2017 2018 Membership Application

Membership: Location Please Select One: Before School After School

$7.00 per day M-F
Kindergarten through 5th Grade, Located at East Washington Academy
New $3.50 per day M-F $15.00 per year
6:00 a.m. to 7:15 a.m. and 2:45 p.m. to 6:00 p.m. (free/reduced lunch)
$7.00 per day M-F
6th through 8th Grade, Located at Southside Middle School
Renewal $3.50 per day M-F $15.00 per year
6:00 a.m. to 8:00 a.m. and 3:30 p.m. to 8:00 p.m. (free/reduced lunch)

9th through 12th Grade, Located at the Boys & Girls Club of Muncie
Transfer N/A $15.00 per year
3:30 p.m. to 8:00 p.m.
Kindergarten through 5th Grade, Located at the Roy C. Buley Center N/A $15.00 per year

School: Current Grade: Shirt Size:

Middle
First Name: : Last Name:

Gender: M F Birthday: Age: Social Security #:

Address:

City: State: Zip: Home Phone:

Medical Information: ____ Attended AIM Summer Camp 2017

ADHD ADD Learning Disability Other Disabilities

Special Information: Allergies, etc.

Does your child take any medication?

Ethnic Background: Household Type: Child/Teen Lives with:

American Indian or Alaska Native Asian Single Parent Both Parents Grandparents
Black or African American White Both Parents Mom Only Legal Guardian
Hispanic/Latino Other Grandparents Dad Only Foster Parents
Two or More Races Guardian Step Mom Other
Native Hawaiian / Other Pacific Islander Step Dad ________________
Unknown

Annual Household Income: Does your Child/Teen participate in the following:

Less than $9,000 $28,000 TANF Free Lunch

$12,000 $32,700 Food Stamps Reduced Lunch
$15,000 $45,000 Medicare / Hoosier Healthwise
$19,000 More than $45,000 HUD or Section 8
$23,000 # of Individuals living in household ______________________

Is parent/guardian a member of the military? Yes N If yes, which branch:

o

Emergency Contact Information: Email: _________________________________________________________________

Mother/Guardian: Phone #: Phone #:

 2017 2018 Membership Application

Father/Guardian: Phone #: Phone #:

Additional contacts if parents/guardians cannot be reached:

Name: Phone #: Email:

Name: Phone #: Email:

Authorized to pick up members from East Washington Academy (EWA), Roy C. Buley Center, Southside Middle School (SMS) and the Boys
& Girls Club of Muncie (BGCM):

Please note: Parents/guardians and additional contacts are automatically authorized to pick up children from EWA, SMS and BGCM. Only
list other people who may be picking up members.

Name: Phone #: Relationship:

Name: Phone #: Relationship:

Authorization to Leave Premises Unescorted:

My child is 12 years or older and has my permission to check him/herself out of the BGCM.
My child is 12 years or older but does not have my permission to check him/herself out of the BGCM.
Children younger than 12 years old may leave the BGCM with a relative so long as the relative is 12 years or older.
My child is younger than 12 years old, but has my permission to leave the BGCM with ______________________________________

Age: Relationship: Brother Sister Cousin Aunt / Uncle

______ I give consent for photographs & video in which my child may appear, to be used in any way the BGCM may care to use
them.

______ I understand the BGCM has adopted a Safe Passage Policy that prohibits members from coming and going as they
please. I understand that once a child has entered the building, they will not be allowed to leave until a
parent/guardian/authorized adult arrives to retrieve them. I understand that the BGCM is not a licensed day care
facility and that staff will not physically restrain children who insist on leaving without parent permission.

______ Transportation Agreement - I confirm that my child is allowed to use transportation facilitated by the BGCM and/or the
Roy C. Buley Center. Transportation may include BGCM and/or the Roy C. Buley Center owned/leased vehicles, MITS or
other arranged transportation. I also confirm that I have discussed my expectations of proper behavior with my child
and understand that any violation of these expectations may cause him/her to lose transportation privileges. I ALSO
AGREE THAT ANY CHANGES TO TRANSPORTATION MUST BE MADE IN WRITING NO LATER THAN THE MORNING OF THE
CHANGE.

______ School Partnership Agreement I AGREE to allow my childs school administration and teachers to communicate with
BGCM regarding my child. This includes discussing grades, behavior, scholarship opportunities, program participation
and other opportunity to benefit my childs membership at BGCM. I understand that BGCM may request information
such as grades, behavior reports, and absenteeism, and may share with the school similar information. This release is
valid until revoked at any time by contracting the school corporation or BGCM in writing.

