Register your child for Boys & Girls Clubs of Lanier’s Virtual Summer Experience

2019-2020 Membership Application

Membership application to participate in Boys & Girls Clubs of Lanier's programs from August 2019 - July 2020
  • Date Format: MM slash DD slash YYYY
  • Household Info

    Please indicate if your family receives any of the following.
    Please check one.
  • Member's Medical Concerns

    If no allergies or medical problems, please indicate by entering NONE

  • If none please type NONE
  • If none, please type NONE
  • Please explain any special needs/concerns for Member
  • Parent Info

  • Emergency Contact Info

    If Same as Parent/Guardian, check "Same as Above." If it is not same as parent/guardian, please enter emergency contact name and phone number in space below.
  • Pick up Information

  • You must submit legal documentation for anyone not authorized to pick up member.
  • Accepted file types: jpg, gif, png, pdf.
  • Additional Household Info

  • Date Format: MM slash DD slash YYYY
  • 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 my include my child’s name, my household information, my child’s grades, and/or survey information to be used for
    reporting purposes ONLY.

  • Please type your name in the box to confirm your response to the member assessment permission form.
  • 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.

  • Please type your name in the box to confirm your response to the Media Permission Form.
  • 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, 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.

  • Please type your name in the box to confirm your response to the School Data Release Form.
  • 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.

  • Date Format: MM slash DD slash YYYY
  • Forms and Waivers

    Select one.
  • Please type your name in the box to confirm your response to the Computers Waiver.
    Select one.
    Select One.
  • Please type your name in the box to confirm your responses to Medical: First Aid and Medical: Treatment Forms.
  • Please type your name in the boxes to confirm your responses to Transportation: From School and Transportation: Field Trips/Special Events/Summer Travel Forms.
  • Please type your name in the box to confirm you agree to the Hold Harmless and Liability Release Waiver Agreement.
  • Two Emergency Contacts other than Parent/Guardian

  • Date Format: MM slash DD slash YYYY
  • Success Academy Parent Compact 2019-2020

    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.
  • Please type your full name in the box to confirm you understand and agree to the contents of the Success Academy Parent Compact
  • Date Format: 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.

  • 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
    - 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 child's Social Security Card
    - Copy of Parent Identification
    - DFCS Afterschool Eligibility Form
    - DFCS Non-Income Eligibility Form (if applicable)

  • Accepted file types: pdf, jpg, doc, png, gif.
    Please upload proof of ONE of the following: TANF, SNAP, Medicaid or SSI, Free or Reduced Lunch
  • Drop files here or
    Accepted file types: jpg, gif, png, pdf.
    Check stubs from the most recent 4 weeks of income. This must be submitted for every person who contributes to your household income.
  • Accepted file types: jpg, gif, png, pdf.
    Please upload a copy of your child's birth certificate.
  • Accepted file types: jpg, gif, png, pdf.
    Please upload a copy of your child's social security card.
  • Accepted file types: jpg, gif, png, pdf.
    Please upload a copy of your identification.
  • Accepted file types: jpg, pdf, doc.
    Please upload your completed DFCS Afterschool Care Program Eligibility Form here.
  • IF APPLICABLE, please upload your completed DFCS Non-Income Declaration Form here.