Register your child for Boys & Girls Clubs of Lanier’s After School Program and Summer Camp
Member's Medical Concerns
If no allergies or medical problems, please indicate by entering NONE
Emergency Contact Info
Pick up Information
Additional Household Info
Member Assessment Permission Form
RE: Member to participate in assessments including but not limited to: Surveys for outcomes measurements, schools, household demographics and customized surveys built for specific programs (i.e. SMART Moves, BE GREAT: To Graduate)For valuable consideration I, the undersigned, hereby irrevocably consent to and give authorization for my child to participate in Member Assessments used by Boys & Girls Clubs of Lanier, Department of Human Services and their subsidiaries, and affiliates. These assessments may include my child’s name, my household information, my child’s grades, and/or survey information to be used for reporting purposes ONLY.
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.
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.
Forms and Waivers
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:
We will use Zoom for the following anticipated program activities:
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.
Two Emergency Contacts other than Parent/Guardian
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:
We, as parents, will support our children's learning in the following ways:
We, as students, will share the responsibility to improve our academic achievement. Specifically, we will:
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.
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- Check stubs from the most recent 4 weeks of income. This must be submitted for every person who contributes to your household income.- Copy of child's birth certificate- Copy of Parent Identification- DFCS Afterschool Eligibility Form- DFCS Non-Income Declaration Form (if applicable)
DFCS Afterschool Care Program Eligibility Form
DFCS Afterschool Care Program Eligibility Form (Spanish)
DFCS Non-Income Declaration Form
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