Welcome! This packet contains all of the forms you need to register a child who is not currently a member of Boys & Girls Club of Detroit Lakes. If you have any questions, please call Tami at 218-847-5700, Ext. 2.

To register a NEW MEMBER: Complete one of each form per child registering:

Membership Form Permission, Release of Information, Assurances, & Release of Liability Form Immunization Record

Complete one of each form per household: Annual Household Information Form Tennessen Warning Notice/Use of Data/Equal Opportunity Information Form

AND if you are registering your child for SUMMER PROGRAMMING: Also complete one of each form per household:

Summer Payment Form ACH Payment Authorization Form

Optional: Complete only if you would like summer payments to be automatically charged to your bank account on the payment due date.

Summer Program Schedule Please list the days and times you think your child(ren) will attend the Club, even if

your responses are only estimations. Indicate any planned vacations or other times your child(ren) will be away from the Club. You are not held to this schedule; the information you provide simply helps us estimate attendance and schedule Club staff accordingly.

READY TO REGISTER? Bring your completed forms to our Club along with the annual membership fee (per child,

per year). If you haven’t had a tour or orientation, one can be arranged at that time.

FEE SCHEDULE as of March 20, 2019

Membership Fee

$75 per child per year. Due at enrollment and every twelve months thereafter. Memberships are not transferrable to other Boys & Girls Clubs. Membership fees are non-refundable.

Summer Fees

$25 per child per day. Includes breakfast, lunch, and afternoon snack. No contract or schedule. Pay only for days attended, no advance notice required. Billed every two weeks.

School Days Out

No charge. Pre-signup and attendance limits may apply.

MEMBERSHIP FORM

For Staff Use Only (circle responses and fill in dates and numbers)

Previous Member? Y N Membership fee paid? Y N

Renewal Date:

/ /

Paid by: Cash Check #: Credit Card

Membership #: Rec’d Parent Handbook? Y N

150 Richwood Road, P.O. Box 83 Detroit Lakes MN 56502-0083

Main: (218) 847-5700 Fax: (218) 847-1897

PARENT/GUARDIAN INFORMATION

Parent 1:

Name First Last

Relation to Child

Child’s Residence Does your child reside here? Yes No

Physical Address

Mailing Address (if different)

City State ZIP

Cell Phone Other Phone Email

Employer Work Phone

Parent 2:

Name First Last

Relation to Child

Child’s Residence Does your child reside here? Yes No

Physical Address

Mailing Address (if different)

City State ZIP

Cell Phone Other Phone Email

Employer Work Phone

MEMBER/CHILD INFORMATION (please print)

Name First Middle Last

Date of Birth \ \ Gender M F

School Grade Current Completed

Ethnicity (you may check more than one box)

American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Pacific Islander White Other Don’t Know

Boys & Girls Club of the Detroit Lakes is a funded program of the United Way of Becker County and is an equal opportunity employer and service provider.

EMERGENCY CONTACTS

Name Relation to Child

Phone Phone

Name Relation to Child

Phone Phone

PERSONS NOT AUTHORIZED TO PICK UP

Name Relation to Child

Court order?

Name Relation to Child

Court order?

CHILD’S MEDICAL INFORMATION Action Plan is required for a severe allergy or medical conditions.

Allergies & Medications: Medical Condition & Medications:

Administered at Home Administered at Club Administered at Home Administered at Club

Please share any information about your child that will help us provide them with the best Club experience possible. Examples: shyness, difficulty hearing, ADD/ADHD, EBD, Autism, learning style preference, interests.

ADD ADHD EBD Autism Spectrum Disorder PTSD Other (please specify) Does your child have an IEP at school? Yes No

Comments:

Confidentiality The information collected on this membership application and on companion documents is necessary for our Club to maintain its charter with Boys & Girls Clubs of America and maintain funding to support our programs. Please provide information that is complete and accurate. All information will be kept confidential.

Membership Fee Annual membership fee—see fee schedule. Membership fees are non-refundable.

