BG TOTS Afterschool Application 2021-22
Application for preschoolers located at ELC afterschool during the 2021-22 school year. After school until 5:30pm.
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Email *
Student First Name *
Student Middle Name *
Student Last Name *
Grade for 2021-22 School year *
Date of Birth *
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Age *
Gender *
Member Status *
If a renewing member, how many years has student been a member?
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Ethnicity- select all that apply *
Required
Street Address *
City *
State *
Zip Code *
Parent phone Cell Number *
Please list all the people who may check out your child during BGC of Coffeyville and their relationship to the child and their phone number. Example: Jane Doe- aunt- 620-777-8888. *
Media Release- Do you give permission for your child to be photographed or videotaped during club programs and for photo or video to be used for newsletters, bulletin boards, or other promotional ideals for the Club? *
How will your child arrive to Club? *
How will your child depart from Club? *
Field Trip Release- Do you give permission for your child to be transported in an agency-insured vehicle for field trips or special circumstances or allow your child to participate in any walking trips the Club make take? *
First Aid and Emergency Medical Care- Do you authorize staff at BGC of Coffeyville who are trained in basic First Aid and CPR to give your child when needed/appropriate? *
Do you understand that in the event of a medical emergency every effort will be made to reach you. However, if you are not reached, you hereby authorize the BGC of Coffeyville's After School Program to transport your child to the nearest medical care facility and /or a facility of your choice? Please list that preferred place below. List yes or no and then list the place. *
Emergency Contact #1 Name- This person will be contacted in the case you are unreachable in a medical emergency. *
Emergency Contact #1 Phone Number *
Emergency Contact #1 Relation to child *
Emergency Contact #1 - Can your child be released to this person? *
Emergency Contact #2 Name- This person will be contacted in the case you are unreachable in a medical emergency. *
Emergency Contact #2 Phone Number *
Emergency Contact #2 Relation to child *
Emergency Contact #2 Can your child be released to this person? *
Child's Physician Name *
Child's Physician Phone Number
List any allergies for your child *
List any chronic health conditions *
Does your child have an individual health plan for their chronic health condition? If yes please provide a copy for BGC Site Director *
Do you give BGC permission to speak to outside agencies in regards to their medical condition? Example- Four County, etc. *
Do you give BGC permission to speak to outside agencies in regards to their medical condition? Example- Four County, etc. If yes please list Agency below and contact person's name
Health Insurance Coverage *
Health Insurance Policy Number
Does your child take medication? *
Does your child take medication? If yes please list medication, dosage, and time of day they take it.
Please check the box(es) for medication your child is allowed to have if needed at club *
Required
Discipline Policy- Initial below to show that you understate our discipline policy below. Members and Parents can expect the following process to happen when behavioral incidents occur BG TOTS: 1- A "green light" means your child had a great day. 2- A "Yellow light" means your child misbehaved and/or failed to follow classroom rules/directions. At the time of the incidents staff will discuss with the child what behavior is expected. A short time out may be given. 3- A "red light" means your child had an "Oh no" day and was observed displaying one or more of the following: excessive disruptions, disrespectful attitude, defacing school/club property, leaving the group without permission, profanity/vulgarity, unsafe/violent, unsafe/violent behavior, fighting. If a child accumulates three red light (strikes) the child will be suspended a minimum of three days depending on the severity of the actions that resulted in the strikes. If another accumulation of three strikes occur the child will be suspended from BG TOTS for five (5) days. If a third accumulation of three (3) strikes occurs the child will be suspended for the remainder of the semester/summer. A determination will be made by the   BGC Chief Operation Officer and the BG TOTS Director as to if the child will be allowed to return to BG TOTS. *
Initial below to show you understand that any severe behavior that risks the safety and well being of the staff, members, or visitors will result in immediate suspension from BG TOTS and may result in criminal prosecution. In addition, the use or distribution of alcohol or any illegal substance on club/school property will result in immediate suspension. Any of the above situations may result in permanent revocation of an individual's club membership.
Technology and Internet Guidelines- Initial below to show you understand the following: Rules- Privacy: Network storage areas are treated the same as school lockers. The Technology Center Directors may review communication to maintain system integrity and will ensure that Club members are using the system responsibly. Storage Capacity: Users are expected to remain within the allocated disk space and delete material which takes up excessive storage space. Illegal Copying: Club members should never download or install commercial software, shareware, or freeware onto network drives or disks, unless given written permission from the Technology Center Director. Members should neither copy others' work or intrude on their files located on the computer. Inappropriate Materials of Language: Profane, abusive, or impolite language should not be used to communicate nor should materials be accessed which are not in line with the rules of Club behavior. A good rule to follow is to NEVER view, send, or access materials that you would not want your Club Staff or parent to see. Should members encounter such material by accident, they should report it to the Technology Center Director immediately. Members will not give out personal information such as address, telephone number, parents' information. *
Please initial below showing you understand that you will be charged $1/per minute after 5:30pm if your child has not been picked up.
Pricing: Select the times you wish for your child to attend. Summer enrollment will start after Spring Break *
Required
Please initial below showing you understand the following: Reimbursement of any paid fees will be unavailable during the duration of the time your child attends The Boys and Girls Club of Coffeyville.   *
Please initial below to show you have read and understand the follow listed in previous questions: The Transportation, behavior/discipline, Field Trip, Medical Care/First Aid, and Internet Safety consents. *
Please type your full name to show all of the above information is true and accurate to the best of your knowledge. Thank you. *
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