What is the Boys & Girls Club and what does my membership mean? The Boys & Girls Club Traditional Unit is a membership organization that is a drop-in recreational program and facility. It is not a licensed childcare or a fee-based program.

Completing a Boys & Girls Club application and submitting payment for dues, does not guarantee membership to the Boys & Girls Club. The Boys & Girls Club may also require meetings or additional information prior to acceptance as a member to ensure the Club has the capability, facilities and professionals to meet the needs of the youth requesting membership. Once membership is accepted, the expectation for families and youth to maintain membership is that Club rules and guidelines are followed. In addition, if a child’s needs change or new information is disclosed, the Boys & Girls Club will review its capabilities, facilities and professionals at that time to ensure it can meet the needs of the youth currently enrolled.

Club Programming & Spaces: The Boys & Girls Club focuses on three priority areas of programming: Academic Success, Healthy Lifestyles and Character & Leadership. Grades 2-5 will be in shared spaces, with 4 & 5 graders having some separate social areas at times. Grades 6-12 will be in shared spaces, with 6-8 and 9-12 graders having their own social and homework areas at times.

How much does it cost to be a member at the Club? The 2020 Club membership due is $25 and the 2020 summer fee is an additional $40 (maximum summer fee of $80 per family), with the purpose to ensure all youth can afford to come to the Club. However, it costs the Club over $800 a year for each member, therefore we highly encourage families to support the Club beyond the membership due and summer fee, if able, by filling out the donation form on the last page of the application. The 2020 summer registration will be available in the spring of 2020 and cannot be paid for ahead of time.

When is the Club open and how old do you have to be to attend the Club? o School Year:

o 2-5 Grade: After school until 8:00 PMo 6-12 Grade: M - Th.: After school until 8:00 PM; F.: After school until 10:00 PM o Early dismissals: After school – 6:00 PM

o Summer 2-5 Grade: 7:30 AM – 6:00 PM; 6-12 Grade: M. T. W. F.: 7:30 AM -6:00 PM, TH: 7:30 AM -9 PMo No School & Snow Days: 7:30 AM – 6:00 PMo Club Closed: Major holidays and transitions between summer and school year sessions, notice will be provided to parents in advance.

The Club will close one day every month for Club in-service (see attached schedule). This keeps our staff well trained, the Club safe, thebuilding clean and makes it possible for us to be open year round.

o Grades Served: 2-12 Grade: First day of summer after graduation from 1st Grade through Grade 12. If your child repeats 1st grade, theymust wait until the summer before they enter Grade 2.

Do I need to fill out the entire application? The application needs to be fully completed to be considered for membership, don’t forget:

o Youth & Parent Signatures: Make sure your child has signed and the guardian has signedo Salary Section: This is used for grants and securing resources to keep dues as low as possibleo Parent Email & Two Emergency Contacts: This helps the Club stay in contact with you, newsletters and in emergencieso School Collaboration Form (for members attending a Yankton School District school): We highly recommend completing and signing

sections #1, #2 and #3 to optimize our collaboration and programming with the schools

Parent/Guardian Orientation Requirements: Orientation Time: Every Tuesday at 5:15 PM It is a Boys & Girls Club membership requirement that all youth and a guardian attend orientation prior to joining the Club at each stage: before 1-5 grade and again before 6-12 grade. All youth are unable to attend the Club as a member until the orientation is attended by youth and guardian, even if guardian and a sibling have previously attended.

Emergencies, Questions & Concerns: o Josh Klimek Executive Director 605-668-9710 jklimek@greatfuturessd.org o Koty Matthiesen Teen Director 605-688-9710 kmatthiesen@greatfuturessd.org o Renee Roemer 2nd-5th Grade Coordinator 605-688-9710 rroemer@greatfuturessd.org o Lindsie Bell Chief Operations Officer 605-692-3333 lbell@greatfuturessd.org o Tim Lease Chief Executive Officer 605-692-3333 tlease@greatfuturessd.org

Yankton 2-5 Grade | 2020

Expires 12/31/2020

BE GREAT!

