2021-2022 Holy Family After School Program Membership Form

2021-2022 holy family after school program membership form

2021-2022 Holy Family After School Program Membership Form

This membership is valid from September 1st, 2020 to December 31st, 2021. Membership Fee is $5.00 per child. Membership Fee is non-refundable.

MEMBER INFORMATION

Child's Full Name *

First

Last

Date of Birth (M/D/Y) *

Physical Address *

Address Line 1

City

State / Province / Region

Postal Code

Mailing Address (If different from Physical Address.)

Address Line 1

City

State / Province / Region

Postal Code

Gender *

Male
Female
Non-binary

Health Card Number *

School *

Grade *

Siblings who are members?

Is this child 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 your child.

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 Name *

First

Last

Relation to Member *

Phone Number *

Cell Number

Email Address *

Employer

Parent/Guardian #2 Name

First

Last

Relation to Member

Phone Number

Cell Number

Email Address

Employer

EMERGENCY CONTACT INFORMATION

*Please provide two emergency contacts OTHER THAN the parent/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 child 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.

Allergies

Medical Condition(s)

Learning/Behavioral Needs

Does your child have a disability? *

(ex: Physical Disability or Cognitive Disability such as: ADHD, FASD, etc.)

If yes, please explain (voluntary).

Other Considerations

Any additional information which may assist your child positively participating in our programs.

PLEASE NOTE: The safety of your child is of upmost importance to us. Therefore, until BGC Battlefords staff become familiar with the child's parents/guardians, you will be asked for a release password or government issued photo ID. Anyone picking up the child other than the parents/guardians will be asked for the same release password or their government issued photo ID. Please indicate what your release password is below. *

CUSTODY AND/OR COURT ORDER

Custody and/or Court Orders *

Not Applicable (skip to name and date)
See Below

If a custody 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 child. Without a custody or court order on file, BGC Battlefords cannot deny access to the non-enrolling parent.

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

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.

Custody and/or Court Order -NAME *

First

Last

Custody and/or Court Order -DATE *

IMPORTANT INFORMATION FOR YOU TO KNOW

Please check off to acknowledge that you have read and understand the information below:

Payments are due prior to the 1st of each service month and children are NOT able to attend the Satellite Site until the account is paid in full. Invoices will be generated on the 1st of every month for the next month's services.

Our Annual Membership fee is $5 - this is due upon completing the membership form. With the membership fee, your child gains access to all programming offered at BGC Battlefords' Main Site, Non-School Days Program, Summer Parks Drop-in Programs, as well as Special Programs (ex: Hockey Program, Music Program, Soccer Program, etc.) This is a one time, annual fee and will only be included on your first invoice.

Payment Methods: E-transfers can be sent to ac.bcgb@stnemyap. Please include the child'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.

An exception to the full-time agreement rate will be made for the months in which Christmas Break, Winter Break and Easter Break occur. Notice of the changed rate will be given at a later date.

IMPORTANT INFORMATION FOR PART-TIME AND CASUAL CONTRACTS

Please check off to acknowledge that you have read and understand the information below:

You must pre-register your child for this program by noon on the day requiring service.

Should you require additional visits outside the allotted amount in your chosen agreement, there will be after school care provided at a rate of $12/day - this fee will be added onto the following month's invoice.

CONTRACT AGREEMENT

Please choose the service agreement required for your child:

AFTER SCHOOL CARE (Class Dismissal to 5:30pm, open earlyon Early Dismissal Days) *

Full-time (child will attend 4-5 days/week with a max of 20 days/month) - $200/month
Part-time (child will attend 2-3 days/week with a max of 12 days/month) - $120/month
Casual (child will attend a max of 5 days/month) - $50/month
Drop-in $15/day

CHANGES TO CONTRACT AND CANCELLATION POLICY

By signing this agreement, you are committing to this service agreement for the 2021-2022 School Year. Please note, changes/cancellations to this agreement require ONE FULL MONTHS’ NOTICE in writing by filling out a Contract Amendment Form prior to the month of service being affected. For example, if you submit the Contract Amendment Form on January 15th, the changes will take effect March 1st and the original contract fee would be owed for January and February. Please contact the office to request this form or visit our website (www.bgcbattlefords.ca). BGC Battlefords reserves the right to terminate this program by also providing one month’s notice to families.

