injured while participating in activities away from home, or at any time when neither available to grant authorization for medical treatment. I will furnish a certified birth certificate of the above named upon request by sponsors or supervisors. I further understand and agree that the Club cannot and will not administer prescription or over the counter medications of any kind to my child (or ward).
In the event of an emergency I authorize BGCCB to secure medical treatment for my child (or ward) and that I, as the legal guardian, will assume any and all responsible for paying medical expenses associated with such treatment.
Electronic Signature (Liability Release Form)
*
First
Last
Date (MM/DD/YYYY)
*
Programs
Boys & Girls Clubs of the Coastal Bend (BGCCB) offers programs which enhance learning in education and career opportunities, character and leadership, social development, fitness and sports as well as health and life skills. During program hours, youth will be asked to participate in program activities. Activities consist of games & high yield learning experiences that promote academic success, good character & citizenship, and healthy lifestyles.
Our programs are designed by separate age groups, 6 & 7, 8 & 9, 10-12 (may be 8-12 in some cases), & 13-18. Depending on the age of your child, the program curriculum may include but is not limited to:
S.M.A.R.T. Moves (Skills Mastery and Resistance Training), a national prevention program that helps young people avoid alcohol, tobacco, other drugs, and teen pregnancy.
Street S.M.A.R.T., a national program on gang and violence prevention and conflict resolution, valuing differences and positive peer helpers.
S.M.A.R.T. Girls, a national program that offers age-specific activities designed to build character and instill the values of integrity, self-discipline, and mutual respect.
Passport to Manhood, a national program that instills in young boys the values and moral compass that will assist them in their journey from adolescence to manhood. I understand that topics of discussion may include physical, emotional, and social changes in our bodies, dating, and sexual issues such as HIV and other diseases, nutritional habits including eating disorders, healthy exercise, communication skills, taking care of your body, ethics, wellness, respect to authority and employment exploration and careers.
In addition, as part of our programs, we may be administering surveys and pre & post-test to assess our member's knowledge and understanding of some of the topics they learn from in the BGCCB program curriculum.
I, as legal guardian of the child(ren) listed on this form, give my permission for them to participate in the program activities mentioned above. All information shared in groups or through questionnaires and surveys will not be linked to my child, as responses will be automatically grouped together with the responses of other Boys & Girls Club members. I understand that if any public presentation of the finding should be made, my child's individual responses will not be linked to him/her or my family. I as the consenting parent/guardian agree to encourage my child and actively participate in the programs. I understand that I can relinquish my permission at any time in writing. I, as the parent/guardian, understand and consent for my child to participate in their age appropriate BGCCB projects, program groups, and activities.
Electronic Signature (Programs)
*
First
Last
Date (MM/DD/YYYY)
*
Authorization
Please read the following, indicate Yes/No for each statement and electronically sign below indicating agreement and permission.
COMPUTER USE AGREEMENT
Computer Use Agreement
*
Choose One
Yes
No
I understand and agree that as a member my child will have access to the internet. While precautions are being taken, it is possible that he/she may access inappropriate sites. The Boys and Girl Clubs will have rules and consequences at the Club for such behavior; however we will not be responsible for the consequences of such access. I give permission for my child to use the Boys & Girls Clubs of the Coastal Bend, Technology Program; including but not limited to computers, tablets, printers, software, the Internet, database access, and audio-visual equipment/game systems. By signing below, I will discuss with my child the importance of following the rules and will accept responsibility for the repair/replacement costs due to my child's negligence or destructive behavior.
DATA COLLECTION WAIVER
Data Collection Waiver
*
Choose One
Yes
No
I give permission for the Club to administer occasional anonymous surveys to my child (or ward) via online or written survey, questionnaires, interviews and focus groups, for purposes of better understanding the needs of my child (or ward) and the impact of the Club on my child (or ward). Information will be kept strictly confidential. Data gathered through these means will be summarized in the aggregate and will exclude all references to any individual response. The aggregated results of the analyses may be shared with club staff, Boys & Girls Clubs of America, funders and other community stakeholders to evidence program effectiveness and/or Club impact on our members.