Yankton 2020 In-Service Calendar

Club Closed:

School Year: January 24

February 28

March 20

April 24

September 25

October 23

November 20

Summer: June 12

July 10

Important Dates The Club will be closed on the dates below for Club in-service.

This keeps our staff well trained, the Club safe, the building clean and makes it possible for us to be open year round.

The Boys & Girls Club may have other, both expected and unexpected, closed dates for holidays, events, etc. The dates above are only highlighting our Club in-service days.

Register for the Summer Program at the Boys & Girls Club of Yankton

Deadline to come on the first day of summer: May 8th Grades: 2nd-5th

Summer Program Fee: $40; $80 maximum for families

Youth’s Name (Please Print) Grade

Member’s Sibling(s) who also attend the Club:

Name Age Full/Half/Step Name Age Full/Half/Step

______________________________________________ _____________________________________________

______________________________________________ _____________________________________________

SUMMER 2020 POOL INFORMATION and Parks and Recreation Activities:

Please fill out the attached form if your child(ren) will be going swimming with the Club for summer 2020. Only pay the

$10/child fee if your child/family does not already have a Summit Center Membership or a GreatLife Membership.

The Club will be providing transportation to and from the pool as well as the extra activities available for sign-up

through the Parks and Recreation Department.

FEE-BASED PROGRAM OPTIONS DATES & TIMES

COST/PARTICIPANT Tie Dye Camp Every other Tuesday from June 2nd – Aug. 11th 9-11am $15

Fishing Camp Monday – Thursday, 9-11 am $25

___ June 8th – June 11th or ___ July 6th – July 9th

Hiking Camp Tuesday – Friday, 9-11 am $20

___ June 23rd – June 26th or ___ July 21st – July 24th

Kid Chef Camp Monday – Thursday, 9-11 am $25

___ June 15 – June 18th or ___ July 13 – July 16th

Disc Golf Camp Monday – Thursday, 9-11 am $25

___ June 29th – July 2nd or ___ July 27th – July 30th

__________________________________________________________________________________________________

Mailing Address State Zip Code

_________________________________________________________

_________________________________________

Parent/Guardian’s Email Parent/Guardian’s Phone Number

Parent/Guardian signature Date

(For Club staff use only)

Date Received: ____ _______

Amount Paid: __ _______

Receipt Number: __ _______

Check / Cash (circle one): Check #_______

The summer program fee is above and beyond a Club membership fee. If this fee is not paid for the summer, it will be an

additional $1.00 a day to come to the Club during summer programming. If you are not a member and want to come to the Club in

the summer, you will need to pay the membership fee and summer fee or $2.00 a day.

Total Amount Due: $_____________

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City of Yankton

Department of Parks and Recreation

Yankton Summer Season Pool Pass Information

$10 Summer Swim Pass - Only valid for those enrolled in

B&G Club Summer Program

Name _____________________________________ Spouse

________________________________

Last First Middle Last First

Middle

DOB_____________________________

DOB__________________________________

__________________________________ _______________________ __________ __________

Address City

State Zip Code

( )____________________ ( )____________________ ( )__________________

Home Phone # Work Phone # Spouse

Work Phone #

EMERGENCY NAME AND NUMBER:

_________________________________________________________

Children (Name) DOB Children (Name)

DOB

ONLY THOSE ENROLLED IN BOYS AND GIRLS CLUB SUMMER PROGRAM SHOULD BE LISTED!

One form can be filled out for families with multiple kids enrolled in Boys & Girls Club

_________________________ ___________ _________________________ _____________

_________________________ ___________ _________________________ _____________

SINGLE ______ $10.00

1. The pass will be valid from May 1, 2020 through August 31, 2020.

2. The pass may only be used for pool usage during normal scheduled open swim times at

The Summit Activities Center Indoor Pool.