Other Fees Our Club charges a flat fee per child, per day for attendance during the summer—see fee schedule. Summer fees are due bi-weekly.

Parent/Guardian Signature Date Child/Member Signature Date

OTHER PERSONS AUTHORIZED TO PICK UP

Name/Phone Name/Phone

Name/Phone Name/Phone

I have read the completed membership application, understand the rules and expectations of Boys & Girls Club of Detroit Lakes as stated in the Membership Handbook, and request that my child be admitted into membership. I have discussed the rules and expectations of Boys & Girls Club of Detroit Lakes with my child.

Boys & Girls Club of Detroit Lakes, Inc.

Permission, Release of Information, Assurances, & Release of Liability

Club Member Name:

Permission & Release of Information I, , the parent or guardian of the minor child listed above, understand that certain Club activities and actions require my written permission. I hereby give Club staff permission for the activities and actions below where I have indicated YES. Transportation of Club Members I give permission for my child to be transported in Club vehicles, including from school to the Club during the school year and to and from other activities, field trips, etc. that I have given permission for and that require the use of Club transportation.

Participation in Activities/Field Trips I give permission for my child to participate in all activities at the Club. Programming may include various field trip experiences throughout the year. I will be informed of field trips prior to the activity through postings at the Club. It is my responsibility to inform Club staff if my child is not allowed to participate in any specific activity or event.

Use of Images I give permission for my child’s picture, moving picture, or any other graphic depiction or likeness to be used by Boys & Girls Club for internal and/or external communications, including newsletters, brochures, reports, webpages, social media publications, event posters, promotional videos, e-mails, etc.

Medical Treatment I give permission to the Boys & Girls Club to seek emergency medical treatment for my child if I cannot be reached and immediate care is necessary. I am responsible for any costs related to medical attention and treatment.

Sunscreen Permission During the Club’s summer program, I give permission for my child to apply sunscreen to his or her exposed skin areas. I am expected to provide sunscreen to be kept and used at the Club.

School Information I give my permission to the Boys & Girls Club and , my child’s school, to exchange information regarding my child. The purpose of the exchange of information is to help both organizations do the best job possible of helping my child be successful in school, at the Club, and in his or her daily life.

Surveys & Questionnaires I give permission to the Boys & Girls Club to survey my child about his or her Club experience and behaviors, skills and attitudes using Boys & Girls Clubs of America Youth Development Outcome Measurement Tool Kit surveys or other survey instruments.

(please print)

YES, I give permission. NO, I do not give permission.

YES, I give permission. NO, I do not give permission.

YES, I give permission. NO, I do not give permission.

YES, I give permission. NO, I do not give permission.

YES, I give permission. NO, I do not give permission.

YES, I give permission. NO, I do not give permission.

YES, I give permission. NO, I do not give permission.

County/Community Agencies Is your child working with a county or community agency ? (circle one) YES NO Agency Name Worker Name I give permission to exchange information between the agency named and Boys & Girls Club to best serve my child and meet his or her needs.

Assurances

My signature below signifies that I understand:

the Club works with children and families to provide a positive experience for all who need us. The Club is not designed to provide long-term, one-on-one programming.

Boys & Girls Club is not, nor does it claim to be, a licensed day care facility. Parents and Club members are responsible for their own transportation to and from the Club. Riding

the bus/van to the Club is a privilege, not a right, and can be revoked for misconduct. the Club strongly recommends that my child NOT bring personal electronic devices to the Club,

including laptops, tablet devices, cellular phones, personal video games, or MP3 players. the Club is not responsible for damaged, lost and/or stolen items. the use of electronic devices, including cell phones, is at the sole discretion of Club staff. my child will have access to the internet at the Club with restrictions as to what websites are allowed. my child may not use social media or participate in chat rooms of any kind while at the Club, and the

taking or sharing of photos, videos, or audio on personal devices is strictly prohibited. a separate medication permission form must be completed by my child’s physician before any

medication will be given to my child by Club staff. Any and all medication I provide to the Club for my child’s use must be provided in its current, original container with complete instructions included.

