*Please note that the above personal information is vital and necessary for our records and the funding that our organization receives. The answers you provide will be kept completely confidential. Your cooperation for providing this information is both appreciated and important.
Authorization for School Release
I give permission to Poplar Bluff R-1 School District and Sacred Heart School to share all grade reports with the Boys & Girls Club of Poplar Bluff to further enhance my child’s education. I give permission for PB R-1 School District to release any information to BGCPB. I give permission for the BGCPB to communicate with my child’s teacher, view and copy grade reports, and discuss strategies that will help my child to become a successful student.
I understand that Boys & Girls Club of Poplar Bluff is not responsible for personal injury or lost or stolen property. By signing this form, I agree to allow my child to be photographed, videotaped, or interviewed for Boys & Girls Club media purposes only. Having been informed that Boys and Girls Club of Poplar Bluff provide supervised athletic, recreational, educational, cultural, and guidance programs for boys and girls, I/We, the Parent/Guardian of the child above, named candidate for membership in Boys & Girls Club of Poplar Bluff, do hereby agree and give consent for his/her participation in any and all activities conducted by the club while he/she is a member. In consideration of permission given to my child/children listed below by the Boys & Girls Club of Poplar Bluff, to participate in all activities, I release and discharge the BGCPB, its agents, employees, commissioners, and officers, from all claims, demands, actions, judgements, and executions, which I ever had, or now have, or may have, or which my heirs, personal representatives, or assigns may have or claim to have against the Boys & Girls Club of Poplar Bluff, its successors, or assigns for personal injuries to my child listed below, known or unknown and injuries to property, real or personal, caused by, arising out of, the activity or activities offered by the Boys & Girls Club of Poplar Bluff. I/We likewise release from responsibility any person transporting my/our child to or from all activities sponsored or conducted by Boys & Girls Club of Poplar Bluff. I/We agree that the Boys & Girls Club of Poplar Bluff may transport my child off the 1306 Victory Lane campus (examples Annex, field trips, Bacon Park, etc.) I have read this release and understand all its terms. I sign it voluntarily and with full knowledge of its significance. I consent to my child participating in all activities as stated above and assumed all risks.
I have received a copy of this facility’s policies pertaining to the admission, care and discharge of the children. I have been informed that a copy of the licensing rules for child care homes or the licensing rules for group child care homes and centers is available at this facility for review. The provider and I have agreed on a plan for continuing communications regarding my child’s development, behavior and individual needs. When my child is ill, I understand and agree that s/he may not be accepted for care or remain in care. I understand that, before the first day of attendance by my child, I will provide proof of completed age appropriate immunization or exemption from immunizations. I understand that I have the right to request notice of whether there are any children enrolled at our facility with immunization exemption on file.
I give permission for Boys & Girls Club of Poplar Bluff to transport my child. I give permission for my child to attend field trips/excursions. I understand that I will be notified in advance when they are planned. I/We agree that the Boys & Girls Club of Poplar Bluff may transport my child off their sites campus (examples other sites, field trips, etc.) I understand members will be walking from building to building while at club. I will provide proof of completed age-appropriate immunizations or exceptions from immunizations before the first day of school. When my child is ill, I understand and agree that he/she may not be accepted for care or remain in care. Staff at BGCPB will communicate regarding my child’s development, behavior, and individual needs.
I understand that I will be notified at once in case of an emergency with my child, and I will make arrangements for medical care of my child with the physician or hospital of my choice. If I cannot be reached to make necessary arrangements, or in a critical emergency requiring medical care, I authorize Boys & Girls Club of Poplar Bluff to contact the physician or hospital of my choice.
I give my permission to the Boys & Girls Club of Poplar Bluff to collect information via online or written surveys, questionnaires, interviews, and focus groups from the minor child listed on this application. 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. The aggregated results of these analyses may be shared with Club staff, Boys & Girls Clubs of America (BGCA), funders, and other community stakeholders to evidence program effectiveness and/or Club impact on our members. I give permission for my child to participate in all prevention programs (Smart Moves, METH Smarts, Smart Girls, Passport to Manhood, etc.) offered by BGCPB.
I understand that the Boys & Girls Club of Poplar Bluff may 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 Poplar Bluff, including data collected via surveys or questionnaires. All information provided to BGCA will be kept confidential.
I have read this release and understand all its terms. I sign it voluntarily and with full knowledge of its significance. I consent to my child participating in all activities as stated above and assumed all risks.
Boys & Girls Club of Poplar Bluff’s 2020 Summer Learning Program
Our Mission: To enable all young people, especially those who need us the most, to reach their full potential as productive, caring, and responsible citizens.
Enrollment Requirements: Sign all forms, all delinquent charges must be paid, pay an enrollment fee of $60.00 per child (Enrollment fee covers the first week your child is in our program.) Spot is not guaranteed until phone call from BGC Administration. Payment is not required until spot is confirmed via phone call from BGC Administration.