3. The pass does not include any lap swimming at the Summit Activities Center Indoor Pool.

4. The pass does not qualify as a SAC membership.

5. Each person wishing to have a pool pass must purchase their own individual pass.

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Yankton Parks and Recreation Registration

All Forms must be turned into the Boys and Girls Club with payment.

Please make all checks payable to: SAC

DO NOT TURN IN AT THE SUMMIT ACTIVITES CENTER

Parent/Guardian Name:___________________________________________________________________ First Last

Do you have an online account? Yes No

Street:

City State, Zip:__________________________________________________________________________

Email Address:

Phone: Home: ( ) Work: ( )

Emergency Contact:

First Last Relationship

Participant: First Last

Gender: Male Female Date of Birth: / /

Please Circle the Programs you would like to register for:

TRADITIONAL SITE:

PROGRAM DATE TIME DAYS HELD PRICE

Swim Lesson LEVEL: June 1-June 12 TBD-Mornings Monday-Friday $26.63

KOBRA Ages 6-9

Ages 10-13

June 1-24

June 2-25

1-2:15pm

1-2:15pm

Monday & Wed

Tues & Thurs

$26.63

$26.63

Memorial

Park Movers

Ages 5-8 June 5-26 10-11:30am Friday’s Only $26.63

Gymnastics

MAX 12

Ages 7-11 July 7-30 8:15-8:55am Tues & Thurs $29.82

Dodgeball/

Kickball

Ages 6-9

Ages 10-13

July 6-July 29

July 7-July 30

1-2:15pm

1-2:15pm

Monday & Wed

Tues & Thurs

$29.82

$29.82

4

Boys and Girls Club

Swim Lesson Registrations 2020

Session will run from June 1 – June 12, 2020

All registration forms and payment must be turned into Boys & Girls Club. No registration forms will

be accepted at the Summit Activities Center.

All checks must be made out to the SAC. The price is $26.63 per child.

Deadline for all forms and payment from Boys & Girls Club to be turned into the SAC is Monday, May

18, 2020. All registration forms and payment should be turned in at one time together.

No registrations or payment will be accepted after this deadline.

If there are questions as to what level your child has taken before, or what level to place your child in,

please call the SAC 668-5234, Monday-Friday, 8am-5pm.

Once lessons have begun, if a child is too advanced or not ready for the level they have enrolled in, we

will transfer them to a more appropriate level.

Level I: Introduction to Water Skills -- The objective of Level I is to help students feel

comfortable in the water and to enjoy the water safely. Student will learn elementary water skills

of which they can build on as they progress through the various levels.

Level II: Fundamental Aquatic Skills -- Must have passed Level I certificate/skills. This course

builds on the fundamental skills and teaches to float without support. Learn basic self-help rescue

skills.

Level III: Stroke Development -- Must have passed Level II certificate/skills. This course builds

on skills from Level II with additional guided practice.

Level IV: Stroke Improvement -- Must have passed Level III certificate/skills. This course

develops confidence in strokes learned thus far and to improve other aquatic skills.

Level V: Stroke Refinement -- Must have passed Level IV certificate/skills. This course provides

further coordination and refinement of strokes.

Level VI: Swimming and Skill Proficiency -- Must have passed Level V certificate/skills. This

course is to polish strokes so students swim with more ease, efficiency, power, and smoothness

over greater distances. Level VI concentrates on fitness swimming and lifeguard readiness which

focuses on preparing students to participate in more advanced courses, such as Water Safety

Instructor and Lifeguard Training.

5

K.O.B.R.A. (KIDS OUT BEING REALLY ACTIVE) ages 6-13

Boys and girls play dodgeball, soccer, basketball, whiffle ball, tennis, kickball, capture the flag, disc golf and more.

K.O.B.R.A. is fun, provides exercise, introduces new games, teaches sportsmanship and teamwork and fosters new

friendships. Children should wear athletic shoes, bring a water bottle and be ready for fun, new activities every

week.

