Membership Application

Springfield Boys & Girls Club
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School Information:

Medical Information:

General:

Household:
NOTE: This information is collected for Grand writing purposes ONLY

Physical:

Disclaimers:
The Springfield Boys & Girls Club encourages members to leave anything of value at home. The Club will not be liable for any lost or stolen items. Large amounts of money, expensive clothes, jewelry, and electronics should be kept at home. Weapons of any kind are not allowed in the Club, and may result in immediate termination. Fighting and using abusive language will not be tolerated and are grounds for suspension and/or termination. Children are to be picked up at the times designated by club officials. If a child is not picked up on time, the parent/guardian may be subject to a late fee.

For all drop-in members, the Club has an Open Door Policy. Members are allowed to come and go as they please. We assume no responsibility for members who choose not to come on a particular day or who choose to leave early. We only supervise youth while in our building, in our play area, or once we pick them up from a school for a particular program. If you want your child to remain in the Club at all times, please instruct them not to leave. If a child does not walk home on their own, please make arrangements prior to pick them up on time. Any child picked up after their allowed time may be subject to late fees and eventually removal from the program. Any children left at the Club after the allotted program time for more than an hour without notification may be considered abandoned and police may be notified.

Authorizations:
Medical: I hereby given consent to have my child treated by a physician or surgeon in case of sudden illness or injury while participating in a SBGC programs. I understand that the SBGC will make every attempt to contact me beforehand. It is also understood that the cost thereof will be my expense.

Surveys/Questionnaires: I hereby give permission for my child to participate in the tracking of SBGC outcomes/goals, which include: taking surveys, participating in focus groups. I also grant access to my child’s academic records i.e. report cards, which will be kept confidential and used specifically for the purpose of evaluating the success of SBGC programs and supporting your child’s academic success.

Technology: I understand that as a member of the SBGC, my child will have access to the Internet. While precautions are taken through cyber patrol, my child may try to access inappropriate sites. SBGC has rules and consequences at the Club for such behavior; however the SBGC will not be held responsible for the consequences of such access.

Miscellaneous: I hereby give permission to my child to become a member of the Springfield Boys & Girls Club. I understand that my child must follow the rules and expectations of the SBGC and its staff. I will explain the rules of the Club to my child and hold him/her responsible to follow those rules. SBGC staff reserves the right to suspend or terminate a member if those guidelines are not followed and I understand no dues will be returned to me.

Photo Release: I hereby give consent to the SBGC and/or its representatives to photograph my child. I authorize them to use these photos in any future publications, events, advertisements, articles, or other use relating to the SBGC. I release the SBGC, its staff, officers, and representatives for all claims of invasion of privacy, defamation or any claim based on the use of said photograph.

Please Read Carefully:
I have received and will read the Parent/Member Drop In Info Handout. I understand my child and I must follow all the rules of the Springfield Boys & Girls Club. By signing below, I agree and will adhere to all of the above disclaimers and authorizations. I also agree that all information is complete and correct to best of my knowledge. I understand failure to disclose any pertinent medical, educational, or social issues may result in termination of membership.

PRIMARY CONTACT

Additional Contact

Additional Contact

Additional Contact

CITY OF SPRINGFIELD OFFICE OF COMMUNITY DEVELOPMENT
INCOME VERIFICATION

The City of Springfield's Office of Community Development has provided HUD-funded assistance to this agency. HUD requires that we provide the information contained below for each person assisted.

All information must be completed.

GENERAL INFORMATION:

DEMOGRAPHIC INFORMATION: (for reporting purposes only)
NOTE: If your program serves children, you must provide characteristics of their household. 1. Number of children served by each group; 2. Number of children from female heads of households.

IMPORTANT: HUD considers race and Hispanic origin to be two separate and distinct concepts. Please fill in information for both ethnicity and race below. PLEASE DO NOT LEAVE ANY SECTIONS BLANK.

Indicate Ethnicity (check one)

Indicate race (select one)

Income of participant household (updated as of December 2012)

Photograph Release and Press Interview Authorization

Dear Parent/Guardian

I hereby consent to and authorize the Springfield Boys & Girls Club and its staff, and or representatives to photograph or interview my minor child (children) as listed below, and to exhibit, print, publish, copyright, distribute or otherwise use such photographs for any publication, event, advertisement, article or other use relating to the Springfield Boys & Girls Club.

I release the Springfield Boys & Girls Club, its directors, officers, employees, and representatives from any and all claims for invasion of privacy, defamation or any claim based on the use of any such photograph or interview. I understand the Springfield Boys & Girls Club may or may not include names when using such photos or interviews.

If I am signing this Release on behalf of minor children, I warrant and certify that I am the parent or legal guardian listed below and that I have legal authority to sign this Release on their behalf.

Springfield Boys & Girls Club Technology Center
Internet and Electronic Mail Permission Form

As a member of the Springfield Boys & Girls Club your child will have access to our Technology Center, which includes access to the Internet and electronic mail (e-mail). To gain access to the Internet and e-mail we ask that the parents read the information below and sign the permission sign the permission form giving your child access to the Technology Center and all that it has to offer.

Some materials accessible via the Internet may contain items that are illegal, defamatory, inaccurate or potentially offensive to some people. The network has a filtering system, which is designed to block the transmission of inappropriate material. However, no filtering system is perfect-users may occasionally have access to material that parents may determine inappropriate. The Club believes that the benefit to the members, in the form of access to the information and opportunities for communication, exceeds any disadvantages. Users are expected to be responsible and use the Internet appropriately according to the rules outlined below.

At times some children will be designing web pages and parents should be aware that information published on the World Wide Web will be public and accessible to Internet users around the world.

Springfield Boys & Girls Club Internet and E-mail Rules

The network is provided for students to conduct research and communicate with others. Access to network services is given to students who agree to act in a considerable and responsible manner. Access is a privilege-not a right. Access entails responsibility. Individual users of the computer network are responsible to their own behavior and communication over those networks. It is presumed that users will comply with SBGC standards and will honor the agreements that have been signed. Beyond the clarification of such standards, SBGC is not responsible for restricting, monitoring or controlling their communications of individuals utilizing the network.

Network administrators may review files and communication (including incoming and out-going e-mail) to maintain system integrity and insure that users are using the system responsibly. Users should not expect that files stored on the network will always be private.

As outlined in the SBGC Technology Center Acceptable Use Policy, the following are not permitted.

  • Harassing, insulting or attacking others via e-mail or other method
  • Damaging computers, computer systems or computer networks
  • Violating copyright laws
  • Accessing other accounts or allowing others to access your account
  • Intentionally wasting limited resources
  • Using the network for commercial purposes, including buying and selling goods and services through the Internet
  • Revealing personal information about yourself or others
  • Using unauthorized chat rooms
  • Using obscene language
  • Sending, receiving, or displaying offensive massage or pictures (including but not limited to pornographic, violent, racially offensive and illegal materials)

Violations may result in loss of access as well as other disciplinary or legal action.

As the parent or legal guardian of a SBGC member, I grant permission for my child to use the SBGC Technology Center and to access networked computer services such as the Internet and electronic mail. I understand that individuals and families may be held liable for violations. I understand that some materials on the Internet may be objectionable, but I accept responsibility for guidance of Internet use - setting and conveying standards for my child to follow when selecting, sharing or exploring information and media.

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