The document is a handbook from the Boys & Girls Club outlining policies and procedures for the upcoming school year. It discusses membership requirements, locations and hours of operation, COVID-19 safety protocols like mask wearing and distancing, code of conduct including dress code, discipline policy, and contact information. The CEO emphasizes that safety is the top priority given the pandemic, and cooperation from families is needed to operate safely.

1. Dear Parent or Guardian,
Thank you for trusting us with the physical, emotional, and educational wellbeing of your child. Please
read over the attached handbook and learn what theBoys & Girls Club is all about. This is an important
step in ensuring that your child has a successful year at the Club. All members and their guardians will
benefit fromthe information enclosed in this booklet.
If you arealready familiar with the Club and our programs, the rules and guidelines laid out in this
handbook may look a little different fromwhat you areused to. This is not the sameClub you are used
to. With COVID-19 overshadowing everything we do, that would be an impossibility. Our first and
foremost priority is your child’s safety, and for us to be able to operate safely, we will need both you and
your child’s full cooperation. Please ensure that they know and understand the rules. Also, please
understand we will have a very low tolerance for rule breaking- especially when it comes to safety. “Keep
your hands to yourself” will be a rule that must be adhered to. Your child will also be required to wear a
mask. Make sure that they are fully aware of the changes before signing up.
Our mission is to inspireand enable all young people to realize their full potential as productive,
responsible, and caring citizens. We can only achieve this mission with your help and support. Our
partnership with you has never been more important than it is now. During these uncertain times, we
must work harder than ever to ensurethat your child is getting the help and guidancehe or she needs.
We are herefor you. We want to be an advocate and an ally for your family. If there is ever anything we
can do to help, please let us know.
Looking forward to a great year!
Best regards,
Kateena Haynes, CEO
Boys & Girls Clubs of Appalachia

2. Membership
Schoolyear: Membership is currently open to all youth between the ages of 6 and 13. A membership
form must be completed and signed by a parent or guardian each year (even if you are simply
renewing your membership). Membership in the afterschool program is free, but financial donations to
help offset the cost of supplies and materials are welcome. Some activities (such as field trips) may
require a small fee.
Summer: Fees for our summer educational enrichment camps are $50 per week. However,
scholarships and payment plans based on household income are available. Our goal is to always keep
costs associated with Boys & Girls Club membership as low as possible to not exclude anyone based
on economic circumstances.
The information you provide us on the membership application is critical.
We ask that every effort be made to present contact information that is both current as well as
accurate. It is the parent's/guardian's responsibility to notify us of any changes to your telephone
number (home, work, emergency contacts, etc.) and/or address information as soon as such changes
occur. Failure to provide current contact information will result in member suspension or possibly
termination.
Orientations are offered to all new members and their parents. Please take advantage of the
opportunity to see and hear what your Boys & Girls Club is all about and how you can give back to the
Club to make it a better place for all of our kids.
Membership in the Boys & Girls Club is a privilege, not a right. The Boys & Girls Club reserves the right
to refuse membership to any child at any time, with or without cause.
Learning Center Locations & Contact Information
Cawood Ledford Boys & Girls Club
Unit Director- Melanie Adams
Office phone- 606-573-0960
Email= clunitdirector@outlook.com
Union College Boys & Girls Club- The Center for Health and Learning
Area Director- Sara Donahue
Office phone- 606-546-1719
Email- sdonahue@unionky.edu
Director of Operations- Kendra Calhoun, clunitdirector@gmail.com
CEO- Kateena Haynes, khaynes@unionky.edu
Club Hours
Cawood Ledford Site
Monday through Friday: 8am until 12pm – 1st
through 4th
Grades
2pm until 6pm – 5th
through 12th
Grades
Union College Site
Monday through Friday: 12pm until 4pm- ages 6 through 12

