2022 Membership Form

2022 Membership Form

Please fill out one form for each child attending.

MEMBER INFORMATION

Member's 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:

Background Information (Voluntary): To support BGCB 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

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 *

Employer: *

Phone Number *

Cell Number *

Email *

Parent/Guardian #2 Information

Parent/Guardian #2 Name

First

Last

Relation to Member

Employer

Phone Number

Cell Number

EMERGENCY CONTACTS

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

Emergency Contact #1 *

First

Last

Relation to Member *

Phone Number *

City of Residence *

Emergency Contact #2 *

First

Last

Relation to Member *

Phone Number *

City of Residence *

MEDICAL INFORMATION

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

Select all those that apply. *

Allergies
Medical Condition(s)
Learning/Behavioral Needs
Cognitive Disability (Such as: ADHD, FASD, etc.)
Physical Disability
Other Considerations (Any additional information which may assist your child in positively participating in our programs.)
None of the above.

Allergies

Medical Condition(s)

Learning/Behavioral Needs

Cognitive Disability

Physical Disability

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

CUSTODY AND/OR COURT ORDER

Custody and/or Court Order *

Not Applicable
See Below

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 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 (month/day/year) *

PAYMENT

Our Annual Membership fee is $5 - this is due upon completing this membership form. With the membership fee, your child gains access to all programming offered at BGC Battlefords' Main Site, Summer Parks Drop-in Programs, as well as all Special Programs (ex: Hockey Program, Music Program, Soccer Program).

Payment Methods:

E-transfers can be sent to ac.bcgb@stnemyap. Please indicate 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. Office hours are Monday-Friday from 8:30am-3:30pm.

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 (month/day/year) *

ASSUMPTION OF THE 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.

COVID-19 Waiver -NAME *

First

Last

COVID-19 Waiver -DATE (month/day/year) *

MEMBERSHIP CONTRACT

Parents/Guardians: Please review the following Participation 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.

BGC Battlefords' Rules:

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

• 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 should my child 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 child has left BGCB premises, the staff, volunteers, and Board of Directors, are not liable for my child. *

• 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 Agreement - NAME *

First

Last

Membership Agreement - DATE & TIME *

Date

Time

*If you would like a copy of this membership, please contact the office at 306-445-0002 or ac.bcgb@ofni

This membership is valid from January 1st, 2022 to December 31st, 2022. Membership Fee is $5.00 per child. Membership Fee is non-refundable. Summer Parks Drop-in Program is FREE OF CHARGE. Membership fee is waived for July and August. 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.

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