Parent/Guardian Agreement

SHIRT SIZE: ______PARENT/GUARDIAN AGREEMENT

OPEN DOOR POLICY I understand that the Boys & Girls Clubs of Stanislaus County (BGCSTAN or “The Club”) has an OPEN DOOR policy. Clubs are open to all members anytime during regular hours of operation. Members may come and go during those hours. I understand that the BGCSTAN is not responsible for the time or manner in which my child may arrive or depart from club premises.

PARENT ORIENTATION I understand that it is my responsibility to attend a site-specific Parent Orientation prior to enrolling my child. Club hours and policies may vary from site to site depending on program funding.

TECHNOLOGY USE I have been given information at the orientation on the appropriate use of computers at the Club. I give my consent for my child to use email and the internet while at the Club according to the rules outlined in the Parent Member Information Manual.

PHOTO RELEASE I consent to allow the Club to use photographs or video of my child participating in Club activities and I waive all rights for compensation. (i.e. Marketing Materials/Social Media Sites).

PARENT HANDBOOK I have read and agree to abide by the policies stated in the Parent Handbook. I understand that failure to abide by the policies in the handbook may result in the removal of my child from Club programs. I understand that if either I or my child violates the rules of the Club my child may be asked to forfeit his or her membership and that no membership fees will be refunded to me.

PARENT RELEASE I give permission for my child to participate in all Boys & Girls Clubs of Stanislaus County Programs. I understand that the Club and its properties are not responsible for personal injury or loss of property. I agree to hold the Club free and blameless from any claim for injury or missing items on the Club’s property or in connection with any Club activity. I hereby authorize Club personnel to administer emergency medical treatment and/or transportation for my child in the event of sudden illness or accident.

MEMBER AGREEMENT  I agree to take care of my Club and the property therein.  I will abide by the rules of the Club at all times.  If at any time I am asked to return my Club membership card, I understand no dues will be returned to me.

Topical Products I give permission for the Boys & Girls Clubs of Stanislaus County to administer sunscreen, insect repellent or other products to my child as need.

Viewing Movies I give permission for my child to participate in viewing movies that are rated PG and below.

______Parent / Guardian Signature Date Member Signature Date

INTAKE Staff Initial______DATA ENTRY

ORIENTATION DATE: ______ Handbook  Entered in KidTrax: Date______/Staff Init____ Received  Emergency Contact Card Made: Date______/Staff Init____ MEMBERSHIP TYPE:  General School Year Summer Day  Member Card Made & Distributed: Date______/Staff Init____ Camp Membership # ______OJP JAG  Copy Made / Sent to Administrative Office: Date______/Staff DOCUMENTS RECD: IEP  Other Init______

PAID: Cash Credit/Debit Card Money Order Scholarship Check #______Amount $______Receipt # ______Summer Camp Registration Form

Please place an X in the box next to the weeks that your child will be attending camp. There is a $10.00 reservation fee per week to reserve placement. This fee in nonrefundable.

Week Theme Fee Field Trip Fee Total 1 May 30th- MAD Science $80 MJC Planetarium $5.00 June 2nd 2 June 5th – Kids cook off $80 Farmers Market Free 10th Vanderhelm Blueberry $3.00 Farm 3 June 12th- Olympic Champions $80 Field day @ West Modesto Free 16th 4 June 19th- Under the Sea $80 Empire Pool $2.00 23rd June 21st- Outdoor Adventure $75 Ages 8 to 10 23rd Camp 5 June 26th- Holiday Hullabaloo $80 Family holiday party Free 30th June 28 to Outdoor Adventure $75 Ages 6 to 7 30th Camp 6 July 3rd- 7th Rockin’ Roll Week $80 Graffiti parade Free 7 July 10th- Hollywood Week $80 Movies $1 14th July 12th to Outdoor Adventure $ 75 Ages 11 to 13 14th Camp 8 July 17th- Western Week $80 Columbia State park Free 21st July 19th to Outdoor Adventure $ 75 Ages 8 to 10 21st Camp 9 July 25th- Peace out summer. $80 Knights Ferry Free 29th Additional T- Shirts: $10.00 per Additional Total Due: Amount Enclosed:

Payment Methods: Cash Check #______Credit Cards/ Invoice For invoicing please include email address:

T-Shirt Size: YS YM YL AS AM AL AXL  Please remember that should a member make a choice that impacts the safety or positive atmosphere for others, that member will be required to leave the Club for the remainder of the day. Should that happen frequently, membership may be suspended or revoked with no refund of program fees.  All Fieldtrips are subject to chance with notice.

FIELD TRIP CONSENT AND RELEASE FORM

Boys & Girls Club of Stanislaus County

PARENT PERMISSION FORM FOR STUDENT TO PARTICIPATE IN FIELD TRIP, WAIVER OF LIABILITY AND CONSENT FOR MEDICAL TREATMENT

I 1, ______(2Parent/Guardian of Student), by signing below agree to the following with respect to my daughter/son’s, ______, (“Student”) participation in the voluntary activity described in this Consent and Release Form.