Release of Liability I, , the parent or guardian of the minor child listed above, for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever discharge the Boys & Girls Club of Detroit Lakes, Inc. and its individual units and the 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 any activities of said organizations either at or away from the Club. Any confidential information requested is for records and funding the organization receives. All information will be kept confidential.

By signing below, I signify that: I have read this document in its entirety. I have selected the permission options that are best for my child. I understand the rules of the Boys & Girls Club and that I have discussed them with my child. I have received a copy of the Boys & Girls Club Membership Handbook. I have read and agree to the above Release of Liability.

These permissions, releases, assurances and release of liability are valid and remain in effect until they are revoked or changed by me at any time in writing by contacting Boys & Girls Club of Detroit Lakes, Inc. Parent/Guardian Signature Printed Parent/Guardian Name Dated

YES, I give permission. NO, I do not give permission.

ANNUAL HOUSEHOLD INFORMATION FORM

Confidentiality statement

The information collected annually on this form is necessary for our Club to maintain its charter with Boys & Girls Clubs of America and maintain funding to support our programs. Please provide information that is complete and accurate. All information will be kept confidential. Boys & Girls Club of Detroit Lakes is an equal opportunity employer and service provider. This form should be completed by the head of a household where the Club member(s) resides. If a child(ren) regularly resides in more than one household, only one form needs to be completed.

Family Setting:

Single parent household

Two parent household

Eligibility for Assistance:

General Assistance

Food Assistance (SNAP)

Free School Lunches

Reduced-Price School Lunches

Child Care Assistance

Energy/Heat Assistance

Social Security Disability Insurance

Supplemental Security Income

Member lives with:

Mother Father Aunt/Uncle

Stepmother Stepfather Grandparent(s)

Foster Home Group Home Legal Guardian

Other:

Total # in Household:

Gross Family Income:

$0 to $9,999 $10,000 to $14,999

$15,000 to $19,999 $20,000 to $24,999

$25,000 to $29,999 $30,000 to $39,999

$40,000 to $49,999 $50,000 to $59,999

$60,000 to $74,999 $75,000 or more

Is Parent/Guardian active in U.S. Military? Yes No If yes, which branch?

If yes, does anyone live on a military base? Yes No

Name of Person Completing Form: (head of household)

• Please select responses that best describe your household •

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Tennessen Warning Notice / Use of Data / Equal Opportunity Information

Department of Employment and Economic Development (DEED) grant recipient:

Please read the Tennessen Warning Notice below and the equal opportunity information on the reverse side. When you finish reading, please sign and date at the bottom.

TENNESSEN WARNING NOTICE: The data we are asking you to provide about yourself is considered private data by Minnesota Statute 13.47 subdivision 2. In order to collect and use this data we must tell you why we need the data, how we intend to use it, and any consequences you may experience if you supply the information or not.

Why we need the data Personal characteristics such as age, gender, ethnicity, race, disability and economic status is collected to evaluate our performance and in some cases, to determine if you’re eligible for special assistance

How we intend to use the data Work and education history will be shared with the Department of Employment and Economic Development (DEED) and may be shared with prospective employers. Additionally other government entities with a legal right to this data may see your information

Consequences to you You can refuse to supply any or all of this information; you are not legally required to provide any of this information. Not supplying sufficient information may limit our ability to provide you the services you want.

For more information DEED Data Practices http://mn.gov/deed/about/what-guides-us/data-practices/ Minnesota Data Practices Act www.revisor.leg.state.mn.us/stats/13/ Minnesota Department of Administration Information Policy Analysis Division www.ipad.state.mn.us/index.html

EQUAL OPPORTUNITY IS THE LAW: (Please see the reverse side for additional information) We consider applicants without regard to race, color, creed, religion, national origin, age, sex, political affiliation or belief, marital status, disability, sexual orientation, or status with regard to public assistance. It is our policy to abide by all federal, state, and local laws concerning discrimination.

