Mentoring with Impact: A Step-by-Step Guide for a Successful Mentoring Program Boys & Girls Clubs of America (Revised September 2010) Page 1 of 2

JUNIOR STAFF VOLUNTEER APPLICATION

Today’s date __________________ Club/Unit ___________________________________ Name______________________________________ Male_____ Female_____ Age: ___________ Date of Birth: ____________________ Shirt Size:________ Applicant Phone:___________________ Address___________________________________City___________________State______ZIP_______ Email address: (applicant) ____________________ (parent email) __________________________ Parent name _____________________________ Parent Phone______________ Other ____________ How many brothers and sisters do you have?_______ Their ages are:____________________________ Are you a current Boys & Girls Club member? Yes_____ No____ If yes, number of years: _______ Do you have any after-school activities/responsibilities? Yes______ No______ If yes, what are they? __________________________________________________________________ Describe your special interests and hobbies (e.g. sports, arts & crafts, computers, music, reading, cooking, games, career interests, foreign languages, painting, reading, etc.) ____________________________________________________________________________________ What clubs or groups do you belong to?____________________________________________________ Awards/acheivements?_____________________________________________ ____________________________________________________________________________________ Why are you interested in participating in this program? _______________________________________ ____________________________________________________________________________________ REFERENCES (Teachers, guidance counselors, employers, church officials, etc.; do not include family members)

Name Address Phone Relation

I have read the Jr. Staff Position Description and understand the duties and responsibility of being a Jr. Staff. I understand that this is a volunteer position and that I will not be paid. _________________________________________ _________________________ (Signature of Youth) (Date)

Mentoring with Impact: A Step-by-Step Guide for a Successful Mentoring Program Boys & Girls Clubs of America (Revised September 2010) Page 2 of 2

Junior Staff Program Parent Consent Form

(To be completed by Parent/guardian of applicant)

Child’s name: ___________________________ ______

Club Unit: __________________________________________

The Junior Staff Program is for Club members ages 13 to 18 wanting to explore a career in youth or human services, particularly Boys & Girls Club work. The program develops Club members’ interpersonal skills, work ethic and sense of community responsibility. Members apply for the program and are selected for this program through an interview process. Members will be responsible for following a set schedule at our club. Requirements:

Must attend the club a minimum of 3 days a week for at least 2 hours a day to waive BGCW program fees. Those attending less may be required to may monthly/summer fees.

$25 annual membership fee at time of enrollment and each August thereafter.

Must attend training in Dothan the last week of May in order to participate in the program each year.

I hereby give my permission for my son/daughter to participate in the Junior Staff volunteer program. I understand and give my permission for my son/daughter to participate in the volunteer work experience program, weekly recreational activities and trips, and training. I understand that my child must meet the requirements listed above to participate. I also understand that this is a volunteer position. I agree to support my child in his or her effort to achieve success in the Junior Staff program, and to attend planned events for the duration of the program. I also understand that my child can be released from the Junior Staff program due to disciplinary actions. Signature ______________________________________________ Date __________ (Parent or Guardian)

Signature _____________________________________________ Date __________ (Junior Staff Candidate)

2/19/2018  

JUNIOR STAFF VOLUNTEER

Volunteer Job Description JOB FUNCTIONS

Enable all young people, especially those that need us the most, to reach their full potential as productive caring, responsible citizens.

SAFETY- Insures the health and safety of members. Help Staff supervise members in program areas.  

Provide guidance and positive role modeling to members Demonstrates positive values and ethical behavior through quality in programs and appearance of the unit at all times. Must work well with other staff Assist in cleaning duties at the club facility.

DUTIES (may include, but not limited) Required to be on duty at the club for a minimum of 2 hrs. per day and at least 3 days a week to waive program fees. Set up and put away activities, materials and equipment for programs Assist members in completion of projects/activities Assist members in learning rules and playing games Keep program areas organized and clean Help distribute food and food set up. Help instruct members to clean their areas. Displays a high level of enthusiasm and commitment for activities. Performs all cleaning duties and other related duties as assigned by management staff.

ADDITIONAL RESPONSIBILITIES: May be required to participate in special programs and/or events.