3. Please be sure to pick-up your child by the posted closing times. Late fees of $1 per minute will be
assessed after 10 minutes. Late fees must be paid before the member(s) will be allowed to return.
The Boys & Girls Club reserves the right to contact the appropriate authorities for assistance when
members are not picked up by a reasonable time and after all emergency contact alternatives have
been exhausted.
Supervision
Our staff members are trained Youth Development Professionals. Screened volunteers often support
our staff. A staff member and/or volunteer will oversee each of our designated program areas.
ALWAYS take the time to remind your child of the need to follow Club rules and directions whether
said directions are given by a staff member or a volunteer. Please note that youth are not allowed on
the Club's grounds during operating hours unless they are signed in and participating in Club activities.
Members should NOT be dropped off prior to the start time of Club activities, as the Club cannot
be held responsible for the supervision of such youth. Also, once a child leaves the Club, he or she
will not be allowed to return until the following day.
Code of Conduct
One of the Club's core beliefs is to provide a safe place to learn and grow. Positive attitudes keep the
Club fun. Below are some simple guidelines members are expected to follow:
Dress Code
Youth should dress comfortably and wear clothes that allow them to participate in typical Boys &
Girls Club activities and programs. We will expect the following...
Masks: Children should be sent to the Club with an easily identifiable mask. We recommend
writing the child’s name on the inside of the mask.
Footwear: Shoes and socks must be worn at all times. Flip-flops and sandals are allowed but
discouraged, as are any other open-toed shoes for safety reasons. Club members may not be
allowed to participate in certain activities if open-toed shoes are worn. The best advice is to
wear tennis/walking shoes every day.
Clothing: Inappropriate clothing of any kind is NOT allowed in the Club. Members wearing
clothes that are too short, too tight or too revealing in any way, or clothes with questionable or
distasteful advertising will be asked to change or leave immediately. This judgment will be left
solely to the discretion of the Club staff.
Discipline Policy
Rules and Regulations
1. Parents must keep up to date emergency contact info on file.
2. All members and parents are expected to know the rules and follow them.
3. Members are expected to follow the instructions of the staff and volunteers and to be
respectful to them and other Club members.
4. Masks are to be worn at all times.
5. Members are to keep their hands to themselves and respect one another's personal space.

4. 6. Anyone receiving a "Red Card" will not be allowed to return to the Club until the parent(s) or
guardian(s) meet with the Director to formulate a behavior plan.
7. Improper language is not permitted. This includes cursing, inappropriate discussions, racist
remarks, etc.
8. Fighting, wrestling, and bullying are not permitted.
9. Running is only allowed when permission is given by a staff member as part of a game or
activity.
10. Only one Club member in the restroom at a time.
11. Eating is only permitted in designated areas.
12. Shoes must be worn at all times.
13. Members are only allowed in supervised areas.
14. We cannot be held responsible for items that are lost, stolen, or damaged. Members are
encouraged to leave personal items, such as mobile phones, at home.
15. All members are expected to clean up after themselves.
16. All Club members should be picked up by the close of Club each day. A fee of $1 per minute
will be assessed for late pick-ups.
17. All members are always to conduct themselves with dignity .
18. Destruction of property will not be tolerated. This includes, writing on walls, desks, chairs,
etc. This also includes intentional destruction of games equipment or using equipment for
purposes other than those intended. Parents will be charged for damaged property.
19. Once a member leaves the Club, he or she will not be admitted again until the next day.
20. No one under the influence of drugs or alcohol will be allowed to participate in the Club or in
Club activities. Tobacco us is also not permitted. We enforce a zero tolerance policy.
21. Weapons or look-a-like weapons will not be allowed on Club property or at any Club activity
22. In addition to the Boys & Girls Club rules, Club members at Union College must also follow
the rules of Union College and Club members at the 21CCLC must also follow the rules of
the Harlan Independent School District.
The safety of all members is of utmost importance to us. Any member who disrupts programs or
creates a dangerous situation will be disciplined appropriately. Members who do not follow rules can
expect to face consequences. Offenses will be handled based on their severity. Parents will be called
to remove any member who has failed to curb his or her disruptive behavior and/or is behaving in an
manor that creates a dangerous situation for themselves, fellow members, staff or visitors.
Disciplinary actions may include, but are not limited to, the following:
 Verbal Counseling
 Time-out
 Suspension from Program Area
 Loss of Club Privileges
 Suspension (one day to two weeks)
 Indefinite suspension (until the situation can be resolved or the parent/guardian is consulted)
 Expulsion (i.e., permanent suspension)
 Contacting the proper authorities
Members are expected to respond to discipline without incident. Failure to do so will almost always
increase any action taken in time or severity. Staff members are trained and fully expected, by policy, to
maintain full control of any situation that occurs in their program area and will NOT tolerate anything
that threatens that control, in appearance and/or manner. Also, please understand that sometimes the
story that gets home is not always complete or accurate. Children sometimes tend to explain an
incident in a manner that will not implicate them or cast blame their way. In addition, staff members,

