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To register your child with one of our units, please submit the following information.  The information you provide will be forwarded to the club you specify.  Parents will still have to pay the membership fee and sign off on Club policies.  Members will need to sign off on the Club rules.  Your child must already be in First grade or higher to attend the summer program.  A copy of a report card may be required, and if participating in sports a birth certificate may also be required.

Choose one of the following options:

Is your child currently a member?

Yes No

Please provide the following Child's information:

Child's First Name
Middle Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
School
Grade
Age

Enter the child's date of birth:

-- mm/dd/yyyy

How many brothers ?

What are their ages?

How many sisters ?

What are their ages?

Please provide the following contact information:

Father's Name  
Employed By
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
FAX
E-mail
Mother's Name
Employed By
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
FAX
E-mail

Child is currently living with:

Please provide the following in the case of an emergency:

Contact Name
Employed by
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
Family Doctor
Doctor Phone

Does your child have any Physical or Medical Restrictions? If Yes, explain?

Enter the date of last Physical Exam:

-- mm/dd/yy

Enter the date of last visit to Dentist:

-- mm/dd/yy

The following information is optional.  Often times we are asked this type of information when applying for grants and other funding.  This information is strictly for statistical purposes.  Your personal information will be kept confidential.  Your assistance is appreciated.

Family Income, choose one of the following options:

Are you receiving assistance from any of the following sources (select any of the following options that apply):

Free School Lunch
Public Housing
Section 8 Housing
WIC
Welfare
Lone Star/Food Stamps

 

 

Member Signature Section

Membership Rules

  1. All members and visitors must register at front counter before doing anything else.

  2. You must have your card with you every day when you come to the Club. If you do not have your Club card, you may be asked to go home and get it.  If you loose your Club card it will cost you .50 cents to replace it.

  3. Running is permitted in the Gym area ONLY.  Absolutely no running anywhere else.

  4. Automatic suspension will result from physical abuse of other members or staff, or physical damage to Boys & Girls Club property.  Length of suspension will be determined by staff.

  5. Shirts and shoes must be worn at all times in the club.

  6. The Club is not a place where bad language is used.

  7. Smoking in the building is not permitted.

  8. The kitchen area is a designated eating area.  No food or drinks are allowed in any other area except during special events.

  9. Littering will not be tolerated.  Please put all trash in the numerous trash containers.

  10. Accidental abuse of equipment will result in a warning.  Continued abuse will result in the loss of all Club privileges.

  11. All members and visitors must have their coats properly hung up or placed on shelves.  All articles of clothing should have name tags on them.

  12. Staff are at the Club to help you.  Notify a staff member if you have any problems.

  13. All members are to be involved with activities in the Club and not loitering outside the Club.

 

I understand the rules set by the Boys & Girls Club and promise to take care of its facility and property.  I understand that if anytime I am suspended from the Club that my registration fees will not be returned.  The Boys & Girls Club has my permission to use my likeness in advertisement and promotional materials.

 

Member Signature____________________________________

            I Agree I Disagree

 

 

Parent Signature Section

 

Disclaimer:

The Boys & Girls Clubs of Deep East Texas is not responsible or liable in any way in the event of harm or injury occurring to the member.  It is agreed that the parent or guardian will not hold Boys & Girls Clubs of Deep East Texas responsible for the welfare or whereabouts of the member.  If the parent or guardian does file a complaint against the Club the parent or guardian agrees to pay for the Boys & Girls Clubs of Deep East Texas legal fees.

 

Parent Signature Section:  I wish my child to become a member of the Boys & Girls Clubs of Deep East Texas and hereby agree to allow my child to participate in all sponsored activities .  I understand that the Boys & Girls Clubs of Deep East Texas is NOT a licensed Day Care facility and exempt from operating under Day Care regulations.  I give permission to use my child’s photograph or likeness and name to publicize the Boys & Girls Club.  I also grant permission in case of accident or injury that emergency first aid be given and the warranted treatment by a doctor or hospital be permitted.  I understand the rules set by the Boys & Girls Club and I will take financial responsibility to any damages caused by my child to the facility and property.  I understand that I will be held responsible for any damages caused by my child, directly or indirectly, while on off site activities.  I understand that if at anytime my child is suspended or taken out of the Club that any registration fees or monthly dues will not be returned. 

Injury Policy:  I will not hold the Boys & Girls Clubs of Deep East Texas responsible for any injury that my child may incur while participating in Club programs.

Come and Go Policy:  I understand the Boys & Girls Clubs of Deep East Texas is not responsible for the time nor mannerin which my child may arrive or leave the Club.  I understand that it is my responsibility to instruct my child in the time and manner in which he/she should leave the Club, and I will not hold the Boys & Girls Club responsible for my child after he/she leaves the facility.

Personal Belongings:  I understand that the Boys & Girls Clubs of Deep East Texas is not responsible for damage or theft of my child’s belongings.

Suspension Policy:  I understand that my child can be asked to return his/her membership card as a result of improper behavior.  I also understand that no dues will be refunded to me if such an incident occurs.

Internet Policy:  I understand that the Boys & Girls Club may have internet capability in its computer lab.  I understand that the Club restricts the use of the computer and the internet and that they will make every effort to ensure the members do not visit inappropriate sites.  Further, I  understand that should my child visit inappropriate sites he/she could have his/her computer privileges revoked and may be suspended from the Club.

 

Parents Signature____________________________________

I Agree I Disagree