Summer Dates: Our 2020 June Summer Program starts on Monday, June 8th and ends on Thursday, July 2nd. Summer Learning Program in June is Monday-Thursday 7:30am – 5:30pm. Closed on Fridays in the month of June. Our 2020 July Summer Learning Program is after PB R-1 Summer School ONLY. Bus transportation is provided. Starting July 6th and ends on Friday July 31st until 5:30pm. High School members may use BGC for the virtual learning program Mon-Fri, July 6th – July 31st 9:00am – 5:30pm.
Who can attend Boys & Girls Club of Poplar Bluff: Due to social distancing restrictions, the 2020 Summer Learning Program is by invite only.
How much will Boys & Girls Club cost during the 2020 Summer Learning Program? Enrolling parents/guardians will be charged $60.00 per week per child or a scholarship weekly fee during our summer program. When your child attends the PB R-1 Summer School, there will be a charge of $15 per week per child. The parent that is signing the member up will be responsible for payments. Duplicate invoices will not be sent to joint custody parents. Payments are required by the last day of the week your child attends. If you are two weeks behind paying, you will receive a phone call.
Programming: BGC offers programming in academic success, good character & leadership, and healthy lifestyles. Club members will be in groups for program and meals based on the grade they were enrolled in the 19-20 school year.
Field Trips – Due to the COVID-19 and Health Officials, all fields trips have been canceled. We will, however, walk to Bacon Park regularly.
Operational Hours and Facilities: 1306 Victory Lane is the primary drop-off and pick-up point for all members. (Please review the NEW pick up and drop off procedures) BGC is open from 7:30a.m.-5:30 p.m. All kindergarten-6th grade members will be in the Middle School Annex for programming and 7th – high school will be on the middle school campus. There is a charge of $1.00 per child for every minute after 5:30 p.m. your child is not picked up. After 30 minutes, BGCPB is required to call authorities. If your child misses 5 days or more, you will receive a phone call from Administration to discuss membership.
Summer School: ALL members are required to attend the PB R-1 Summer School Program. Bus transportation will be provided. All members MUST be transported by bus at all sites. There are no parent drop-offs. Any members wanting to attend BGC after summer school will be charged $15 per week per child.
Meals: BGC will offer breakfast, lunch, and dinner to members. Breakfast will be served at 8:30-9:00 a.m. Lunch will be served from 12:00-12:30 p.m., and dinner at 3:00-3:30 p.m. If your child has special dietary needs, please make sure it is listed on the medical form. If your child does not like what is on the menu they may bring a sack lunch. ALL meals will be served in the classroom.
Drop Off & Pick Up Policies: Parents must arrive at BGC between 7:30am – 9:00am. (NO EXCEPTIONS) Parents will not get out of vehicle. A member of the BGC Staff will approach the vehicle and perform a health screening and escort your child to their room for the day. If your child has tested positive or exposed to someone who tested positive for COVID-19, they may not return for 7 days. End of the day pick up is from 3:30pm – 5:30pm (NO EXCEPTIONS) If a person is not listed on your child’s membership forms as an authorized person to pick up your child, we cannot release your child to them. Please make sure to bring a photo ID the first few times you pick up a member. All parents must stay in their vehicles while waiting for their child. Please be patient as this is a new policy for all of us. Please allow yourself at least 10 minutes for drop off and pick up.
Discipline Procedures: Due to the overwhelming need at BGC and limited space available, there will be a ZERO tolerance for the following behavior: Fighting, destruction of property, refusal to cooperate with staff, vandalism, disrespect to staff, etc.
Member Safety: Keeping your child safe is very important at Boys & Girls Club. Parents are not allowed anywhere in the Boys & Girls Club Facility. It is necessary to keep updated information on our club members and their parents. Please inform BGC front desk staff any member information changes such as phone number, address, authorized pick up list, etc. BGC has an emergency preparedness plan stating that in the event of an emergency causing evacuation, we will transport your child to the softball field at Bacon Park. Do not send your child and/or siblings to club if they are sick or showing ANY of the following signs: Cough, Shortness of breath or difficulty breathing, sore throat, headache, fever, chills. BGC cannot store, dispense, or apply medicine. If your child has a temperature over 98.6, they will be isolated and parents will be notified. Once a child’s temperature reaches 100 degrees the child must be picked up immediately. Child may not return to BGC until they are 72hrs symptom and fever free without medication. In the event of an emergency, BGCPB will follow best practices per state licensing guidelines. Your child will remain in the same classroom for the duration of the day. There will be assigned bathroom breaks.
COVID-19: Boys and Girls Club of Poplar Bluff will be staying up to date on any and all changes issued by the state of Missouri and local health officials. Procedures could be changed at any time. If a staff member should test positive for COVID-19, BGC must close for 14 days from the first onset of symptoms. If a child should test positive for COVID-19, everyone who was in contact with the child will be notified and required to self-quarantine for 14 days.
Other Notes: Do not allow your child to bring personal items to club. BGC is not responsible for lost or stolen items, however, there is a lost and found area where lost items will be stored. Follow us on Twitter, Facebook, Remind 101, and visit bgcpb.org. You will be notified by Friday, May 29th if your child has been accepted into our program.