BE GREAT!

What is the Boys & Girls Club and what does my membership mean? The Boys & Girls Club 1-5 Grade Unit and The Boys & Girls Club Teen Center 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 1-5 will be in shared spaces, with 4 & 5 graders having some separate social areas at times. Grades 6-12 are 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 $25 (maximum summer fee of $75 per family), with the purpose to ensure all youth can afford to come to the Club. However, it costs the Club over $1,050 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 are you open and how old do you have to be to attend the Club? o School Year:

o 1-5 Grade- M. T. Th. F: Afterschool – 9 PM; W.: Afterschool - 8 PM; and Sat.: Sign up available at front desko 6-12 Grade – M. - Th.: Afterschool – 7 PM, F: Afterschool – 10 PM, Sat: Sign up available at front desko Early dismissals: Afterschool – 6:00 PM

o Summer:o 1-5: 7:30 AM – 6:00 PM; 6-12: 7:30 AM - 6:00 PM

o Snow Day & No School Day:o 1-5: 7:30 AM – 6:00 PM; 6-12: 7:30 AM – 6:00 PM

o 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, the building clean and makes it possible for us to be open year round.

o Grades Served: ECE: Age 3 through Kindergarten & Traditional Sites: First day of summer after Kindergarten through Grade12. If your child repeats K or did JK they must wait until the summer before they enter grade 1.

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 emergencies

Parent/Guardian Orientation Requirements: Orientation Time: Every Monday at 5:15 pm for 1-5 Grade and Tuesday at 5:15 for 6-12 Grade 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 ECE program, again before 1-5 grade and again in 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 Chelsea Lang, Executive Director, 605-692-3333 or 605-692-6666, clang@greatfuturessd.orgo Matt Sass, Elementary Director, 605-692-3333, mattsass@greatfuturessd.orgo Erinn Thomas, Teen Director, 605-692-6666, ethomas@greatfuturessd.orgo Lindsie Bell, Chief Operations Officer, 605-692-3333, lbell@greatfuturessd.orgo Tim Lease, Chief Executive Officer, 605-692-3333, tlease@greatfuturessd.org

Brookings1-5 Grade | 2020

Expires 12/31/2020

Brookings 2020 In-Service Calendar

Club Closed:

School Year: January 24

February 28

March 20

April 24

September 25

October 23

November 20

Summer: June 19

July 17

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 Brookings Deadline to attend the first week of summer: May 8th

Grades: 1st-5th Summer Program Fee: $25; $75 maximum for families

Youth’s Name Grade

Sign up for Extra Summer Fun! Turn this page over for descriptions!

Parent/Guardian Signature Parent/Guardian E-mail Date

(For Club staff use only)

Date: ___________

Amount Paid: _________

Receipt Number: ____________

Check / Cash (circle one): Check #_______

Total Amount Due (summer fee + camps): ________________

This 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.

*Signing this form gives your child permission to ride the Club bus if they are going to the pool.

One Day Summer Camps ($15 each):

Tie-Dye Camp

May 26th, 9-11am

June 25th, 9-11am

July 28th, 1-3pm

Pokémon Camp

May 28th, 9-11am

June 30th, 9-11am

July 30th, 1-3pm

Jewelry Camp

June 23rd, 9-11am

July 2nd, 9-11am

August 18th, 9-11am

One Week Summer Camps ($30 each):

Fishing Camp

June 1st-4th, 9-11am

July 6th-9th, 9-11am

August 3rd-6th, 9-11am

Kid Chef Camp

June 8th-11th, 9-11am

July 13th-16th, 1-3pm

August 10th-13th, 9-11am

Dance Camp

June 15th-18th, 9-11am

July 20th-23rd, 1-3pm

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Tell us more about these camps!

Parents will receive an email reminder one week before camp. The email will include all details (what should my child bring/wear?)