REQUIREMENTS Must be 13 -18 years old Must be a member of the club and pay annual membership fee Attend Club a minimum of 3 days a week with minimum 2 hours per day Leadership Skills- Must be able to control a room and motivate youth CPR training preferred Personal conduct must be one of high moral standards; honest, trustworthy, compassionate, encouraging, hardworking, team

player, self-motivated, puts children first above personal needs! PHYSICAL REQUIREMENTS/WORK ENVIRONMENT: This position requires working outside and standing for long periods of time as well as cleaning the facilities. DISCLAIMER: The information presented indicates the general nature and level of work expected of volunteers in this classification. It is not designed to contain, nor to be interpreted as, a comprehensive inventory of all duties, responsibilities, qualifications and objectives required of volunteers assigned to this position. Member Name:__________________________________________________ Parent Signature: _____________________________ Member Signature: _______________________________________________ Date: _____________  

THE ROLE OF THE JUNIOR STAFF Junior Staff are responsible for assisting Program Staff in daily programs, services and activities for Club members.   

CLUB COPY 

2/19/2018  

JUNIOR STAFF VOLUNTEER

Volunteer Job Description JOB FUNCTIONS

Enable all young people, especially those that need us the most, to reach their full potential as productive caring, responsible citizens.

SAFETY- Insures the health and safety of members. Help Staff supervise members in program areas.  

Provide guidance and positive role modeling to members Demonstrates positive values and ethical behavior through quality in programs and appearance of the unit at all times. Must work well with other staff Assist in cleaning duties at the club facility.

DUTIES (may include, but not limited) Required to be on duty at the club for a minimum of 2 hrs. per day and at least 3 days a week to waive program fees. Set up and put away activities, materials and equipment for programs Assist members in completion of projects/activities Assist members in learning rules and playing games Keep program areas organized and clean Help distribute food and food set up. Help instruct members to clean their areas. Displays a high level of enthusiasm and commitment for activities. Performs all cleaning duties and other related duties as assigned by management staff.

ADDITIONAL RESPONSIBILITIES: May be required to participate in special programs and/or events.

REQUIREMENTS Must be 13 -18 years old Must be a member of the club and pay annual membership fee Attend Club a minimum of 3 days a week with minimum 2 hours per day Leadership Skills- Must be able to control a room and motivate youth CPR training preferred Personal conduct must be one of high moral standards; honest, trustworthy, compassionate, encouraging, hardworking, team

player, self-motivated, puts children first above personal needs! PHYSICAL REQUIREMENTS/WORK ENVIRONMENT: This position requires working outside and standing for long periods of time as well as cleaning the facilities. DISCLAIMER: The information presented indicates the general nature and level of work expected of volunteers in this classification. It is not designed to contain, nor to be interpreted as, a comprehensive inventory of all duties, responsibilities, qualifications and objectives required of volunteers assigned to this position. Member Name:__________________________________________________ Parent Signature: _____________________________ Member Signature: _______________________________________________ Date: _____________

THE ROLE OF THE JUNIOR STAFF Junior Staff are responsible for assisting Program Staff in daily programs, services and activities for Club members. 

JR. STAFF COPY

UNIT: McMullan Rehobeth Slocomb Geneva Year: ______________ Monthly Payment Method: _____________

MEMBERSHIP APPLICATION New

Please print & fill out application completely. BGCW will NOT accept incomplete applications Renewal (all expire July 31

st)

MEMBER INFO (Please Print) First Name: Middle Name: Last Name:

Address: Nick Name:

Zip Code: County: City: Primary Phone:

Birthdate: Email: Cell Phone (Member):

Gender: Age: Race/Ethnicity: Shirt Size (Circle one):

Name of School: Current Grade:

Has your child ever attended this Club: Other Siblings attending club:

HOUSEHOLD INFO (Please Print) (Information kept private and confidential. Used for grant purposes only.)

Single Parent Household?: Head of Household: Annual Household Income Number of Persons in Household: (for grant purposes please)

MEMBER’S MEDICAL CONCERNS (PLEASE PRINT) Medical Problems and or Allergies MEDICATION / Inhalers etc: Administer at club*? Yes No

*Any medication needed while at the BGCW must be accompanied by a medical form signed by physician. Medication must be in original bottle with correct label and dosage instructions. Please ask front desk for medication form. Physician & Phone Number: Insurance Co. / Policy number or Medicaid Number:

Please Explain Any Special Needs/Concerns For Member:

YS YM YL AS

AM AL AXL A2X

/ /

Female Male

Black or African American White/Caucasian Hispanic/Latino Other _______________

Asian Native American Multi-Racial

Yes No Yes No Names :________________________________________________

MEMBER LIVES WITH: (CHECK ONE)

