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2023 Summer Application

When will you be attending BGC
School your child currently attends
Member Information:
T-shirt Size
Parent/Guardian Contact Information:
Member Lives With:
Please check ALL that apply to your family:
Qualify for:
Does your child have an IEP (indivualized education plan) or attended specialized classes for behavior management?
Does your child have a companion at school?
Authorization for Emergency Medical Care

*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. 

For Scholarship Opportunities, please upload your most recent 3 paystubs or your 2022 Tax Returns below:

No file selected

Authorization for School Release

I give permission to Poplar Bluff R-1 School District to share all grade reports with the Boys & Girls Club of the Heartland 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 the Heartland 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 the Heartland 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 the Heartland, 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 the Heartland, 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 the Heartland, 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 the Heartland.  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 the Heartland. I/We agree that the Boys & Girls Club of the Heartland 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 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 childcare homes or the licensing rules for group childcare 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 the Heartland 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 the Heartland may transport my child off their site's 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 the Heartland to contact the physician or hospital of my choice.  I give my permission to the Boys & Girls Club of the Heartland 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 the Heartland 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 the Heartland, 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.

Authorization for School Release Form



Boys & Girls Club of the Heartland's 2023 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 $40.00 per child (Enrollment fee covers the first week your child is in our program.) Spot is not guaranteed until an email from BGC Administration. Payment is not required until spot is confirmed via email from BGC Administration.

Summer Dates: Our 2023 June Summer Program starts on Monday, June 5th and ends on Friday, June 30th (after summer school - 5:30 p.m.) June 19th is a holiday. PB R-1 Summer School will not be is session, BGC offices will be closed. BGC will be closed to kids July 1st - July 4th. Full Camp Days will begin on Wednesday, July 5th and ends on Friday August 4th. Camp Day hours are 7:30 a.m. - 5:30 p.m. BGC will be closed to kids August 7th - 18th. JUNE All Day Summer Program for High School and out of district students is 7:30 a.m. - 5:30 p.m. MUST be dropped off no later than 9:00 a.m. Bus Transportation is provided for PBR-1 Summer School students ONLY.

Who can attend Boys & Girls Club of the Heartland: Kids ages 6yrs - 18yrs can attend Boys & Girls Clubs of the Heartland.

How much will Boys & Girls Club cost during the 2023 Summer Learning Program? Enrolling parents/guardians will be charged a $40.00 enrollment fee per child. When your child attends PBR-1 Summer School, there will be a charge of $10 per week. All day Summer Program will have a $10 per day per child, up to $40 per week charge.  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 22-23 school year.

Field Trips – We have several field trips planned for the 2023 Summer Program. A field trip schedule will be provided the first week.

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 7:30 a.m.-5:30 p.m. All kindergarten-6th grade members will be in the Annex for programming and 7th – high school will be at the middle school campus site. 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 Summer School Program if available. Bus transportation will be provided to only PBR-1 students. All members MUST be transported by bus at all sites. Parent drop off are only accepted for PBR-1 High School, and out of district members. Any members wanting to attend BGC after summer school will be charged $10 per week per child.

Meals:  BGC will offer breakfast, lunch, and snack 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 snack 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.

Drop Off & Pick Up Policies: Parents must arrive at BGC between 7:30am – 9:00am. (NO EXCEPTIONS) Parents will not get out of vehicle. 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. Pick up signs will be distributed the first day your child attend. Pick up sign MUST be visible to allow a quicker pick-up process. All parents must stay in their vehicles while waiting for their child. 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.

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 You will be notified by Friday, May 26th if your child has been accepted into our program.

Summer School Learning Program Policy and Procedures
What are drop off times for the summer program?
MUST answer correctly to submit form
What time must your child be picked up by?
MUST answer correctly to submit form
What MUST you have with you to pick up your child?
MUST answer correctly to submit form