2022-23 Membership Form - Boys & Girls Clubs of the Lewis-Clark Valley

Information About Your Child: Please Fill Out ALL Sections

ATTENTION PARENTS: Participation in all Club sports programs requires a current (2022-23 school year) Club membership. If you are from a rural area outside of Lewiston, Clarkston, Asotin, or Lapwai, please contact our athletic department for details at 208-746-2301. THIS MEMBERSHIP IS FOR SPORTS ONLY!!

After the membership form is completed you will receive a link to register your child for the upcoming sport registration. Thank you for your support.

Which Club would you like your child to attend?*

None - I am registering for athletic program participation only.

If you are from Lapwai - DO NOT USE THIS ONLINE FORM.
Please note below.

Note: For Lapwai memberships, please CLICK HERE to download the membership form and return in-person to the Lapwai Club.Top of Form

Name:*

First Middle Last

Is this a First Time (NEW) Membership or Renewal?:*

First Time
Renewal

If Registered Last Year, Do You Know Your Membership # ?:*

Yes
No

Membership #:

Gender:*

Male
Female

Age:*

Date of Birth:*

Ethnicity:*

Mailing Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Physical Address is the Same as Mailing Address:*

Yes
No

Physical Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone:*

Grade:*

2022-2023 School Year

Name of School:*

Guardian Information:

Guardian #1:*

First Name Last Name

Relationship to Child:*

Cell Phone #:

Home Phone:

Employer:

Work Phone:

Email:*

Add Another Guardian:*

Yes
No

Guardian #2 Information:

Guardian #2:

First Name Last Name

Relationship to Child:

Cell Phone #:

Home Phone #:

Employer:

Work Phone #:

Email:

Emergency Contact:

Name:*

First Last

Relationship to Child:*

Cell Phone #:

Home Phone #:

Work Phone #:

Other Information:

Any Food Allergies, Medical Conditions, or Behavior Challenges?*

Yes
No

Please Explain:

Does Your Child Take Any Medications?:*

Yes
No

Please List Medications Here:

Physicians Name:*

First Name Last Name

Physicians Phone #:*

Do You Have Medical Insurance?*

Yes
No

Annual Income: Applicants MUST provide information. This will be used for statistical purposes only.*

Child Lives With:*

If "Other," Please List:

Number of People Living in This Household:*

Single Parent Household:*

Yes
No

Do You Qualify for Free or Reduced Lunch:

If needing a scholarship, you must bring in proper paperwork.

Free
Reduced
Neither

Do You Reside in a Public Housing Community?:*

Yes
No

If "Yes," Which One?:

If Employed by The Military, Which Branch?:

Membership Fee:

