Chegwin, Evans & Riverside School Year Program Registration

How many children will you be registering?*
- 1
- 2
- 3

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Parent/Guardian #1
First and Last Name*
First Last
Home Address*
Street Address Address Line 2 City State ZIP Code
Email*
Cell Phone*
Would you like to receive text message communication to this phone number?
- Yes
- No
Employer*
Work Phone
Are you active in the Armed Forces?*
- Yes
- No
Parent/Guardian #2
First and Last Name
First Last
Home Address
Same as Parent/Guardian #1

Street Address Address Line 2 City State ZIP Code
Email
Cell Phone
Would you like to receive text message communication to this phone number?
- Yes
- No
Employer
Work Phone
Are you active in the Armed Forces?
- Yes
- No

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Are you in need of financial assistance?*
Inability to pay fees will not be a barrier to participation. Fee Waivers are available. No documentation is required to obtain a fee waiver. Please select from the following options:
- No, I can pay the $40
- Yes, I will need the discounted rate of $20
- Yes, I am unable to pay at this time
Please share your exact yearly household income:*
Please list your family’s exact yearly household income.

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Child #1 Information
First and Last Name*
First Last
Child's Birth Date*
Child's Gender*
Child's Ethnicity*
Child Lives With*
Child's School Attending*
2020-21 Grade*
Child 1 Cost
Child's Schedule*
Please mark which cohort your child is in (which days they will be attending school in person). *Please note that they can only attend the afterschool program on the 2 days that they are in school. Please mark which cohort your child is in (which days they will be attending school in person). *Please note that they can only attend the afterschool program on the 2 days that they are in school. Full time virtual students are unable to attend at this time.
- Cohort A- Monday and Tuesday
- Cohort B- Thursday and Friday
Please List any Medical Conditions your Child May Have
Please list any Medications Your Child Takes
Does your child qualify for free or reduced lunch?*
- Yes
- No
Do you give your child permissions to leave on their own?*
- Yes, anytime
- Yes, after ________________
- No
After what time is your child allowed to leave?*

: HH

MM
Child #1 Media permission
- Please check here if you do not want your child to appear in any media coverage for the Boys & Girls Club of Fond du Lac

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Child #2 Information
First and Last Name*
First Last
Child's Birth Date*
Child's Gender*
Child's Ethnicity*
Child Lives With*
Child's School Attending*
Grade Going Into Fall 2020*
Child #2 Cost
Child's Schedule*
Please mark which cohort your child is in (which days they will be attending school in person). *Please note that they can only attend the afterschool program on the 2 days that they are in school. Please mark which cohort your child is in (which days they will be attending school in person). *Please note that they can only attend the afterschool program on the 2 days that they are in school. Full time virtual students are unable to attend at this time.
- Cohort A- Monday and Tuesday
- Cohort B- Thursday and Friday
Please List any Medical Conditions your Child May Have
Please List any Medications Your Child Takes
Does your child qualify for free or reduced lunch?*
- Yes
- No
Do you give your child permissions to leave on their own?*
- Yes, anytime
- Yes, after ________________
- No
After what time is your child allowed to leave?*

: HH

MM
Child #2 Media permission
- Please check here if you do not want your child to appear in any media coverage for the Boys & Girls Club of Fond du Lac

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Child #3 Information
First and Last Name*
First Last
Child's Birth Date*
Child's Gender*
Child's Ethnicity*
Child Lives With*
Child's School Attending*
Grade Going Into Fall 2020*
Child #3 Cost
Child's Schedule*
Please mark which cohort your child is in (which days they will be attending school in person). *Please note that they can only attend the afterschool program on the 2 days that they are in school. Full time virtual students are unable to attend at this time.
- Cohort A- Monday and Tuesday
- Cohort B- Thursday and Friday
Please List any Medical Conditions your Child May Have
Please List any Medications Your Child Takes
Does your child qualify for free or reduced lunch?*
- Yes
- No
Do you give your child permissions to leave on their own?*
- Yes, anytime
- Yes, after ________________
- No
After what time is your child allowed to leave?*

: HH

MM
Child #3 Media permission
- Please check here if you do not want your child to appear in any media coverage for the Boys & Girls Club of Fond du Lac

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Emergency Contacts / Pick Up Information
Non Parent/Guardian #1 Emergency Contact
Name*
First Last
Home/Cell Phone*
Relationship to Child*
Does this contact apply to all of the kids you are registering?*
- Yes
- No
Which kids will this contact apply for?*
Non Parent/Guardian #2 Emergency Contact
Name*
First Last
Home/Cell Phone*
Relationship to Child*
Does this contact apply to all of the kids you are registering?*
- Yes
- No
Which kids will this contact apply for?*
Non Parent/Guardian #3 Emergency Contact
Name
First Last
Home/Cell Phone
Relationship to Child
Does this contact apply to all of the kids you are registering?
- Yes
- No
Which kids will this contact apply for?*
Please list any other individuals that are allowed to pick up
First Name Last Name
Pick Up Password*
This password must be given when calling or texting to pick up your child.
Late pickup agreement*
By checking the box, I understand that if my child is not picked up by 6:00pm, I will be charged a $5.00 fee. I also understand that if my child is not picked up within 15 minutes of closing time, the Club will contact the police to ensure my child’s safe return to home.
Agree*

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Signature and Agreement
Please Read Carefully

Behavior Policy & Expectations

I have read and understand the Boys & Girls Club of Fond du Lac’s PBIS Expectations and Behavior Policy. I understand that all members are expected to follow these policies at all times when they are part of Boys & Girls Club activities. I also understand that failure to follow these policies will result in specific consequences for members that could result in temporary or permanent suspension from the program without a refund of membership fees. Read the PBIS Expectations and Behavior Policy here

Medical Emergency

In the event of an emergency I understand that every attempt will be made to contact me. If I cannot be reached I hereby give my permission to the physician selected by the Boys & Girls Club staff member to secure proper treatment for my child.