Both Parents Foster care/DFACS Mother Aunt/Uncle Father Other______________ Grandparent(s)

MEMBER RECEIVES:

□ SSDI □ SSI □TANF

Food Stamps School Lunch Program None

LUNCH PROGRAM

Free Lunch Reduced Lunch None

Yes No

Male Female

$

PARENT INFORMATION (Please Print) PRIMARY PARENT/GUARDIAN- (Authorized for pick-up and Emergency contact) First Name Last Name Relation to Member:

Cell Phone Phone:

Place of Employment Employer Phone Number Extension Parent Email

SECONDARY PARENT/GUARDIAN- (Authorized for pick-up and Emergency contact) First Name Last Name Relation to Member:

Cell Phone: Phone: Employer & Work Number: Address: (if different from Member)

PICK UP INFORMATION Additional Contacts Authorized for Pick Up: Only those listed above and below will be available to pick up member. Must be 18 or older. (If needed, additional contacts may be listed on the back of this page- please make a note if additional on back) Name Relation to Member Phone Number 1. Name Relation to Member Phone Number

2.

Name Relation to Member Phone Number 3. Name Relation to Member Phone Number

4. Name Relation to Member Phone Number

5.

Person(s) NOT authorized to pick up member: Name of person(s) NOT authorized to pick up member: Have you attached legal documentation?

NOTE: YOU MUST PROVIDE LEGAL DOCUMENTATION (if a Biological parent is listed)

Yes No

- -

- -

BGCW Forms & Waivers

PLEASE READ CAREFULLY & INITIAL. CHECK MARKS ARE NOT ACCEPTABLE

I have read the completed application and have read and understand the attached rules/policies of the Boys & Girls Clubs Wiregrass (BGCW) and request that my son/daughter be admitted into membership and I grant permission for my child to participate in current and future programs. I have explained the rules to my son/daughter and agree that BGCW will not be responsible for any accident to him/her while on the premises of BGCW or while engaged in any of its activities away from BGCW.

Print Child’s Name: ________________________________________________

Parent/Guardian Signature: __________________________________________ Date: __________

Member Survey Permission Form (Initials Required)

RE: Member to participate in assessments including but not limited

to: Surveys for outcomes measurements, schools, household demographics and customized surveys built for specific programs (i.e. SMART Moves, BE GREAT: Healthy Habits) I, the undersigned, hereby consent to and give authorization for my child to participate in Member Survey/ Assessments used by Boys & Girls Clubs Wiregrass, Department of Human Services and their subsidiaries, and affiliates. These assessments may include household information, my child’s grades, and/or survey information to be used for reporting purposes ONLY. ____ I give permission for my child to participate in Member Assessments. ____ I DO NOT give permission for my child to participate in Member Assessments.

Media Permission Form (Initials Required)

RE: Use of name, photograph and identity in connection with

advertising and/or promotion of the organization. I, the undersigned, hereby authorize the Boys & Girls Clubs of Wiregrass and their subsidiaries, affiliates and advertising agencies use of my child’s photographs or works of art in any BGCW marketing materials (Youth of the Month, website, Facebook, flyers, signs ,etc.) . ____ I give my BGCW Media Permission

____ I DO NOT give BGCW Media Permission

MEDICAL: (Initials Required – 2 locations) In the event of an emergency, the Club must have written consent to seek medical treatment for your child. ____ I authorize administration of basic first aid ____ I DO NOT authorize the administration of basic first aid

____ I give BGCHC permission to seek medical

treatment for my child. I understand that treatment may include emergency transportation, x-rays, or surgery in some circumstances for my child, and I agree to assume responsibility for charges associated with this or any other treatment given to my child.

____ I DO NOT give BGCHC permission to seek medical treatment for my child.

GENERAL POLICIES (Initials Required) Please initial that you have read and understand the following policies: ___ 1. Late Payments- After school program payments are due on the 1st of each month. Late fee is $5.00/day after the

5th of the month. Fees are not prorated for absences. Summer payments are due before the session starts or as stated in signed agreement.

___ 2. Return Fee- There is a $35.00 return fee for any returned checks. ___ 3. Cancellations- You are responsible for any program payments until club is notified of cancellations. After 1

month of absence, your child will be considered inactive and lose their transportation slot (McMullan Unit). ___ 4. Late Pick-up fee- Any child picked up after hours will be charged $1.00 per minute and fee is due when child is

picked up. ___ 5. Discipline Policy- I have read the attached discipline form with my child. We understand and accept the policy.