COMPLAINT AND APPEAL POLICY: If you feel that anyone in our office has treated you unfairly, you have the right to file a complaint. If you have been denied services, you have the right to an appeal. If you wish to file a formal complaint or an appeal, please see a staff member for assistance.

I have been made aware of and understand this Tennessen Warning notice. (If you do not understand this statement, please ask that a staff member explain it to you.) I agree that the information on this form may be shared among Minnesota WorkForce Center agencies for the purpose of helping me find employment or training. I have read the equal opportunity information found on the reverse side ”NOTICE TO THE PUBLIC”, Equal Opportunity Is The Law. I understand that I have the right to file a complaint of discrimination.

Names of Children:

Signature (If Under 18, Signature of Parent or Guardian) Date

This material is available in alternative formats, such as large print, Braille, or audio tape.

NOTICE TO THE PUBLIC

Equal Opportunity Is The Law

It is against the law for us as the recipient of DEED funds to discriminate on the following bases:

Against any individual in the United States, on the basis of race, color, religion, sex, national origin, age, disability, political affiliation or belief; and

Against any beneficiary of programs financially assisted under Title I of the Workforce Investment Act of 1998 (WIA), on the basis of the beneficiary=s citizenship/status as a lawfully admitted immigrant authorized to work in the United States, or

his or her participation in any DEED-funded program or activity.

The recipient must not discriminate in any of the following areas:

Deciding who will be admitted, or have access, to any DEED funded program or activity;

Providing opportunities in, or treating any person with regard to, such a program or activity; or

Making employment decisions in the administration of, or in connection with, such a program or activity.

What to Do If You Believe You Have Experienced Discrimination

If you think that you have been subjected to discrimination under a DEED funded program or activity, you may file a complaint within 180 days from the date of the alleged violation with either:

Name/Title of Designated Equal Opportunity Officer: Susan Tulashie, Equal Opportunity Officer Lori Peterson, Director of Public Affairs Workforce Development Division 690 Jackson Street Department of Employment and Economic St. Paul, MN 55130 Development PHONE: 651-726-2582 1st National Bank Building FAX: 651-200-4100 332 Minnesota Street, Suite E200 EMAIL: Lpeterson@bgc-tc.org St. Paul, MN 55101 Direct: 651-259-7586 Fax: 651-215-3842 MN Relay 7-1-1 or 1-800-627-3529 www.PositivelyMinnesota.com

If you file your complaint with the recipient, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the Minnesota Department of Economic Development, Workforce Development Division (see address above). If the recipient does not give you a written Notice of Final Action within 90 days of the day on which you filed your complaint, you do not have to wait for the recipient to issue that Notice before filing a complaint with the Civil Rights Center (CRC). However, you must file your CRC complaint within 30 days of the 90-day deadline (in other words, within 120 days after the day on which you filed your complaint with the recipient). If the recipient does give you a written Notice of Final Action on your complaint, but you are dissatisfied with the decision or resolution, you may file a complaint with CRC. You must file your CRC complaint within 30 days of the date on which you received the Notice of Final Action. The above “NOTICE TO THE PUBLIC” applies to the federal programs covered under the Workforce Investment Act. Complaints concerning services provided by non-WIA programs may be processed differently.

The recipient* must provide the notice to all appropriate parties including: club members and applicants for services; participants; applicants for employment; employees; unions or professional organizations that hold collective bargaining or professional agreements with the recipient; sub-recipients that receive DEED funds from the recipient; members of the public, including those with impaired vision or hearing. *Term to Know–Recipient: Any entity to which financial assistance is extended, directly from the U.S. Department of Labor or through the Governor or another recipient; excluding the ultimate beneficiaries of the programs or activities.

Updated January 2015

SUMMER PAYMENT FORM

HOUSEHOLD BILLING INFORMATION (please print)

All summer billing statements will be e-mailed to the person(s) responsible for paying summer fees. Please complete the information below so that we can be certain summer billing statements are sent properly and reach you in a timely manner. In the event you have no e-mail account, statements will be sent to your mailing address.