LOCATION: Summit Activities Center

FEE: $25 plus tax

JUNE 1-24 Mondays & Wednesdays 1-2:15 p.m. (Ages 6-9) JUNE 2-25 Tuesdays & Thursdays 1-2:15 p.m. (Ages 10-13)

MEMORIAL PARK MOVERS ages 5-8

Boys and girls enjoy the outdoors through games, exploring nature, group activities, art projects and more. Each day

finishes with supervised playtime at the Memorial Park playground. In case of inclement weather, class will be

cancelled. Class size: 20.

LOCATION: Memorial Park Wood Shelter

FEE: $25 plus tax

JUNE 5-26 Fridays 10-11:30 a.m.

GYMNASTICS ages 7-11

Ready for some tumbling fun this summer? Boys and girls may sign up for both sessions if there are openings.

Class size: 12.

LOCATION:

Summit Activities Center

(Gymnastics Room)

FEE: $28 plus tax

JULY 6-JULY 30

Tuesdays & Thursdays 8:15-8:55 a.m.

DODGEBALL, KICKBALL AND MORE ages 6-13 Participants learn sport fundamentals and the importance of sportsmanship and teamwork by playing variations of dodgeball, kickball and other structured games. Participants work together to enjoy activities that promote physical activity, coordination and motor skills. Wear athletic shoes and bring a water bottle. LOCATION:

Summit Activities Center

FEE: $28 plus tax

JULY 6-JULY 30

Mondays & Wednesdays 1-2:15 p.m. (Ages 6-9)

Tuesdays & Thursdays 1-2:15 p.m. (Ages 10-13)

1

2020 Expires 12/31/2020

2008 Mulberry Street, Yankton, SD 57078 605-668-9710

www.greatfuturessd.org

YANKTON 2– 5 GRADE MEMBERSHIP APPLICATION

OFFICE USE ONLY

Membership Number: Orientation Date: Payment Type: Cash Check #__________

New Member / Renewal: Card Printed Date: Receipt #:

Entered By: Date: Photo Taken Date: Accepted By: Date:

Expiration Date: 12/31/2020 Welcome Email Date: Location Accepted:

Youth First Name:__________________________________Youth Last Name:_______________________________ Member’s Sibling(s):

Name Age Full/Half/Step Name Age Full/Half/Step

______________________________________________ _____________________________________________

______________________________________________ _____________________________________________

Circle the Appropriate Annual Household Income (this is for grant purposes only)

0-$37,700 $37,701-$43,100 $43,101-$48,500 48,501-$53,850 53,851-$58,200

$58,201-$62,500 62,501-$66,800 66,801-$71,000+

Parent/Guardian Information: Both parents/guardians information needs to be filled in below:

Parent/Guardian (Primary Club Contact):___________________________________________________ Gender: M F

Address: _____________________________________ City: ____________________ State: _____ Zip: _________

Home Phone: _____________________ Cell Phone: _____________________ Work Phone: _____________________

Email (at least one email is required to be on file): _______________________________________________________________

Place of Employment: ______________________________________________________________________________ □ If single parent, please check this box

Parent/Guardian:__________________________________________________________________ Gender: M F

□ Check this box if home address is same as above

Address: _____________________________________ City: ____________________ State: _____ Zip: _________

Home Phone: _____________________ Cell Phone: _____________________ Work Phone: _____________________

Email: ___________________________________________________________________________________________

Place of Employment: ______________________________________________________________________________

2

Youth Information:

First Name:__________________________ Middle: _________________________ Last: _______________________

Age:__________________ Date of Birth: _____________________ Gender (circle): M F

Ethnicity (circle): Number in Household: __________________

African American Asian

Caucasian Hispanic

Multi-Racial Native American ____________________(Tribe)

Native Hawaiian/Pacific Islander Other

Academic information: School:__________________________________________Grade:___________ School Year: ________________ Anticipated Graduation Year:____________ Teacher____________________________________________ Is your child on an Individualized Education Plan or 504? ___Yes ___No Does your child have a specific academic? ___Yes ___No If yes, please explain: _________________________________________________________________________________________________ _________________________________________________________________________________________________ Medical Information: Does your child have asthma? ___Yes ___No Do they use/carry an inhaler? ___Yes ___No ___N/A