Arrival and Departure Policy

I understand that it is my responsibility to be sure that my child understands their arrival and departure procedure to and from the Club. I understand that staff will make every effort to inform me if my child leaves the site, but that the Club is not responsible for my child once they have left the building. I understand that if my child is not picked up on time when the club is closed, I will be charged a fee. I also understand that if my child is not picked up within 15 minutes of closing time, the Club is mandated to contact the police.

Media/Photo Permission

I do give my permission to have my child appear in any media coverage for the Boys & Girls Club of Fond du Lac unless I have checked the box on the member information page stating that they may not appear in media coverage.

Travel Policy

I authorize BGCFDL to transport my child by foot, bus or van within the local city during normal Club operating hours.

Program Participation

I understand that enrollment in the Boys & Girls Club School Year program requires participation in academic enrichment activities and academic support .

CLC

I hereby give permission for the participant(s) listed on this application to take part in the Community Learning Center’s (CLC) activities, which may include off-site events, academic assistance, continuing education, and recreational programs. If a medical emergency arises, program staff will take all steps necessary to ensure the safety of the participant and will call if necessary, a public emergency vehicle for transport to an emergency facility. I understand that I will be responsible for any transportation charges and medical expenses incurred. I am aware of, and understand, there may be a potential risk inherent with participation in any activity and that the Fond du Lac School District and the City of Fond du Lac does not provide accident insurance and cannot assume responsibility for injury to any participants of any activities associated with the AfterSchool Club House Programs. I give my consent to the school district and Boys & Girls Club of Fond du Lac to share the participant’s student records with each other for purposes of providing educational support and assistance. In addition, I understand that school district and or Boys & Girls Club of Fond du Lac will use participant records to evaluate individual progress and improvement, as well as to evaluate the impact of the program on student achievement and to obtain continued funding for the program.

Parent Guide - Chegwin Site

I have read and understand the parent guide(s) for the programs my children are in:
Click to read the Chegwin Elementary School Site Parent Guide here.

Parent Guide - Johnsonville Site (Evans & Riverside)

I have read and understand the parent guide(s) for the programs my children are in:
Click to read the Johnsonville Site Parent Guide here.
Signature*
Today's Date*
Date Format: MM slash DD slash YYYY

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COVID-19 Waiver

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.

Boys & Girls Clubs of Fond du Lac put in place preventative measures to reduce the spread of COVID-19; however, the Club cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending the Club could increase your risk and your child(ren)’s risk of contracting COVID-19.

Agreement Acknowledgment

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending the Club and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Club may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Club employees, volunteers, and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the Club or participation in Club programming (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless the Club, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Club, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Club program.
Signature*
Today's Date*
Date Format: MM slash DD slash YYYY

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COVID-19 Policies Acknowledgment*
Please check the box next to each statement regarding our COVID-19 policies for the 2020-21 school year program to acknowledge that you understand and will follow them.
- 1. Social distancing will be used during the program and my child must follow all new policies while in attendance.
- 2. My child will not bring unnecessary items into the program. This includes toys, electronics, purses, food etc.
- 3. If my child comes to Club, it is because everyone in our home is healthy and symptom free, with no known exposure to COVID-19. If anyone in my home is diagnosed with COVID-19 I will inform BGC staff immediately.
- 4. I understand that if my child is at an increased risk of severe illness I need to communicate with program staff immediately to see if they can safely serve my child.
- 5. I understand staff will sign my child in and out. Non-program adults will only be allowed in the building on a limited basis.
- 6. If my child shows signs of illness during care, I, or another authorized person, will pick up my child within 60 minutes.
- 7. I understand that my child will be expected to wear a mask while at the Club unless I reach out to Club staff to discuss alternate options
- 8. I understand this situation is fluid and subject to change per state, other local authority, and program needs.
- 9. I understand failure to follow these new safety guidelines may result in termination of my child's membership.
Signature*
Today's Date*
Date Format: MM slash DD slash YYYY

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Payment & Completion
PLEASE NOTE:
School Year Program Fees are non-refundable. All registrations are subject to Boys & Girls Club of Fond du Lac Administration approval.
Total
$0.00
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Name
This field is for validation purposes and should be left unchanged.

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Chegwin, Evans & Riverside School Year Program Registration

Chegwin, Evans & Riverside School Year Program Registration 2020

Step 1 of 13

Parent/Guardian #1

Parent/Guardian #2

Child #1 Information

Child #2 Parent/Guardian Information

Parent/Guardian #1

Parent/Guardian #2

Child #2 Information

Child #3 Parent/Guardian Information

Parent/Guardian #1

Parent/Guardian #2

Child #3 Information

Emergency Contacts / Pick Up Information

Non Parent/Guardian #1 Emergency Contact

Non Parent/Guardian #2 Emergency Contact

Non Parent/Guardian #3 Emergency Contact

Signature and Agreement

Behavior Policy & Expectations

Medical Emergency

Arrival and Departure Policy

Media/Photo Permission

Travel Policy

Program Participation

CLC

Parent Guide - Chegwin Site

Parent Guide - Johnsonville Site (Evans & Riverside)

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19

Agreement Acknowledgment

Payment & Completion

First Name	Last Name