Names of Club Members Please list the names of all children on this account.

Person(s) Responsible for Payments on Account

E-mail Address (where

statements should be sent)

Mailing Address

City State ZIP

Cell Phone Other Phone

Notes Please include any information related to billing that will assist us in making the process as easy as possible for everyone. Examples: parents from different households are sharing the responsibility for payment or child care assistance will be used.

150 Richwood Road, P.O. Box 83 Detroit Lakes MN 56502-0083

Main: (218) 847-5700 Fax: (218) 847-1897

The Club charges a $25.00 flat fee per day per child for summer programming regardless of time spent at the Club. Fees are paid for only those days that a child attends. You are responsible for keeping your summer fee account current. Billing occurs every two weeks throughout the summer. We accept payments by debit or credit card, check, ACH transfer, money order, and cash. If you qualify for assistance, you are responsible for paying the Club any portion of your summer fees that are not covered by assistance.

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ACH Payment Authorization Form

Recurring Payments Will Make Your Life Easier! • It’s convenient - saving you time and postage. • Your payment is always on time – helping the Club provide the best services possible.

Here’s How Recurring Payments Work: Boys & Girls Club of Detroit Lakes will issue an invoice for Club summer fees every two weeks and send it to you at the e-mail address you have provided. The invoice will clearly state the due date for ACH payment. You authorize equivalent charges to your checking account. You will be charged the balance due as indicated on the issued invoice with terms of net 7 days. The charge will appear on your bank statement as an “ACH Debit to Boys & Girls Club of Detroit Lakes”. You agree that no prior-notification will be provided unless the date or invoice amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected. Please complete the information below: I ____________________________ authorize Boys & Girls Club of Detroit Lakes to charge my bank account

indicated below on the on the due date of submitted invoice for payment of Club summer fees.

Billing Address ____________________________ Phone# ________________________

City, State, Zip ____________________________ Email ________________________

Account Type: Checking Savings

Name on Acct _______________________________

Bank Name _______________________________

Account Number _______________________________

Bank Routing # _______________________________

Bank City/State _______________________________

SIGNATURE DATE I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Boys & Girls Club of Detroit Lakes in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH transaction being rejected for non-sufficient funds (NSF), I understand that Boys & Girls Club of Detroit Lakes may, at its discretion, attempt to process the charge again within 30 days. I agree to an additional $35 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.

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Developed by the Minnesota Department of Health - Immunization Program www.health.state.mn.us/immunize (12/13)

Name _________________________________________________ Birthdate _____________________

Date of Enrollment _______________________________________Minnesota law requires children enrolled in child care to be immunized against certain diseases or file a legal medical or conscientious exemption.Parent/Guardian: You may attach a copy of the child’s immunization history to this form OR enter the MONTH, DAY, and YEAR for all vaccines your child received. Enter MED to indicate vaccines that are medically contraindicated including a history of disease, or laboratory evidence of immunity and CO for vaccines that are contrary to parent or guardian’s conscientiously held beliefs.

Sign or obtain appropriate signatures on reverse. Complete section 1A or 1B to certify immunization status and section 2A to document medical exemptions (including a history of varicella disease) and 2B to document a conscientious exemption.

For updated copies of your child’s vaccination history, talk to your doctor or call the Minnesota Immunization Information Connection (MIIC) at 651-201-5503 or 800-657-3970.