This form helps the club obtain state funds and grant monies needed to keep our non-profit rates low. Form

must be fully complete. Thank you!

Mentoring Program- PARENT/GUARDIAN CONSENT FORM

I, the parent or legal guardian for _______________________ hereby gives my permission for my child to participate in the daily Mentoring Program at the Boys & Girls Club. I fully understand that the program involves mentors, who shall be selected from the club or community and will be screened (including a criminal background check) and trained before beginning in the program. A mentor will be expected to spend a minimum of one hour per week with members on-site at the Boys & Girls Club. The mentor is not allowed to take or meet my child beyond the Club facility. I understand that my child will participate in an orientation session at the Club in which the program will be explained. The program is planned to last one year and continuation may then be discussed. I understand that during the course of the mentoring program there may be special group events (incorporating all mentors and youth) and family events planned. I understand that the staff of the Club will provide ongoing monitoring of the mentoring activities. I give the Boys & Girls Club Mentoring Program Coordinator permission to obtain my child's academic and attendance records from my child's school. I permit the Mentoring Program staff and the Boys & Girls Club to utilize photographs of my child taken during his/her involvement in the mentoring program and waive all rights of compensation. _____________________________________ (Signature of Parent/Guardian) _____________________________________ (Printed name of Parent/Guardian) Date__________________

Thank you!

MEMBER DISCIPLINE POLICY The goal of the Boys & Girls Club of the Wiregrass is to provide a safe environment for all children. It is the hope of the Staff that every member treats the Club with respect and demonstrates proper behavior. It becomes necessary, however, to deal with inappropriate behavior quickly, professionally and in a compassionate manner. Below you will find a detailed explanation of inappropriate behaviors and their consequences. Parents and children must read and sign this policy. The underlying goal of this policy is to reinforce the idea that all behaviors (appropriate and inappropriate) and their consequences are in the child’s control.

• Suspensions shall be for 1-5 days and will depend upon the severity of the behavior. This included all club programs/functions. • Suspensions include all Club programs • The Executive Director and Program Director shall review all suspensions. The child and parent shall have the opportunity to schedule a follow up conference before the child is able to return to the club. • The Boys & Girls Club will inform parents of the availability of information and referral services and shall provide this information on request of the parent(s). • Continuous inappropriate behavior(s) will result in permanent removal from the program and revocation of Club membership. • All behavioral infractions shall be documented and put the child’s membership folder. Parental Behavior: The following may be reasons for a child’s termination from a program or Club membership and will be determined by the Executive Director and/or Program Director. Parental inappropriate behavior includes but is not limited to: • Disrespect, humiliation or ridicule directed to staff, parents or coaches. • Disrespect to the Club and/or the program by speaking poorly of staff and/or management. • Speaking inappropriately to children – concerns regarding Club members should be directed to staff. • Inappropriate touching, pushing, and shoving of staff or children. • Asking personal questions of children or staff. Should a problem arise with another child, staff member or parent, all concerns should be addressed to the Executive Director or Program Director. Confidentiality will be maintained at all times toward Club members and their families. Staff and Administration are available to schedule mutually convenient meetings to discuss any problems or conflicts.

Minor Infractions - Screaming/Yelling - Rough Housing - Running in the Building - Disrespect to other members (name calling, teasing, etc.) - Being in an unsupervised area

Consequences Phase 1 – Warning/Time out Phase 2 – Activity Restriction/Notify Parents Phase 3 – Suspension from program

Major Infractions - Disrespect to Staff or Equipment - Bullying/Intimidation - Leaving the Building and/or property without permission - Inappropriate Behavior in bathrooms/locker rooms, on bus/van or during an activity

Consequences Phase 1 – Activity Restriction/Notify Parents Phase 2 – Suspension from program Phase 3 – Termination of membership Also – restitution for all broken equipment

Serious Infractions - Attempts to injure (punching, slapping, biting, pinching, etc.) - Threatening other members and/or staff (w/ physical harm) - Inappropriate comments and/or touching - Stealing - Throwing items out of bus or fence(*)

Consequences Phase 1 – Suspension from program or transportation (*) Phase 2 – Termination of membership Also – restitution for stolen items