______ MEDIA/CELL PHONE/I-PAD ELECTRONICS I agree that my child is NOT permitted to carry or use a cell phone during
participation in programs. They will be required to turn in any cell phone, MP3 player, electronic video game or other
media device to the front desk staff when they arrive and pick it up as they leave. I also agree that, because such items
are prohibited, any loss, damage or theft will be my responsibility and I release BGCM from liability. I also understand
that BGCM may or may not allow my child to use his/her I-PAD or other electronics depending on scheduled programs
and my childs performance/behavior. If/when use is permitted, I understand it will be under supervision and for
educational purposes only and threat my child will follow all guidelines issued by the school corporation.
 2017 2018 Membership Application

______ I have read and agree to abide by the policies stated in the Parent Handbook. I understand that failure to abide by the
policies in the handbook may result in the removal of my child from Club programs.

______ I understand that if I am late picking up my child from EWA or SMS (after 6:00 p.m.), then I will have to pay $1.00 for
every minute that I am late (5 minute grace period is given). I also understand that if I am late picking up my teen from
BGCM (after 8:00 p.m.), then I will have to pay $1.00 for every minute that I am late (5 minute grace period is given).

______ I give permission for my child to participate in all Boys & Girls Clubs Programs. In consideration of said minor being
permitted to enter any branch of the Boys & Girls Club of Muncies (the Club) for observation, use of facilities and/or
equipment or participation in any program, I hereby:

______ Acknowledge that (I) I have read this document, (ii) I have inspected the facilities and equipment, (iii) I accept them as
being safe and reasonably suited for the purposes intended, and (iv) I voluntarily sign this document.

______ Release the Clubs, it directors, officers, employees, volunteers, governing board, agents, representatives (collectively
Releasees) from all liability to me for any loss or damage to property or injury or death to person, whether caused by
Releasees or by any person associated directly or indirectly with the Club, its officers, directors, employees or
volunteers or otherwise while my child is in or near any Club branch or participating in any Club activity.

______ Agree not to sue Releasees for any loss, damage, injury or death described above and indemnify and hold harmless
Releasees and each of them from any injury to persons or property sustained by any person caused by any act, neglect,
default, or omission of the undersigned or of any person associated directly or indirectly by him upon or in connection
with this activity or whether caused by the negligence of the Releasees or otherwise, whether the said injury or
damage occurs upon or adjacent to the property. The undersigned at his own cost, expense and risk shall defend any
and all actions, suits or other legal proceedings that may be brought or instituted against the Club on any such claim or
demand, and pay or satisfy any judgment that may be rendered against the Club in any such action, suit or legal
proceedings or result thereof.

______ I assume full responsibility for, and risk of, bodily injury, death or property damage due to the negligence of Releases or
otherwise.

______ I do hereby authorize the Clubs as agent for the undersigned, to consent with respect to said minor, to any x-ray
examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospital care which is deemed
advisable by, and is to be rendered under general or special supervision of, any physician and surgeon licensed under
the provisions of the Indiana Medical Practice Act on the medical staff of any hospital, whether such diagnosis or
treatment is rendered at the office of the physician or at the hospital. I understand that the Club is not responsible for
costs incurred for medical care.

______ I intend this document to be as broad and inclusive as is permitted by the laws of the state of Indiana; if any portion
hereof is held invalid, I agree that the balance shall continue in full force and effect.

______ Payment must be received at the beginning of each week for each child/teen participating in the before school program
for either EWA or SMS.

Signature of Parent/Guardian: Date:

For Office Use Only:
Membership #: Receipt #: New/Renewal Member:
Check
Membership Paid: Cash: : Credit Card:
Entry Date: Expiration Date: Processed By:
 2017 2018 Membership Application

Safe Passage Policy

Traditionally, the Club operated under an Open Door policy in which members were free to come and go as they
wish throughout the day. However, in the interest of our members safety, we have reevaluated our policies such
that members will no longer be free to come and go from the Club throughout the day as they wish.

Beginning immediately we will implement our new Safe Passage Policy. Under this policy:
Members must scan in and out each day;
Members under the age of 12 must be retrieved from the Club by a parent, guardian or other authorized
adult;
Members age 12 and older may leave the club unescorted with written permission from a parent or guardian
and a signed release of liability;
Members 12 and older may also escort other members of their household from the Club (with written
permission);
No member, regardless of age, will be allowed to return to the Club once they leave the premises for the day;
Members that leave unescorted without written permission will face disciplinary actions up to and including
suspension and termination of membership.

Why are we implementing this policy?

The primary reason for this change is to encourage members to stay at the Club for as long as possible, rather than
leave the premises unsupervised where they may be exposed to dangers that are beyond the control of our staff.

Over the past couple of years, we have also gotten more and more feedback from parents who were not happy with
the open door policy. Parents want to know that their children are safe and supervised.

Approved: 2017