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2024 Summer Application

When will you be attending BGC
Member Information:
School your child currently attends
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 2023 Tax Returns below:

No file selected

Authorization for School Release

I give permission to Poplar Bluff R-1/Neelyville R-IV/Doniphan/Naylor/Malden/Risco/Gideon School Districts to share all grade reports with the Boys & Girls Club of the Heartland to further enhance my child’s education.  I give permission for Poplar Bluff R-1/Neelyville R-IV/Doniphan/Naylor/Malden/Risco/Gideon 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 601 Barrett Drive campus (example field trips, parks, 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 2024 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 and turn them into Boys & Girls Club prior to starting the program. New members will start on Mondays ONLY.

Summer Dates: Our Malden, Risco & Gideon 2024 Summer Program begins on June 24th and ends August 9th. We will be closed on July 4th and 5th. 

Who can attend Boys & Girls Club of the Heartland at Malden: Malden, Risco & Gideon students enrolled in Kindergarten - 5th grade are eligible for BGC membership.

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 were enrolled in the 23-24 school year. A schedule will be posted on the parent board for more specific information that will be taking place. 

Field Trips – We have several field trips planned for the 2024 Summer Program. A field trip schedule will be passed out on the first day of the summer program. 

Operational Hours and Facilities: 601 Barrett Drive in Malden is the primary drop-off and pick-up point for all members attending the Malden, Risco & Gideon Summer BGC program. BGC is open from 7:30 a.m.-5:30 p.m. Monday - Friday. Transportation will not be provided. 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.

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

Drop Off & Pick Up Policies: Parents must arrive at BGC between 7:30am – 9:30am unless prior arrangements are made with BGC staff. Parents will drive up to the gym door of the First General Baptist Church (601 Barrett Drive) in Malden and wait for a BGC staff to greet members. 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. 

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, theft, 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: 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

Summer School Learning Program Policy and Procedures