Does your child have an allergy? ___Yes ___No If yes, please list allergy and associated symptoms: Allergy_________________________________________ Symptom(s):__________________________________________ Allergy_________________________________________ Symptom(s):__________________________________________

Does your child have other medical conditions or diagnoses? ___Yes ___No If yes, please explain: _________________________________________________________________________________________________

_________________________________________________________________________________________________ The Boys & Girls Club is a drop-in recreational facility, not a licensed daycare facility, and is not responsible for or allowed to dispense, store and/or oversee medication of any kind, including all non-prescription medications. Parents/Guardians are able to come to and sign in to the Boys & Girls Club and administer medication to their child. The Boys & Girls Club can follow its incident and accident policies and procedures, including:

• Support your child through a team effort • Call 911 in case of an emergency situation • Follow normal incident/behavior protocol, if needed, as outlined through Boys & Girls Club of the Northern Plains, Inc. policy

By signing my name below, I certify that I have read, understand and agree to the above.

Parent Name Date

3

Please check one item from each group below: Single Parent: ____ Yes ____ No Is the member a child of Military personnel and not living on a base? ____ Yes ____ No *If you marked yes, the Department of Defense has partnered with us so your membership fee can be waived if you fill out the appropriate form. Ask the front desk for the form when turning in this membership. Are you willing to volunteer at the Club? ____ Yes ____ No Qualify for Free Lunch: ____ Yes ____ No Qualify for Reduced Lunch: ____ Yes ____ No

Additional Emergency Contacts (in addition to Parents/Guardians): *MUST HAVE AT LEAST 2 CONTACTS*

First Name:______________Last Name:_______________

Phone Number: __________________________________

City, State: ______________________________________

Relation to the Child: ______________________________

Please write below if someone is NOT ALLOWED TO PICK UP MEMBER

(If a biological parent, legal documentation must be provided) Name: ___________________________________________ Relationship to Member: _____________________________ Does this contact live in the Member’s household? Yes [ ] No [ ] (If not, please fill in address below) City/State/Zip: _____________________________________ Brief description of individual __________________________ _________________________________________________ _______________________________________________________

First Name:______________Last Name:_______________

Phone Number: __________________________________

City, State: ______________________________________

Relation to the Child: ______________________________

First Name:______________Last Name:_______________

Phone Number: __________________________________

City, State: ______________________________________

Relation to the Child: ______________________________

First Name:______________Last Name:_______________

Phone Number: __________________________________

City, State: ______________________________________

Relation to the Child: ______________________________

Please write below if someone is NOT ALLOWED TO PICK UP MEMBER

(If a biological parent, legal documentation must be provided) Name: ___________________________________________ Relationship to Member: _____________________________ Does this contact live in the Member’s household? Yes [ ] No [ ] (If not, please fill in address below) City/State/Zip: _____________________________________ Brief description of individual __________________________ _________________________________________________ _______________________________________________________

4

Permission Information: 1. I give my permission to the Boys & Girls Club of the Northern Plains, Inc. and my child’s school to exchange information regarding the minor

child listed on this application. The purpose of the exchange is to help both organizations do a better job of helping the student be successful in school, in the Boys & Girls Club and in life. This release is valid for one year and may be revoked at any time by contacting my child’s school or the Club in writing.

____ Yes ____ No ____________________________________________________________

Parent Signature

2. I give permission for my child’s picture, moving pictures, or any other graphic depiction or likeness, to be used by the Boys & Girls Club and its activities.