Tie Dye Camp:

Members will explore colors through the art of Tie Dye! Participants will receive a white t-shirt on which they will execute their tie dye masterpieces! All clothing will be ready to be taken home and worn by the end of the week!

Pokémon Camp:

Members will receive their own pack of Pokémon cards to trade and then will be able to

compete against other members with their cards! Members are able to bring their own Pokémon cards from home to include in their decks.

Jewelry Camp:

Members will have the opportunity to show their artistic flair by making their own jewelry! All jewelry created will be able to be taken home at the conclusion of the camp.

Fishing Camp:

Youth will explore the Dakota Nature Park as they learn to reel in various South Dakota fish!

Kid Chef Camp:

Members will learn about the different aspects of cooking and what it takes to make a meal! Members will then help make a recipe that they get to eat. Each day will focus on a different meal – breakfast, lunch, snacks, and dessert! All three sessions will have different recipes.

Dance Camp:

Members will learn different dance techniques such as leaping, turning, and flexibility. At the end of the week, members will perform a dance that incorporates all the techniques learned!

What about lunch?

Hot lunch is served at the Club every day for $3 if you sign your child up at the front desk before 10:00am. After 10:00am, the cost is $4. You can pay now and

put money on your child’s Club lunch account, or you can pay daily. Check out our menu in our summer newsletter!

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2020 Expires 12/31/2020

1126 Southland Lane, Brookings SD 57006 Tel 605-692-3333 Fax 605-692-9199

www.greatfuturessd.org

BROOKINGS 1 – 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: ______________________________________________________________________________

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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 need? ___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

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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 __________________________ _________________________________________________ _______________________________________________________

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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 1 -5 grade and again in 6 -12 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 the Northern Plains, Inc. 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)

We highly recommend filling out and signing #1, #2, and if possible of #3 to optimize our collaboration and programming with the schools, communication on bussing situations, with families and to serve your youth best. You are able to select signing none, some or one if you wish.

AUTHORIZATION FOR RELEASE OF SCHOOL RECORDS AND/OR EXCHANGE OF WRITTEN AND/OR ORAL INFORMATION

1. Name of School: ________________________________________________________________________________

Student Name: Date of Birth: Grade:

______________________________________________________________________________________________

Date Requested: ___________________ Date Mailed: _____________________ Date Fixed: ___________________

2. Oral Exchange of student information between _____________________________________________________

(Professional outside Brookings School District) and staff from the Brookings school building noted on this form. This

exchange is authorized for 12 months beyond the authorized signature date listed below.

______________________________________________________________________________________________Authorized Signature of Parent, Guardian or Eligible Student Date3. Check one or both if applicable:

Records are requested FROM the following school District/Agency/Professional:

Attention: _____________________________________________________

District/Agency/Professional: _____________________________________________________

Address: _____________________________________________________

_____________________________________________________

Telephone: ______________________ Fax Number: ___________________

It is requested that records be sent TO the following school District/Agency/Professional:

Attention: _____________________________________________________

District/Agency/Professional: _____________________________________________________

Address: _____________________________________________________

_____________________________________________________

Telephone: ______________________ Fax Number: ___________________

In accordance with the Family Educational Rights and Privacy Act of 1974, as amended, enacted as Section 438 of the General Education Provisions Act, in effect April 11, 1988. I hereby give permission for the release of any and all confidential information, to include:

1. Transcript of grades 7. Special education records, such as

2. Grades at time of withdrawal a. current IEP

3. Birth Certificate b. education multi-disciplinary evaluations,

4. Attendance record psychological evaluations

5. Health and medical records (including c. socio/developmental reports

immunizations and sports physical) d. treatment records

6. Educational records

NOTE: We request that no permanent files be sent on the student named above. Send only copies of the information indicated. ______________________________________________________________________________________________ Authorized Signature of Parent, Guardian or Eligible Student Date

Boys & Girls Club of the Northern Plains, Inc.: 605-692-3333

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 Brookings

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 $1,050 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.