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Parents of new members please complete this form to register your child for 2022 Summer Camp.
Membership application to participate in Boys & Girls Clubs of Lanier's programs for Summer 2022
Household Info
Member's Medical Concerns
If no allergies or medical problems, please indicate by entering NONE
Parent Info
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, householddemographics 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 MemberAssessments used by Boys & Girls Clubs of Lanier, Department of Human Services and their subsidiaries, and affiliates. Theseassessments my include my child’s name, my household information, my child’s grades, and/or survey information to be used forreporting 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 ofLanier, 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 andother media outlets, and personal information that I supply to the Companies, in connection with advertising and promotion of theCompanies and/or their products in any media, form or material selected by the Companies, without any right of prior review or furtherapproval, whether such advertising and promotion to the public, to the trade, or both, and in the corporate releases, newsletters andother communications of the Companies, and I hereby waive, and release and discharge said Companies and all agents, employeesand 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 ofthis release if known to me, and waive all right with respect to such use of my name, photograph, identify, and personal informationincluding 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 academicinformation, report card information or tutorial information) may be shared professionally with a Boys & Girls Clubs staff member, aGeorgia Department of Human Services Case Manager (if applicable), or the school system child attends (i.e. Gainesville City, HallCounty, or Forsyth County). Files for all programs funded in whole or in part by the Georgia Department of Human Services are availablefor monitoring and subject to audit by the Georgia Department of Human Services. Communication of member information to persons oragencies 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 contentsthereof, 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 andlegal representatives of the Companies and shall be binding upon my heir, executors, assigns and legal representatives.
Forms and Waivers
Two Emergency Contacts other than Parent/Guardian
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:
Parents
We, as parents, will support our children's learning in the following ways:
Students
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.
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 Parent Identification- DFCS Afterschool Eligibility Form- DFCS Non-Income Declaration Form (if applicable)
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