5. though well trained and experienced, are human, so please call the Club if you have any questions at
all concerning disciplinary measures or any other Club activity. Your support and involvement as the
parent/guardian is vital to our success as youth development professionals.
Yellow Cards and Red Cards
When a child's behavior consistently disrupts the programs of the Boys & Girls Club or take up a
considerate amount of staff time, it can negatively impact the Club experience for all our members. In
an effort to better work with parents to address chronic misbehavior, we have developed a discipline
procedure that relies on cards to communicate with parents.
How it works:
 You receive no card: Your child had a great day at the Club. He might have received a timeout,
but he was able to complete the rest of the day with no problems.
 You receive a yellow card (or warning card): Your child struggled through the afternoon and
ignored staff instructions resulting in multiple timeouts. On the card, you will find a description of
your child's behavior. When a staff gives you the card, they will also inform you of any
consequences your child has earned (suspension, loss of privileges, etc.)
 You receive a red card (or stop card): Your child has previously received two warning cards or
has created such a difficult situation that our standard discipline tools are inadequate to address
the problem. Anyone can have a bad day, but collecting three cards within the course of a year
shows a pattern of poor behavior that must be addressed. Parents or guardians must meet with
our Director before the child can return to the Boys & Girls Club. These meetings are scheduled
subject to her availability. Depending on Club attendance and the current waiting list, if
your child receives a red card, he or she may not be able to return to the Club until the
next semester.
Phone Calls
To reduce the spread of germs, our phones are for Club business only. Members should not
plan to use our phones. If you must make an inquiry, you can call and speak to a Club staff but
please do not expect to call the Club and speak to your child. Our lines need to remain open in the
event of an emergency. Please make any necessary arrangements before your child comes to the Club
so that you do not have to call the Club and your child does not have to call you.
Personal Belongings
DUE TO COVID, ONLY MINIMAL PERSONAL BELONGINGS SHOULD BE BROUGHT TO THE
CLUB. We will furnish all supplies and each child will have his/her own scissors, paper, pencils,
crayons, etc. All personal belongings brought into the Club by a youth are the responsibility of that
youth. The Boys & Girls Club is NOT responsible for lost, damaged or stolen items. Please discourage
your child from bringing anything to the Club that is not completely necessary, especially money.
Necessary items, such as backpacks and jackets should be clearly marked with the member's name.
Items that are not collected from our lost-and-found within two weeks will be donated to a local charity.
Medication
The Boys & Girls Club is NOT allowed, by policy, to dispense, store and/or oversee medication of any
kind, including all non-prescription medications. If medication is needed, it is the parents' responsibility