Student has my consent to participate in the field trip described above and may participate in all activities associated with the field trip or school-related trip (hereinafter, “Field Trip”).

A. 3Student and Parent/Guardian understand that Student’s participation in the Field Trip is an honor and a privilege and that Student shall act responsibly and with self-control throughout the Field Trip’s duration. Student and Parent/Guardian acknowledge that Student is a person of sufficient maturity to make reasonable decisions about his/her conduct, and Student shall accept full responsibility for such conduct while participating in this Field Trip.

B. 4Student agrees to abide by the discipline code of the Boys and Girls Club while participating in the Field Trip, commencing at the time of departure from school premises until Student returns to his/her home:

i. A copy of the discipline code is attached to this Consent and Release Form. ii. Student will stay within the designated geographic parameters throughout the Field Trip.

C. Student and Parent/Guardian understand and agree that if Student violates any of the rules set forth in the Boys and Girls Clubs discipline code, it will be within the sole discretion of the Field Trip supervisor or other designated supervisor (“Supervisors”) to take whatever disciplinary action is necessary, including immediate notification of Parent/Guardian, dismissal from the Field Trip, or any other discretionary action that may be deemed appropriate.

D. Student and Parent/Guardian acknowledge that there are certain risks inherent in participating in field trips. Such risks may include, but are not limited to, accident, delay, injury, illness or damage to personal property. Student and Parent/Guardian further agree that the Supervisors cannot ensure the safety of Student. Student and Parent/Guardian expressly assume these risks and agree that they will not hold the Supervisors or the Boys and Girls Clubs of Stanislaus County responsible if such events occur.

E. Student and Parent/Guardian, as a condition of Student’s participation in the Field Trip, hereby agree to indemnify and hold harmless and waive all claims or suits for damages or injury arising from Student’s participation in the Field Trip and liability against the Boys and Girls Clubs of Stanislaus County, its officers, agents, employees, and volunteers, for injury, accident, illness, or death occurring during or by reason of this Field Trip. Student and Parent/Guardian hereby waive any and all rights to hold Supervisors and the Boys and Girls Clubs of Stanislaus County personally, individually, jointly or severally liable for any and all claims.

F. In the event of an accident, injury and/or medical emergency, Supervisors are hereby authorized to consent to and obtain whatever emergency medical treatment, surgery or dental care is considered necessary from and in the best judgment of the attending physician, medical care facility, hospital, paramedic unit or other health care provider deemed appropriate by Supervisors in the circumstances. In the event it is impossible to receive instructions for Student’s care, full authorization is given to any licensed physician and/or surgeon for the provisions of medical treatment, including the administration of drugs or medication, and the performance of surgical treatment for the relief of pain and/or the preservation of life and/or health and well-being. Student and Parent/Guardian understand that this authorization is given in advance of any specific diagnosis or treatment being required and that such authorization is given to provide Supervisors and the Boys and Girls Clubs of Stanislaus County with the power to secure reasonable medical care under emergency circumstances. Medical costs incurred shall be the responsibility of the Student and Parent/Guardian.

G. Student and Parent/Guardian agree to pay for such medical care whether or not the costs are insured by Student or Parent/Guardian’s health insurance. Student and Parent/Guardian understand that an attempt will be made to contact Parent/Guardian by telephone if possible, before such care is administered.

Emergency Contact(s)

Name: ______Phone Number: ______

Medical History

Information that may be of importance: ______

Medication student is taking (if any): ______

Medication student should not take: ______

H. The Boys and Girls Clubs of Stanislaus Countydoes not provide insurance for accidental injuries to students. Please Review with the Participating Student

Boys & Girls Clubs of Stanislaus County Code of Conduct

1. Play fairly & Be honest 2. Bring membership card and T-shirt everyday 3. Be respectful of Boys & Girls Club staff 4. Say only good things about others 5. Resolve disagreements in a positive way 6. Be respectful of other members & their property 7. Avoid use of improper language 8. Applaud efforts of other members 9. Run in the designated areas only 10. Participate only in the program area open to your age group 11. Listen 12. Have fun

Boys & Girls Clubs of Stanislaus County Transportation Code of Conduct

1. Youth should conduct themselves in an orderly manner at all times. 2. All Youth must be in seat belt (if applicable) when vehicle is in motion. 3. Staff and/or chaperones are responsible for seating arrangements. 4. Youth will remain seated while vehicle is in motion. 5. Youth must refrain from loud talking, horseplay, throwing objects on or from the vehicle or doing anything that will distract from the driver's attention. 6. All parts of the body must be kept inside the vehicle at all times. 7. Eating or drinking in the vehicle is not permitted. 8. It is the responsibility of the staff, chaperones, and each rider to help keep the vehicle clean. 9. The use of profanity on the vehicle will not be allowed.

I have read, understand, and voluntarily agree to all provisions stated above. I give my permission for my child to participate in the Field Trip described herein.

Parent/Guardian Name:

Parent/Guardian Signature:

Address:

Date: Phone: