2022 - 2023 Afterschool Registration - Boys & Girls Clubs of Lanier

2022-2023 Membership Application

Membership application to participate in Boys & Girls Clubs of Lanier's programs from August 2022 - July 2023. **Before starting the application, please copy & paste this URL into your browser to ensure you have all the required documents on hand: https://www.boysgirlsclubs.com/membership-registration-required-documents/

Step 1 of 6

Program Registration*
I am registering my child for the following program:
County*
I am registering my child for the Afterschool Program location below:*
For sites that are full, your child will be added to the waiting list.
I am registering my child for the Afterschool Program location below:*
For sites that are full, your child will be added to the waiting list.
I am registering my child for the Afterschool Program location below:*
For sites that are full, your child will be added to the waiting list.
Member Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone*
Member Date of Birth*
MM slash DD slash YYYY
Member's SSN (REQUIRED)*
Gender*
- Male
- Female

Member's Medical Concerns

If no allergies or medical problems, please indicate by entering NONE
Allergies*
If none please type NONE
Medical Problems/Medicine Needs*
If none, please type NONE
For more information please review Boys & Girls Clubs of Lanier's Safety Procedures
Physician Name and Address
Physician Phone
Insurance Company and Policy Number
Medicaid Number
Can Member Swim?*
- Yes
- No
Special Needs/Concerns
Please explain any special needs/concerns for Member

Parent Info
Primary Parent/Guardian*
First Last
Home Phone*
Cell Phone*
Primary Email*

Application confirmation will be sent to this email address
Employer Name & Work Number
Occupation
Secondary Parent/Guardian
First Last
Home Phone
Cell Phone
Email
Employer Name & Work Number
Occupation
Pick up Information
Name of Person(s) NOT Authorized to pick up member

You must submit legal documentation for anyone not authorized to pick up member.
Upload Legal Documentation Here
Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.
Additional Household Info
Number of Persons in Family Unit (# in household)*
Annual Household Income*

Two Emergency Contacts other than Parent/Guardian
Emergency Contact #1*
First Last
Relation to Child*
Emergency Contact #1 Phone*
Emergency Contact #2*
First Last
Relation to Child*
Emergency Contact #2 Phone*
Consent*
I have read and understand all policies and procedures.
Member's Name*
First Last
Parent/Guardian Name*
First Last
Success Academy Parent Compact 2020-2021

Program Goal 1: Improve academic performance

Program Goal 2: Improve classroom behavior

Program Goal 3: Improve parental involvement in education and literacy programs

BGC Lanier Success Academy

To help build and develop a partnership with parents to help their children achieve high academic standards, Boys & Girls Clubs of Lanier will:
- Provide a healthy afterschool snack daily.
- Provide daily academic enrichment services to studetns attending the program including certified tutorials and homework help.
- Provide expanded learning opportunities for college/career readiness.
- Monitor academic progress and report monthly to parents (with parental permission for access to Power School and communication with school day teachers, counselors, and other appropriate staff).
- Provide transportation to and from the afterschool program.
- Provide fun learning opportunities for parents/guardians/families that encourage engagement in student's school performance.
Parents

We, as parents, will support our children's learning in the following ways:
- Establish routines to support my child's success in school:
  - monitor attendance
  - homework & reading
  - nutrition
  - Computer and social media usage
  - Appropriate curfews
- Ensure that my child attends school on a regular basis and arrives at school on time.
- Make sure that my child's homework is completed and returned to school on time.
- Stay informed about my child's education and communicate with the school by promptly reading all notices from the school or the school district either received by my child or by mail and responding as appropriate.
- Ensure that your child attends 21st Century Scholar Success Academy program in order to achieve academic success a minimum of 3 days per week.
- Become actively engaged in my child's learning experience during the school day and after school.
- Attend a minimum of 3 family engagement events held by 21st Century afterschool program
- Allow appointed 21st Century staff and tutorial instructors to access and monitor student academic performance using Power School and regular communication with school day teachers, counselors, and other appropriate school staff.
Students

We, as students, will share the responsibility to improve our academic achievement. Specifically, we will:
- Attend school regularly and complete all daily homework and return it to school on time.
- Model Respect, Restraint, and Responsibility and the school code of conduct.
- Be responsible for giving my family members all information sent home from school and afterschool
- Attend the 21st Century program regularly (minimum 3 days per week).
- Take an active role and responsibility in my education and college/career readiness through participation in afterschool tutoring and enrichment activities.
Student Name*
First Last
Parent's Electronic Signature*

Please type your full name in the box to confirm you understand and agree to the contents of the Success Academy Parent Compact
Today's Date*
MM slash DD slash YYYY
Notice of Exemption

I acknowledge that I have been informed that this program is not a licensed child care facility. I also understand this program is not required to be licensed by the Georgia Department of Early Care and Learning and this program is exempt from state licensure requirements.
Electronic Signature*

Please type your full name in the box to confirm you understand and agree to the Notice of Exemption.
Required Documentation

The following documentation is required to complete your child's membership application:

- IF APPLICABLE, Proof of services, including: TANF, SNAP, Medicaid or SSI, Free or Reduced Lunch
- If you do not receive any of the above services (TANF, SNAP, Medicaid or SSI, Free or Reduced Lunch) Check stubs from the most recent 4 weeks of income are required. This must be submitted for every person who contributes to your household income.
- Copy of Parent Identification
- DFCS Afterschool Eligibility Form
- DFCS Non-Income Declaration Form (if applicable)
Required Documentation*
- I will upload all required documents.
- I am not able to upload these documents to the online membership application and need to make alternate arrangements to submit.
Proof of Services (if applicable)
Accepted file types: pdf, jpg, doc, png, gif, Max. file size: 50 MB.
Please upload proof of ONE of the following: TANF, SNAP, Medicaid or SSI, Free or Reduced Lunch
Proof of Income
Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, img, Max. file size: 50 MB, Max. files: 10.
Check stubs from the most recent 4 weeks of income. This must be submitted for every person who contributes to your household income.
Parent Identification
Accepted file types: jpg, gif, png, pdf, doc, docx, img, Max. file size: 50 MB.
Please upload a copy of your identification.
DFCS Afterschool Care Program Eligibility Form
Accepted file types: jpg, gif, png, pdf, doc, docx, img, Max. file size: 50 MB.
Please upload your completed DFCS Afterschool Care Program Eligibility Form here. Copy & paste this URL into your browser to download the form: https://www.boysgirlsclubs.com/wp-content/uploads/2021/12/FFY-2022-Afterschool-Care-Program-Eligibility-Form-Updated-11-2021-English-fillable.pdf
DFCS Non-Income Declaration Form (If Applicable)
Accepted file types: jpg, gif, png, pdf, doc, docx, img, Max. file size: 50 MB.
IF APPLICABLE, please upload your completed DFCS Non-Income Declaration Form here. Copy & paste this URL into your browser to download the form: https://www.boysgirlsclubs.com/wp-content/uploads/2020/05/DFCS-Afterschool-Care-Program-Non-Income-Declaration-Form-2020.pdf

2022 – 2023 Afterschool Registration

2022-2023 Membership Application

Step 1 of 6

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