Child Care Immunization Form Must be on file before a child attends child care

Type of Vaccine DO NOT USE () or () 1st DoseMo/Day/Yr

2nd DoseMo/Day/Yr

3rd DoseMo/Day/Yr

4th DoseMo/Day/Yr

5th DoseMo/Day/Yr

Required (The shaded boxes indicate doses that are not routinely given; however, if your child has received them, please write the date in the shaded box.) Diphtheria, Tetanus, and Pertussis (DTaP, DTP)• 3 doses during 1st year (at 2-month intervals)• 4th dose at 12-18 months• 5th dose at 4-6 years

Indicate vaccine type: DTaP or DTP

Polio (IPV, OPV)• 2 doses in the first year• 3rd dose by 18 months• 4th dose at 4-6 years

Measles, Mumps, and Rubella (MMR)• Required for children 15 months and older• 1st dose on or after 1st birthday• 2nd dose at 4-6 years

Haemophilus influenzae type b (Hib)• 2-3 doses in the first year• 1 dose required after 12 months or older• For unvaccinated children 15-59 months, 1 dose is required• Not required for children 5 years or older

Varicella (chickenpox)• Required for children 15 months and older• 1st dose on or after 1st birthday• 2nd dose at 4-6 years

Pneumococcal Conjugate Vaccine (PCV)• Required for children age 2 - 24 months• 3 doses in the first year• 4th dose after 12 months• At least 1 dose is recommended for children 24-59 months in

child care

Hepatitis B (hep B)• 2-3 doses in the first year• 3rd dose (final dose) by 18 months

Hepatitis A (hep A)• 2 doses separated by 6 months for children 12 months and

olderRecommended

Rotavirus (2-3 doses between 2 and 6 months)

Influenza (annually for children 6 months or older)

5th dose not required if 4th dose was given on or after the 4th birthday

4th dose not required if 3rd dose was given on or after the 4th birthday

Developed by the Minnesota Department of Health - Immunization Program www.health.state.mn.us/immunize (12/13)

Name _______________________________________________________Instructions, please complete:Box 1 to certify the child’s immunization status Box 2 to file an exemption (medical or concientious)

A. Children who are 15 months or older:For children who are 15 months or older and whohave received all the immunizations required by lawfor child care:

I certify that the above-named child is at least 15months of age and has completed the immunizationswhich are required by law for child care.

Signature of Parent / Guardian OR Physician / Nurse Practitioner / Physician Assistant / Public Clinic

_____________ Date

B. Children who are younger than 15 months:For children who are younger than 15 months ORhave not received all required immunizations:I certify that the above-named child has received theimmunizations indicated. In order to remain enrolledthis child must receive all required vaccines within18 months from initial enrollment date. The dates onwhich the remaining doses are to be given are:

Signature of Physician / Nurse Practitioner / Physician Assistant / Public Clinic _____________ Date

1. Certify Immunization Status. Complete A or B to indicate child’s immunization status.

A. Medical exemption:No child is required to receive an immunization ifthey have a medical contraindication, history ofdisease, or laboratory evidence of immunity. For achild to receive a medical exemption, a physician,nurse practitioner, or physician assistant must signthis statement:I certify the immunization(s) listed below arecontraindicated for medical reasons, laboratoryevidence of immunity, or that adequate immunityexists due to a history of disease that waslaboratory confirmed (for varicella disease see *below). List exempted immunization(s):

Signature of physician / nurse practitioner / physician assistant _____________ Date

*History of varicella disease only. In the case ofvaricella disease, it was medically diagnosed oradequately described to me by the parent to indicatepast varicella infection in ___________ (year)

Signature of physician / nurse practitioner / physician assistant (If disease occurred before September 2010, a parent can sign.)

B. Conscientious exemption:No child is required to have an immunization thatis contrary to the conscientiously held beliefs ofhis/her parent or guardian. However, not followingvaccine recommendations may endanger thehealth or life of the child or others they come incontact with. In a disease outbreak, children whoare not vaccinated may be excluded in order toprotect them and others. To receive an exemptionto vaccination, a parent or legal guardian mustcomplete and sign the following statement andhave it notarized:I certify by notarization that it is contrary to myconscientiously held beliefs for my child to receivethe following vaccine(s):

Signature of parent or legal guardian _____________ Date

Subscribed and sworn to before me this: _______ day of _____________________ 20____

Signature of notary (A copy of the notarized statement will be forwarded to the commissioner of health.)

2. Exemptions to Immunization Law. Complete A and/or B to indicate type of exemption.