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Member Information:
Will your child be attending PB R-1 "In School" classes for the 22-23 School Year?
First, Middle, Last
Street, City, State, Zip
Parent / Guardian Contact Information
Work/School Schedule (State Licensed Requirement)
Work / School Schedule
Member Lives With:
Please check if applicable
Does your child have an IEP (individual education plan) or attend specialized classes for behavior management?
Does your child have a companion aide at school?
Do you plan on bringing your child for Campdays?
If Yes, you MUST pre-register AND pre-pay at least 1 week in advance to attend
Are you interested in being part of the BGC Advisory Committee
Authorization for Emergency Medical Care
Name & Phone
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Filling in the Special Health or Medical Requirement Section MUST have a Dr's Note
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Name & Phone

*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 vital.

Authorization for School Release

I give permission to PB R-1 / Neelyville R-IV School District to share all progress reports with the Boys & Girls Club of Poplar Bluff to further enhance my child’s education.  I give permission for PB R-1 / NEELYVILLE R-IV School District to release any information to BGCPB.  I give permission for the BGCPB to communicate with my child’s teacher, view and copy progress 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 / 1101 Highway 160 (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 understand that all sites are licensed exempt with the exception of Kindergarten Center and Lake Road Elementary. 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 (i.e. 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.

I have read and understand the Authorization for School Release. Please enter name above

2022-2023 School Year Policy & Procedures

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 (Lake Road and Kindergarten Center must also provide shot records and health statement). All delinquent charges must be paid and pay the first monthly membership fee of $20.00 per child.

Afterschool Dates: PB R-1 2022-2023 After School Program starts on Monday August 22, 2022, and ends the last full day of school. Neelyville R-IV 2022-2023 After School Program starts Wednesday August 24, 2022, and ends the last full day of school.

Who can attend Boys & Girls Club of the Heartland? All students enrolled in “in person” classes who are enrolled in kindergarten – 12th grade in the PB R-1/Neelyville R-IV School Districts are eligible for BGCPB membership. The state of Missouri requires kids to be 6yrs old and up to attend camp days.

How much will Boys & Girls Club cost 2022-2023 School Year? Enrolling parents/guardians will be charged a monthly membership fee of $20.00 per month per child for all regular afterschool days throughout the 22-23 school year. The parent that is signing the member up will be responsible for payments. BGCPB Camp days will be $15.00 per day per child, MUST pre-register AND pre-pay online 2 weeks in advance @

Programming: BGC offers programming in character and leadership development, education and career development, health and life skills, the arts, and sports, fitness, and recreation. Club members will be in groups for Power Hour and programming based on the grade they are enrolled in the 22-23 school year. A schedule will be posted on the parent board at each site for more specific information that will be taking place.  BGC is not responsible for making transportation arrangements with the school. It is the parent’s responsibility to inform the school of changes in afterschool transportation arrangement.

Operational Hours and Facilities: ALL SITES will be open until 6:30 pm, Monday through Friday. Transportation will not be provided from school-based sites to Middle School Unit or other school-based sites.  Camp days will be at the Middle School Unit @ 1306 Victory School Lane open 7:30 a.m.-5:30 p.m. to any members who are enrolled in the 22-23 school year. Drop off time during Camp days will be 7:30-9:00am and pick up will be from 3:30-5:30pm. There is a charge of $1.00 per child for every minute after 6:30 pm during regular school days and 5:30 during camp days that your child is not picked up. After 30 minutes, BGCPB is required to call authorities. Camp Days MUST be pre-registered and pre-paid 2 weeks in advance to attend. NO EXCEPTIONS!

Meals:  BGC will provide a full meal and or snack to members at all of our locations.

Drop Off & Pick Up Policies: Each site will have a different procedure depending on the physical layout of each school.  Parents will not be required to sign out their children.  Special provisions can be made for parents with newborns during inclement weather or other extenuating circumstances. 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. Middle School members are required to stay until 4:00p.m.

Discipline Procedures: Step 1 will be a warning to the child. Step 2 is sentences or other appropriate consequences for the child. Step 3 will be a time out of program or In-Club Service. Step 4 your child will have an administrative meeting with the child and a parent. Step 5 is suspension. Fighting, destruction of property, refusal to cooperate with staff, or vandalism will result in immediate suspension. If a member poses a threat to their own safety or safety of others, they may be placed on a behavior management plan. This plan provides notice and accountability to avoid permanent suspension.  If your child is suspended from their attending school district, they are not allowed to attend BGC due to club being on school property.

Member Safety: Your Child’s Safety is Paramount at the Boys & Girls Club. 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. In the event of an emergency causing evacuation, BGC has an emergency preparedness plan in place at each site that will be followed. Do not send your child to club if they are sick. BGC cannot store, dispense, or apply medicine. If your child has a temperature over 98.6, parents will be notified. Once a child’s temperature reaches 100 degrees the child must be picked up immediately. In the event of an emergency, BGCPB will follow best practices per state licensing guidelines. 

Other Notes: Do not allow your child to bring personal technology devices to club. BGC is not responsible for lost or stolen items. If a child changes schools, please inform BGC to check for availability. (We cannot guarantee there will be a spot available at their new school.) Follow us on Twitter, Facebook, and visit You will be notified by Thursday, August 18th if your child has been accepted into our program.

I have read and understand the 2022-2023 School Year Policy & Procedures. Please enter name above.

USDA Nondiscrimination Statement

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution
is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation),
disability, age, or reprisal or retaliation for prior civil rights activity.
Program information may be made available in languages other than English. Persons with disabilities who require alternative means of
communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the
responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact
USDA through the Federal Relay Service at (800) 877-8339.
To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint

Form which can be obtained online at:
05080002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The

letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action
in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation.
The completed AD-3027 form or letter must be submitted to USDA by:

1. mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW Washington, D.C. 20250-9410; or 

2. fax: (833) 256-1665 or (202) 690-7442; or

3. email:

This institution is an equal opportunity provider.