6. to administer it at the proper times. The only exception is rescue medication (i.e. Epi pens, Asthma
inhalers) and staff can only administer those with a note from the physician.
Accidents
The Boys & Girls Club strives to maintain a safe and secure environment. There is an assumed risk in
many of our core programs, including, but not limited to sports. Please feel safe in knowing that our
trained staff is attentive to providing the safest environment possible. The completed membership
application authorizes the Club staff to seek medical treatment for a member, if necessary, and that any
associated costs for such care are the responsibility of the parent or guardian. The Boys & Girls Club
does NOT provide medical insurance for members. In the event of a serious injury, the staff will call 911
immediately and then call the parents/guardians or alternative emergency contacts. Updated contact
information is your responsibility and is crucial to your child's well-being.
Infestation or Contagious Conditions
Any and all suspected transferable infestations or transmittable contagious conditions (including
COVID) will be addressed fully in the following manner and without exception...
1. Parents will be contacted for immediate removal of the member from Club facilities. In the
meantime, child will be relocated to an isolation area.
2. Proof of treatment from a health care facility AND written approval from the Unit Director is
required before the child will be allowed back into the Club.
Additionally- The Boys & Girls Club has a strict "no-nits" policy. If your child is suspected of having lice,
his/her head will be checked in a private location by Club staff. If nits or lice are found, he/she will be
sent home and will not be allowed to return until he/she if found to be nit-free.
Food
The Boys & Girls Club understands and appreciates the need for a healthy diet among all of our
members and snacks will be provided regularly. It is our goal to encourage healthy eating habits that
promote the well-being of our youth. The Club has a designated area and a designated time for eating.
Please keep food and drinks out of the areas where such items are prohibited. If your child is on a
restricted diet due to food allergies, we must have a note from your physician on file. If the restricted
diet is due to religious reasons, we must have a note from the parent or guardian stating such.
“The U.S. DepartmentofAgriculture (USDA) prohibits discrimination againstits customers,employees,and applicants for
employmenton the bases ofrace, color, national origin,age,disability,sex, gender identity, religion,reprisal,and where
applicable,political beliefs,marital status,familial or parental status,sexual orientation,or if all or part of an individual's i ncome
is derived from any public assistance program,or protected genetic information in employmentor in any program or activity
conducted or funded by the Department.(Notall prohibited bases will applyto all programs and/or employmentactivities.)If
you wish to file a Civil Rights program complaintofdiscrimination,complete the USDA Program Discrimination Complaint
Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html,or at any USDA office, or call (866) 632-9992 to
requestthe form. You may also write a letter containing all of the information requested in the form. Send your completed
complaintform or letter to us by mail at U.S. DepartmentofAgriculture, Director, Office of Adjudication,1400 Independence
Avenue, S.W., Washington,D.C.20250-9410,by fax (202) 690-7442 or email at program.intake@usda.gov.Individuals who
are deaf, hard of hearing or have speech disabilities maycontactUSDA through the Federal Relay Service at (800) 877 -8339;
or (800) 845-6136 (in Spanish).USDA is an equal opportunityprovider and employer.”

7. Please note: All information is confidential and will not be released to any third party.
I have read the membership application and understand the rules and regulations of the Club. I agree
to follow these rules. I also understand that if I break these rules, I may be suspended from the Club. I
recognize that it is my responsibility to know and follow the rules.
Member's Signature Date
I have read the membership application, understand the rules of the Boys & Girls Clubs of Appalachia,
and request that my child be admitted into membership. I have explained the rules to my child. I agree
that the Boys and Girls Club is not responsible for any accident to my child while on the premises or
while engaged in any activities that are conducted away from the Club. I understand that the Boys and
Girls Club is not a daycare operation and staff members, under normal circumstances, are not allowed
to prohibit a member from leaving the facility per the regulations of the Kentucky Department of
Protective & Regulatory Services governing facilities/programs exempt from licensure as child cares. I
further agree that it is my responsibility to keep the information on this application current.
I hereby authorize and consent to the Boys and Girls Club recording my child's picture and voice on
photographs, films, audio-video tapes to use for the purpose of publicity, advertising, and sales
promotion without any compensation whatsoever. I further release the Boys and Girls Club from any
and all claims for damages, libel, slander, and invasion of privacy arising out of the use of the foregoing
material.
As a parent or guardian of a Club member, I hereby authorize the Boys and Girls Club, in the event of a
medical emergency to seek transportation to a hospital. I authorize medical treatment from a licensed
physician if, in the opinion of the licensed physician, the medical emergency may endanger the Club
member's life, cause disfigurement, physical impairment, or undo discomfort if treatment is delayed.
This authority is granted only after a reasonable effort has been made to contact me or authorized
persons with the phone numbers identified on this application.
I give permission to the Boys and Girls Club to survey and interview my child to find out what his/her
behavior, skills, and attitudes are in regards to issues such as health risks and habits, positive self-
esteem, respect to diversity, education and educational resources, positives relationships, career
choices, and connection to community, as well as his/her experience at the Club. I understand that this
information will remain private, and that only my child's Club director and program aides will be able to
look at his/her responses.
I understand that my child's responses will be automatically grouped together with the responses of
other Boys and Girls Club members for any public presentation of the finding, and that my child will
never be individually linked to his/her responses. In addition, I understand that I can take back my
permission at any time by giving written notice to the Club director of the Boys and Girls Club. Finally, I
understand that I can receive a copy of the signed consent forms and that, upon request, I may arrange
a meeting with the Club director to discuss questions or concerns.
Parent/Guardian Signature Date