Changes to Contract and Cancellation Policy - NAME *

First

Last

Changes to Contract and Cancellation Policy - DATE *

MEDIA CONSENT & RELEASE

BGC Battlefords has the right to use any artwork, photographs, video, and/or audio of my child while participating in Club activities for the purpose of advertisement and promotional campaigns in the future. My child'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 association with a child's image without written permission of the parent/guardian. *

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

Media Consent & Release - NAME *

First

Last

Media Consent & Release - DATE *

ASSUMPTION OF RISK AND WAIVER OF LIABILITY RELATING TO COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is contagious and is believed to spread mainly from person-to-person contact. BGC Battlefords has put in place procedures to reduce the spread of COVID-19. Regardless of the precautionary measures in place, BGC Battlefords cannot guarantee that you or your child(ren) will not become infected with COVID-19. All program guidelines are subject to change with no notice upon government recommendations and requirements. Attending BGC Battlefords programs could increase your risk and your child(ren)’s risk of contracting COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending BGC Battlefords programs and that exposure or infection may result in injury, illness, health complications or death. I understand that the risk of becoming exposed to or infected by COVID-19 at BGC Battlefords programs may result from the actions or omissions of myself and others, including, but not limited to, BGC Battlefords’ employees and program participants, and their families. By my signature, I confirm that I have read and understand the COVID-19 Procedures as posted on the BGC Battlefords website (https://www.bgcbattlefords.ca/covid-19-information/) or as shown to me in-person.

I voluntarily agree to assume all risks and accept sole responsibility for any issues or complications my child(ren) or myself may experience or incur in connection with my child(ren)’s attendance and participation in BGC Battlefords programming. On my behalf, and on behalf of my children, I hereby release and hold harmless BGC Battlefords (legal name, Battlefords Boys and Girls Club), its employees, the program facility and all representatives from all liabilities, claims, actions, damages, costs, or expenses of any kind arising out of or relating to it. I understand and agree that this release includes any claims based on the actions, or omissions of BGC Battlefords, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any BGC Battlefords program.

Parent/Guardian - NAME *

First

Last

DATE *

MEMBERSHIP CONTRACT

Parents/Guardians please review the following Participant Code of Conduct with your child:

If you want to become a member of BGC Battlefords (BGCB) and enjoy the privileges a member has, you must agree to respect the staff, volunteers, other members, yourself, the building, and the equipment. YOU MUST UNDERSTAND THAT BGCB IS A SAFE PLACE FOR ALL MEMBERS, AND IF YOU ACT IN A WAY THAT MAKES SOMEONE FEEL UNSAFE OR BULLIED, YOU WILL BE ASKED TO LEAVE. You will follow the rules set by the staff. You also understand that if you do not abide by these rules, you may lose your privileges and may not be able to return to BGCB in the future. BGCB's Rules:

Parents/Guardians please read and agree to, by initialing beside, the following statements:

I understand that my child is being asked to abide by the Participant Code of Conduct of BGCB. Should my child not abide by these guidelines, 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 child's safety before and after the hours of operation. *

I understand that my child may leave the premises of BGCB at their own will, and that I will make every effort to communicate with my child when they are to leave BGCB. *

I understand that should my child not be picked up prior to the closing hours of BGCB, 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 child has my permission to attend programs offered through BGCB, some of which will 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 child by BGCB, I waive my legal right against BGCB, its staff, volunteers, 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 Contract -NAME *

First

Last

Membership Contract - DATE *