Policies, Terms, Conditions and Waiver of Liability*

Read Now
I Agree to the Club Policies

Policies, Terms, Conditions and Liability 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 the Lewis-Clark Valley has 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. MEMBERSHIP FEES & GUIDELINES: The membership fee for youth between the ages of 5 – 18 (school aged) is a one-time fee for the school year. The cost is $25.00 per child for the school year. *MEMBERSHIP FEE AT THE LAPWAI CLUB IS FREE OF CHARGE* Membership runs for the entire school year. Participation in any or all Club programs requires a current Club Membership! Refund requests are done on a case by case basis. It is our policy to not allow a refund once our service has been provided and a member has already started to participate in our programs. If a refund is issued, please allow 7-10 days for processing. PROGRAM REGISTRATION: To participate in Boys & Girls Club programs you must complete a registration form for the specific program. Every BGCLCV program requires a current registration form. Boys & Girls Clubs offer additional fee based programs during the year which may incur additional costs. Check with the Club you are registering with for the specifics of these programs. All fees must be paid in advance. We encourage members not to bring items of value while participating in Club Programs. We also encourage members to take responsibility for all of their personal belongings. The Boys & Girls Club and staff are not responsible for lost or stolen items. SCHOLARSHIP POLICY: Reduced fees are available to families based on specific eligibility criteria. Inquire at the front counter for more information. Proof of eligibility (Free or Reduced Lunch Form from School District) is required before we can process the membership or reduce the program fee. Scholarships are not given for fees already paid. For families and youth needing financial assistance with membership and program fees, we offer the following: • If the child is on the free lunch program at school, the fee based program is reduced in half and must be paid up front. If the child is on the reduced lunch program at school, the fee based program is reduced by ¼ and must be paid up front. MEMBERSHIP HANDBOOK: I will receive a link to the Handbook via confirmation email for review and will support the discipline procedures of the BGCLCV. I also full understand that failure to accept responsibility for inappropriate actions by either myself or my child may result in loss of program access. PHOTO RELEASE CONSENT: I hereby give my consent to Boys & Girls Clubs of the Lewis Clark Valley to use any images that may be taken of my child while registered as a Club member in marketing and promotional materials. I relinquish all rights to copyright, title, property interest and/or any other interest in said photographs and I waive the right to inspection and approval of the finished reproduction. TECHNOLOGY POLICY: I understand that the BGCLCV will provide my child internet access from the Club’s computer education centers and that technology usage is a privilege and that Club staff may revoke this permission at any time. I also understand that my child’s cell phone may only be used as a communication device and shall not interrupt Club programming. Failure to follow the Electronic Devices Policy will result in confiscation of the device, and it will be held at the front counter for Parent/Guardian pick up. This may also result in disciplinary action. SURVEYS & QUESTIONNAIRES: I understand that the BGCLCV may ask my child to participate in surveys about his or her experience, behaviors, skills and attitudes to assess program effectiveness. MEMBER CONSENT: My child promises to take care of their Club and property by respecting Club Staff, Club Members, and Club equipment. They also understand they are expected to behave respectfully and follow all of the rules of the Club. If they choose not to follow the rules they may lose the privilege to attend the Club. CONSENT FOR MEMBERSHIP, PARTICIPATION, HOLD HARMLESS, MEDICAL AUTHORIZATION: As a parent or legal guardian of the above named child, I hereby give my consent for his/her membership in the Boys & Girls Clubs of the Lewis Clark Valley. I give permission for the applicant to be transported and participate in all BGCLCV sponsored activities and events, to administer surveys and to use the applicant’s picture in publications. I give my permission to the Boys & Girls Club of the Lewis Clark Valley to share information about the minor child listed on this application with Boys & Girls Clubs of America (BGCA) for research purposes and/or to evaluate the program’s effectiveness. Information that will be disclosed to BGCA may include the information provided on this membership application form, information provided by the minor child’s school or school district, and other information collected by Boys & Girls Club of the Lewis Clark Valley including data collected via surveys or questionnaires. All information provided to BGCA will be kept confidential. Any and all information received will be kept strictly confidential. Data gathered through these means will be summarized in the aggregate and will exclude all references to any individual responses. I give my permission to my child’s School District to exchange information regarding the minor child listed on this application. I agree to hold harmless BGCLCV, members of their board, staff, authorized volunteers and instructors for accidental injury to the applicant or damage to the applicant’s property. I further give authority to the BGCLCV staff, instructors and authorized volunteers in case of accident, injury or sickness of the applicant when in their care to render first aid, provide transportation and admittance to a medical facility. In addition, I authorize and consent to all medical, surgical, diagnostic, and hospital procedures as may be performed or prescribed by a physician. I waive rights to informed pre-consent for such treatment. I understand that BGCLCV does not cover the applicant with any primary medical insurance coverage and that the parent/guardian is financially responsible for any treatment provided. Members are covered under a group accident medical plan for balances due after primary medical insurance has paid benefits. Claim must be made on a form provided by BGCLCV within 90 days of the accident injury.

I Agree to the Terms, Conditions and Waiver of Liability*

Yes
No

Billing Information:

Total School Year Membership Fee

The child's membership must be renewed each school year. Membership expires at the end of each school year.

$0.00

Payment Method:*

Credit Card

Credit Card

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Membership Form

Information About Your Child: Please Fill Out ALL Sections

If you are from Lapwai - DO NOT USE THIS ONLINE FORM. Please note below.

Guardian Information:

Guardian #2 Information:

Emergency Contact:

Other Information:

Policies, Terms, Conditions and Liability Waiver

Billing Information:

If you are from Lapwai - DO NOT USE THIS ONLINE FORM.
Please note below.