DATA SHARING WAIVER
Data Sharing Wavier
*
Choose One
Yes
No
I understand that the Boys & Girls Clubs of the Coastal Bend (BGCCB) share information about my child with Boys & Girls Clubs of America for research purposes and/or to evaluate the program's effectiveness. Information that will be disclosed may include the information provided on this membership application form, information provided by the my child's school or school district, and other information collected by Boys & Girls Clubs of the Coastal Bend including data collected via surveys or questionnaires. All information provided to and from BGCCB will be kept confidential.
SCHOOL INFORMATION
School Information
*
Choose One
Yes
No
I give permission for the Club exchange information regarding my child, to make and retain copies of my child's (or ward's) report cards and/or progress reports or to be given access to school records pertaining to my child (or ward) in order to better understand the academic needs of my child (or ward) and to better assist him/her in his/her educational pursuits. I understand that copies made of report cards and/or progress reports will remain confidential and will only be viewed by BGCCB staff. I give permission for the Club to obtain age verification of my child (or ward) from their current school.
MEDIA AND PHOTOGRAPHIC RELEASE
Media And Photographic Release
*
Choose One
Yes
No
The Boys & Girls Clubs of the Coastal Bend as well as Boys & Girls Clubs of America frequently use photographs and information from surveys and quotes that members do to publicize programs. Your permission is needed to use photos, testimonies, and videos, including information from surveys and/or quotes of your child(ren) on our web site (www.bgccb.org) in informational brochures, social media and in news articles. I give my consent for any photographs or reproductions thereof (while he/she is engaged in Club-related activities) and in which my child(ren) appear or quotes my child(ren) give to be used in anyway the Club may choose including grant/publicity/fundraising purposes.
MOVIE USE AGREEMENT
Movie use Agreement
*
Choose One
Yes
No
I give consent for my child/children to view family movies that are rated "G" OR "PG" that is provided by the Boys & Girls Clubs of the Coastal Bend for specific programming. Movies rated PG-13 are only permitted in the Teen Center with youth ages 13+. Any movie rating above PG-13 will require an additional permission slip for the parent/guardian to sign.
LATE PICKUP FEES
Late Pickup Fees
*
Choose One
Yes
No
I understand and agree that my child (or ward) must be picked up by closing time or a fee of $30 will be charged at six minutes after the regular scheduled time of closure and a $1.00 for each minute afterwards. If my child is not picked up 30 minutes after closing, local authorities may be notified. All fees are expected to by paid prior to my child(ren) returning to the Club and to maintain eligibility for after-school transportation service.
NO REFUND POLICY
No Refund Policy
*
Choose One
Yes
No
I understand and agree that the Club does not refund membership and/or registration costs. In addition, I understand and agree that my child (or ward) must obey all standards of conduct. I further understand that behavioral problems that cannot be resolved may result in my child (or ward) being suspended from the Club without monetary refund.
GENERAL ACKNOWLEDGEMENT
The undersigned represents that he/she is the parent and/or legal guardian of the minor named in this application, and represents that he/she has the legal authority to execute the consents and releases named within. If the child/applicant is signing for him or herself, the undersigned warrants that he/she has reached the age of legal majority according to the State of Texas.
Electronic Signature (General Acknowledgement)
*
First
Last
Date (MM/DD/YYYY)
*
Submit
Home
About Us
Boys & Girls Clubs of America
Our Team
Our Board
Careers
Policies
Our Clubs
Registration
>
Early Learning Center
Greenwood - Spring
Flour Bluff - Fall
Ingleside - Fall
Youth Athletics
MyFuture Login
Events
Beads, Bets, & Beignets
Serve It Forward Pickleball Champions
Donate
Wish List