2021-2022 Raise the Grade Program Registration Form

2021-2022 raise the grade program registration form

2021-2022 Raise the Grade Registration

MEMBER INFORMATION

Teen's Full Name *

First

Last

Date of Birth (Month/Date/Year) *

Physical Address (If different from mailing address.)

Address Line 1

City

State / Province / Region

Mailing Address *

Address Line 1

City

State / Province / Region

Postal Code

Gender *

Male
Female
Non-binary

School *

Grade *

Health Card Number *

Siblings Who are Members of BGC Battlefords:

Is this teen in Foster Care? *

If yes, name of childcare worker:

Background Information (Voluntary): To support BGC Battlefords in tracking progress, statistics, and applying for funding, please check if any of the below categories apply to you.

Country of Origin:

Primary Language(s) Spoken *

Secondary Language(s) Spoken:

Family Setting (Primary Residence): *

Two Parent/Guardian Household
One Parent/Guardian Household

PARENT/GUARDIAN INFORMATION

Parent/Guardian #1 Information

Parent/Guardian #1 Name *

First

Last

Relation to Member *

Phone Number *

Cell Number *

Email *

Employer: *

Parent/Guardian #2 Information

Parent/Guardian #2 Name

First

Last

Relation to Member

Phone Number

Cell Number

Employer

EMERGENCY CONTACTS

* Please provide two emergency contacts OTHER THAN the parents/guardians listed above. *

Emergency Contact #1 Name *

First

Last

Relation to Member *

Phone Number *

City of Residence *

Emergency Contact #2 Name *

First

Last

Relation to Member *

Phone Number *

City of Residence *

MEDICAL INFORMATION

Does your teen have any needs/requirements in the following areas? If yes, please explain further. If applicable, please indicate any diagnoses and medications that they are taking.

Select all those that apply. *

Allergies

Medical Condition(s)

Learning/Behavioral Needs

Physical or Cognitive Disability (Such as ADHD, FASD, etc.)

Other Considerations (Any additional information which may assist your child in positively participating in our programs.)

CUSTODY AND/OR COURT ORDER

If a custody or court order exists a copy of the order must be given to BGC Battlefords. The parent/guardian is responsible for providing accurate and up to date information concerning the legal guardianship of the teen. Without a custody or court order on file, BGC Battlefords cannot deny access to the non-enrolling parent.

Custody & Related Court Orders: *

See Below
Not Applicable

Please list anyone who is NOT ALLOWED to pick up your teen:

I have provided BGC Battlefords with legal documentation (custody or court order). Without this, BGC Battlefords cannot legally deny access to a non-enrolling parent.

Date

Name

First

Last

PAYMENT

Raise the Grade registration fee is $5 - this is due upon completing the registration form. With the registration fee your teen gains access to all the benefits and opportunities offered through Raise the Grade. These include but are not limited to mentorship, academic help, career planning, and meals.

Payment Methods:

E-transfers can be sent to ac.bcgb@stnemyap. Please include the teen's full name in the memo section. BGC Battlefords is set up for automatic deposit of e-transfers which means no password is required. When e-transfer is not available, the other forms of payment accepted at the office are: cash, debit or credit.

MEDIA CONSENT & RELEASE

BGC Battlefords has the right to use any artwork, photographs, video, and/or audio of my teen while participating in Club activities for the purpose of advertisement and promotional campaigns in the future. My teen's image may be published or used in newspapers, promotional videos, television commercials, television news items, program brochures, posters, social media sites, etc. or otherwise displayed to the public or used for other educational/fundraising purposes, either in whole or in part by BGC Battlefords, BGC Canada and/or external partners. No names will ever be used in the association with a teen's image without written permission of the parent/guardian. *

Yes, I agree.
No, I do not agree.

REGISTRATION CONTRACT

Parents/Guardians: Please review these guidelines/rules with your teen.

If your teen wants to participate in BGC Battlefords (BGCB) Raise the Grade Program and enjoy the privileges as a participant, you have to agree that your teen will respect the staff, volunteers, and the other members. YOU MUST UNDERSTAND THAT RAISE THE GRADE IS A SAFE PLACE FOR ALL PARTICIPANTS, AND IF YOUR TEEN ACTS IN A WAY THAT MAKES SOMEONE FEEL UNSAFE, THEY WILL BE ASKED TO LEAVE. Your teen will follow the rules set by the staff. You also understand that if your teen does not abide by these rules, they may lose their privileges as a result and may not be able to return to Raise the Grade and/or BGCB in the future.

Parents/Guardians please read and initial beside the following statements agreeing to:

• I understand that my teen is being asked to abide by the rules of BGCB and Raise the Grade. Should my teen not abide by these rules, I agree to work with the staff of BGCB to help resolve the situation. *

• I understand that BGCB staff and volunteers will be supervising activities and programs during the hours of operation, and that it is my responsibility as parent/guardian to ensure my teen’s safety before and after the hours of operation. *

• I understand that the RTG program runs daily, and the expectation is that my teen attends on a regular basis (at least twice a week). *

• I understand that my teen will be working closely with a volunteer mentor. All mentors have undergone a screening process and have been specifically paired with your teen based on their interests and goals. *

• I understand that should my teen leave BGCB premises before authorized to do so by a parent/guardian and/or staff, staff will make all reasonable efforts to contact me. I further understand that once my teen has left BGCB premises, BGCB, its staff, volunteers, and/or Board of Directors, are not liable for my teen. *

• I understand that should my teen not be picked up prior to the closing hours of Raise the Grade, the staff may be in contact with authorities such as the Battlefords RCMP and/or Social Services. *

• I agree that under no circumstances are BGCB staff members, volunteers, or board members responsible for lost or stolen belongings. *

• I further understand that my teen may have offsite opportunities through Raise the Grade, some of which may require transportation to another location. *

• With full knowledge of the existence and nature of my legal right and in consideration for the opportunities provided to my teen by BGCB and Raise the Grade, I waive my legal right against BGCB, its staff, volunteers, and/or Board of Directors for any injury or damage suffered during or by reason of practicing, participating or assisting in a BGCB service, program, or experience. *

• I further authorize the application of emergency medical attention and undertake to be responsible for any hospitalization, medical, ambulance or other expenses. *

Membership Agreement - NAME *

First

Last

Membership Agreement - DATE & TIME *

Date

Time

BGC Battlefords is committed to protecting the confidentiality of personal information. The information collected will assist BGC Battlefords in service delivery and is kept confidential.

Name