Boys & Girls Clubs of Lanier

Media Permission Form

RE: Use of name, photograph and identity in connection with advertising and/or promotion of the organization.
For valuable consideration I, the undersigned, hereby irrevocably consent to and authorize the unrestricted use by Boys & Girls Clubs of Lanier, Department of Human Services and their subsidiaries, affiliates and advertising agencies (“Companies”) of my child’s name, photographs, works and art and identity in various BGCL website and collateral material, as well as miscellaneous print publications and other media outlets, and personal information that I supply to the Companies, in connection with advertising and promotion of the Companies and/or their products in any media, form or material selected by the Companies, without any right of prior review or further approval, whether such advertising and promotion to the public, to the trade, or both, and in the corporate releases, newsletters and other communications of the Companies, and I hereby waive, and release and discharge said Companies and all agents, employees and officers of the Companies, including their agencies, media producers and customers from, any claims, liabilities and demands, past, present of future, including and that I do not now know of or anticipate arising in the future, none of which would affect my execution of this release if known to me, and waive all right with respect to such use of my name, photograph, identify, and personal information including but not limited to publicity, privacy, psychological injury and libel.

School Data Release Form

The Boys & Girls Clubs of Lanier will maintain all member files in a confidential manner. Pertinent information(i.e. all academic information, report card information or tutorial information) may be shared professionally with a Boys & Girls Clubs staff member, a Georgia Department of Human Services Case Manager (if applicable), or the school system child attends (i.e. Gainesville City, Hall County, Habersham County or Forsyth County). Files for all programs funded in whole or in part by the Georgia Department of Human Services are available for monitoring and subject to audit by the Georgia Department of Human Services. Communication of member information to persons or agencies other than listed above will require written approval of the member’s parents.

Permission Agreement

I represent that I am the below-named parent/guardian, that I am over the age of 21, that I have read the foregoing and fully understand the contents thereof, that the consideration that I have received for this Agreement, Release, and Waiver is fair and equitable, and that I hereby give this Agreement, Release, and Waiver of my own free choice. This Agreement, Release, and Waiver shall ensure to the benefit of the successors, assign, licensees and legal representatives of the Companies and shall be binding upon my heir, executors, assigns and legal representatives.

In an effort to continuously serve members, Boys & Girls Clubs of Lanier is providing distance-based Club experiences through which Club staff will facilitate program activities through an online platform. Boys & Girls Clubs of Lanier will use an application provided by a third party that members, parents/guardians and/or staff will access via the Internet and use for purposes of communication and programming. This platform is called Zoom.

This letter seeks consent for your child to utilize Zoom for distance-based Club program purposes. Zoom provides an opportunity to deliver video and chat-based educational experiences to members via any device. Please be aware that Zoom collects information about its users and has its own privacy terms and conditions to which members must adhere. Please review Zoom’s privacy terms and conditions carefully before registering your member:  http://zoom.us/terms and http://zoom.us/privacy.

In order to participate in distance-based Club experiences, you will need to provide the following:

• A computer, mobile, or tablet device with access to the Internet
• A quiet space at home in which members can participate in distance-based experiences under the supervision of an adult
• To register for Zoom, you will need to provide some customer data, including but not limited to: your email address and first and last name (for more information, see https://zoom.us/privacy)   

We will use Zoom for the following anticipated program activities:

• Group chats
• Video conferencing
• Media sharing (for example, uploading images of artwork or other projects)

Our commitment to keeping the young people we serve safe is always our number one priority. Boys & Girls Clubs of Lanier will actively monitor member activity on Zoom and will make every effort to protect member information by, among other things, maintaining control of, and access to, the data collected; prohibiting re-disclosure of member information; limiting the purposes for which the online platforms may use member information; ensuring there is no advertising and that no member information is collected for commercial purposes.

Further, all activities online must comply with Boys & Girls Clubs of Lanier’s safety policies, including the Membership Rules, Bottom Line on Supervision, and Positioning, which are available in the Standard Operating Procedures Manual.

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)