Author: Rachel

2020-2021 Student Enrollment Form
Boys & Girls Clubs of Harford & Cecil Counties
Conowingo Baptist Church

Any information requested on this form is used for recording purposes or required for funding. The answers you provide on this membership form will be kept CONFIDENTIAL.

STUDENT Information (Please Print)
*denotes required information

*First Name:	Middle Name:	*Last Name:
Nickname:	*Birthdate and current grade level:	*Gender: / Male_______ Female______
Ethnicity: / __African American / __Native American / __Caucasian / __Hispanic/Latino / __Asian / __Multiracial / __Other	*Home Address:	Check all that apply: / __Maryland Scholarship (Child / Care Subsidy) / __TANF / __Food Stamps / __ General Assistance / __SSDI / __SSI / __Free/reduced lunch / __Medicaid / __Single Family Home

PARENT Information (Please Print)
*denotes required information

*First Name:	Middle Name:	*Last Name:
*Home Address:	*Home/Cell Phone Number: / Home: / Cell:	Email Address:
Place of employment:	Work Address:	*Work Phone Number
Check All that apply: / __Military / __Student	Family Size:	Annual Family Income: / __Less than 20,000 / __21,000-30,000 / __31,000 to 40,000 / __41,000 to 50,000 / __51,000 to 60,000 / __61,000 to 70,000 / __71,000 to 80,000 / __81,000 and over

SECOND PARENT Information (Please Print)
*denotes required information

*First Name:	Middle Name:	*Last Name:
*Home Address:	*Home/Cell Phone Number: / Home: / Cell:	Email Address:
Place of employment:	Work Address:	*Work Phone Number:

Check All that apply:
__Military __Student

STUDENT Medical Information
Health Concerns (please specify): / Behavioral Concerns (please specify): / Allergies (please specify):
Any Medications: / Medications student will need during hours of care:
*Insurance Company:
*Physician or Physician Group:
Address:
*Dentist or Dental Group:
Address:

	*Phone Number:

	*Phone Number:

Emergency Contacts Information:
TWO MUST BE ON FILE

1

*denotes required information. At least one phone per Emergency Contact MUST be listed.

*First Name:	*Last Name:	Phone Number Home:	Phone Number Work:	Phone Number Cell:
*Address: Street/Unit #	*City:	*State:	*Zip Code:	Relationship to student:

2

*denotes required information. At least one phone per Emergency Contact MUST be listed.

*First Name:	*Last Name:	Phone Number Home:	Phone Number Work:	Phone Number Cell:
*Address: Street/Unit #	*City:	*State:	*Zip Code:	Relationship to student:

*Student’s Grade:	*Check type of care you are requesting: / ____Before school / ____After school / ____Before and After School

I have read and explained the rules to my student and agree that the Boys and Girls Club of Harford and Cecil Counties and the Boys and Girls Club School Based Programs will not be responsible for any accident to the student while on premises or while engaged in any of the activities away from the Boys & Girls Club and School Based Program.
____________________________________ ___________________________________ _____________
Parent or Guardian Signature Parent’s Name Date
____________________________________ ___________________________________ _____________
Student’s Signature Student’s Name Date

Boys & Girls Clubs of Harford & Cecil Counties
Boys & Girls School Based Programs
Code of Conduct
Play Fairly and Be Honest
Be Respectful of Boys & Girls Club Staff S
ay Only Good Things About Others
Resolve Disagreements in a Positive Way
Be Respectful Of Other Members and Their Property
Take Care of Your Boys & Girls Club Facility and Equipment
Avoid Use of Improper Language
emove Hats Before Entering Building
Applaud The Efforts of Others
Run Outside Only or designated areas
Participate Only In Program Areas Open To Your Age Group
Listen During Assemblies
Dress Appropriately At All Times
Smoking, Drugs, Alcohol and Other Drugs and Weapons Are Strictly Prohibited
Stealing will not be Tolerated!
Please read the following and initial where indicated:
I understand and agree that my child (or ward) must be picked up by closing time or a fee will be charged which must be paid before my child (or ward) can return to the Club. _______ (initial)
I understand and agree that BGCHC does not refund membership fees and that my child (or ward) must obey all rules (Code of Conduct). I further understand that behavioral problems that cannot be solved can result in my child (or ward) being suspended from BGCHC without monetary refund. _______ (initial)
It is expressly understood and agreed that BGCHC shall not be responsible or legally liable for any losses of personal property, for any bodily injuries, or the results thereof, incurred and suffered by the applicant on any property of the BGCHC or in connection with any activities of any of its Units, or while engaged in any of the BGCHC’s activities away from the Club.
I give permission for ________________________ (Name of School) to release a copy of my child, _____________________, report card for the entire school year to the Boys & Girls Clubs of Harford & Cecil Counties. I understand the information obtained from report cards will be confidential and used to assess the progress of my child.
Internet Usage Agreement: The opportunity to use Club’s computers is based upon clear guidelines and agreements: (1) always be respectful of others, (2) never give out personal information over the computer, (3) always remember you are responsible for what you do online, (4) always follow the computer lab supervisor’s instructions, (5) never agree to meet in person with anyone you meet online and (6) never visit ‘off-limits’ web sites. Failure to uphold these agreements will result in revocation of the member’s online privileges. _______ (initial)
____________________________________ ___________________________________ _____________
Parent or Guardian Signature Student’s Signature Date

Permission Sign Off Form
I acknowledge that I have received and therefore responsible for the information present in the Parent Handbook for Boys & Girls for School Based Programing. I have completed the enrollmemt form, Emergency Card (OCC 1214), Health Inventory/Health Assessment (OCC 1215), Medication Administration Form (OCC 1216) if necessary, Seizure Medication Administration Form (if necessary), Asthma Action Plan (if necessary), Emergency Form Information Form for Children with Special Needs ( forms necessary) for enrollment into The Boys and Girls School Based
Program.
____________________________________ ___________________________________ _____________
Parent or Guardian Signature Parent’s Name Date
I acknowledge that the Director of the Boys & Girls School Based Programing at my student’s elementary school has informed me of my tuition and the payment schedule. I acknowledge that any change in information needs to be updated as soon as possible and that if I am to withdraw my student I need to let the Program know two weeks prior in writing.
____________________________________ ___________________________________ _____________
Parent or Guardian Signature Parent’s Name Date
I give my consent for photographs or video taping in which my student my appear, to be used in ay way the Boys & Girls Club and School Based Programing may care to use them; as long as it is consistent with BGCHC mission. This may include, but not limited to; newsletters (electronic or paper), FaceBook, website, advertising materials, presentations, posting in the clubs and posting within the program’s area.
____________________________________ ___________________________________ _____________
Parent or Guardian Signature Parent’s Name Date
I acknowledge that I have been shown the Guide to Regulated Child Care. I know where in the program it will be posted and a staff member has briefed me on the information present in the pamphlet.
____________________________________ ___________________________________ _____________
Parent or Guardian Signature Parent’s Name Date
I have reviewed, read and explained the internet/computer policy with my student; and therefore my student is responsible for following the policy. My student understands the discipline consequences of not adhering to the policy.
____________________________________ ___________________________________ _____________
Parent or Guardian Signature Parent’s Name Date