Versión en español de este formulario
Please Read Carefully
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
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.
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.
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.
I authorize BGCFDL to transport my child by foot, bus or van within the local city during normal Club operating hours.
I understand that enrollment in the Boys & Girls Club School Year program requires participation in academic enrichment activities and academic support .
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.
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.
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.
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.