____ Yes ____ No _______ Initials

RELEASE FORM I, the parent/guardian of the minor child listed on this application, for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever discharge the Boys & Girls Club of the Northern Plains, Inc., and Boys & Girls Clubs of America, their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organizations such as staff, directors or volunteers, from all liability, claims, demands, or causes of action for any and all loss, damage, injury or death and any claim of damages resulting from use of facilities owned or controlled by the above organizations, or participation in activities of said organizations either at or away from the Club. Medical Treatment I give permission to the Boys & Girls Club of the Northern Plains, Inc. to seek emergency medical treatment for my minor child if I cannot be reached. I understand that Club employees cannot transport children to the hospital and that if a life threatening situation occurs, the AMBULANCE will be contacted first and then the PARENTS. I will be responsible for any/all costs of medical attention and treatment. Surveys and Questionnaires I, the parent/guardian of the minor child listed on this application, give permission for Boys & Girls Club of the Northern Plains, Inc. to survey my child about his or her Club experience and behaviors, skills and attitudes using Boys & Girls Clubs of America’s Youth Development Outcome Measurement Tool Kit surveys or other survey instruments. Restraining I understand that when a youth is in a dangerous situation to themselves or others they will be removed from the situation. Rec Program I understand that the Boys & Girls Club is classified as a recreation program and not a licensed afterschool program. As a recreation program, the Boys & Girls Club does not maintain specific ratios within the program spaces. I also understand that the Boys & Girls Club cannot legally keep my child from leaving the Club. However, by having my child and myself sign below, I am entering into a contract with my child that states he/she will stay checked into the Club until a parent/guardian or other authorized adult picks them up. The Club will enforce this contract. Miscellaneous I understand that the Boys & Girls Club of the Northern Plains, Inc. is not responsible for lost or stolen items. Any items placed in the lost and found will be discarded on the 15th of every month. Late Fees I understand that my child/children must be picked up by closing time each day. I understand that I will be charged $10.00 per child for every 15 minutes that my child/children remains at the club after closing time. Time is rounded up to next 15 minutes. For example: 1-14 minutes that child/children remain at the club after closing time = $10.00 per child 15-29 minutes that child/children remain at that club after closing time = $20.00 per child, etc. I have read the completed application and this form, understand the rules of the Boys & Girls Club and request that my child be admitted into membership.

I understand it is a Boys & Girls Club membership requirement that all youth and a guardian attend orientation prior to joining the Club and at ______ the time of their first enrollment in the Club program in 2nd -5th grade and again in 6th -12th grade. All youth are unable to attend the Club as Parent a member until the orientation is attended by youth and guardian, even if in the same family. I also understand that if I have completed Initials orientation in the past it is my responsibility to go to the Club website at www.greatfuturessd.org and read, review and follow the Boys &

Girls Club of the Northern Plains, Inc. parent handbook and listen to the recorded orientation. I hereby give my permission for my child to become a member for the Boys & Girls Club of Yankton. I understand that the Club is Not Responsible for the time or manner in which he/she may arrive at or leave the Club, and that the Boys & Girls Club of the Northern Plains, Inc. and its property are not responsible for personal injury or loss of property.

Parent Signature Date

Youth Signature (REQUIRED)

Donation Options (You may donate to more than one category.)

Annual Operating Campaign Endowment

Amount ($) Amount ($)

Payment Options Cash or Check Stock Crop Exchange

Credit Card EFT Deduction (Please attach voided check)

Name Telephone

Address

Email

Employer Will Match My Gift? Yes No

Thank you. By contributing you help make a positive impact on the life of children in your community. The Boys & Girls Club is exempt from federal income tax under Section 501(C)(3) of the Internal Revenue Code and contributions are tax-deductible to the extent allowed by law

with tax ID of 73-1630215. No goods or services were provided in consideration of this contribution.

Parent/Guardian PledgeBoys & Girls Club of Yankton

Signature Date

Name on Card

Card #

exp. date 3-digit code on back

Amount per month ($) for month(s)

Name and address of financial institution

Checking or savings account #

Bank routing # (between |: |: on bottom left

Amount per month ($)

A Club membership dues are $25.00 a year with the purpose to make sure all kids can afford to come to the Club. However, it costs over $800 a year to fund each child coming to the Club so we highly encourage you, if

you are able, to support the Club and membership beyond the $25.00.