8. Responsible Computer Use Guidelines
The Boys & Girls Clubs of Appalachia computer network and Internet access are available to members
to enhance their educational experience and become literate in an increasingly technological world.
The purpose of these Responsible Use Guidelines is to foster the appropriate use of that network and
the Internet. The following Guidelines apply to all users whenever they access the Boys & Girls Club's
network connection.
Educational Purpose
The network has been established for educational purposes limited to classroom activities, career
development, and independent scholastic research on appropriate subjects. The network has not been
established as a public access service or a public forum. The Club has the right to place reasonable
restrictions on the material you access or post through the system. You are also expected to follow the
Club's behavior standards when accessing the network. You may not use the Union College network
for commercial purposes. This means you may not offer, provide, or purchase products or services
through this network. You may not use it for political lobbying, but you may use the system to
communicate with elected representatives and to express your opinion on political issues.
Personal Safety
You will not post personal contact information about yourself or other people. Personal contact
information includes (but is not limited to) home, school, or work addresses and telephone numbers.
You will not agree to meet with someone you have met online without your parent's approval. A parent
or guardian should accompany you to this meeting. You will promptly disclose to the Educational
Director or any other Club staff member or adult volunteer any message that you receive that is
inappropriate or makes you feel uncomfortable.
Illegal Activities
You will not attempt to gain unauthorized access to the network or to any other computer system
through the network. This includes attempting to log on through another person's account or access
another person's files. These actions are illegal, even if only for the purposes of "browsing." You will not
make deliberate attempts to disrupt the computer system or destroy data by spreading computer
viruses. You will not use the network to engage in any illegal act, including but not limited to arranging
for the purchase or sale of drugs or alcohol, engaging in criminal activity, or threatening the safety of
another person.
System Security
You are responsible for your individual user account and should take all reasonable precautions to
prevent others from being able to use your account. Under no conditions should you provide your
password to another person. You will immediately notify a Club staff member or adult volunteer if you
have identified or witnessed a possible security problem. Do not go looking for security problems,
because this may be construed as an illegal attempt to gain access.
Inappropriate Language
Restrictions against inappropriate language apply to public messages, private messages, and material
posted on Web pages. You will not use obscene, profane, lewd, vulgar, rude, inflammatory,
threatening, or disrespectful forms of communication. This applies to verbal and written language,
diagrams, photographs, representations, videos or any other form of communication. You will not post
information that could cause damage or a danger of disruption. You will not engage in personal attacks,
including prejudicial or discriminatory attacks. You will not harass another person. Harassment is
persistently acting in a manner that distresses or annoys another person. If you are told by a person to

9. stop sending him or her messages, you must stop. You will not knowingly or recklessly post false or
defamatory information about a person or organization.
Respect for Privacy
You will not re-post a message that was sent to you privately without permission of the person who
sent you the message. You will not post private information about another person.
Plagiarism and Copyright Infringement
You will not plagiarize works that you find on the Internet. Plagiarism is taking ideas or writings of
others and presenting them as if they were yours. You will respect the rights of copyright owners.
Copyright infringement occurs when you reproduce a work that is protected by a copyright without
authorization. If a work contains language that specifies appropriate use of that work, you should follow
the expressed requirements.
Inappropriate Access to Material
You will not use the network to access material that is profane or obscene (pornographic), that
advocates illegal acts, or that advocates violence or discrimination toward other people (hate literature).
A special exception may be made for hate literature, if the purpose of your access is to conduct
research, and both your teacher and parent or guardian approve. If you mistakenly access
inappropriate information, you should immediately tell the Club Staff member or volunteer. This will
protect you against a claim that you have intentionally violated this policy. Your parent or guardian
should instruct you if there is additional material that he or she thinks would be inappropriate for you to
access. The Boys & Girls Club fully expects you to follow your parent's or guardian's instructions in this
matter.
Your Rights
The network is considered a limited forum, similar to the school newspaper and therefore the Club
reserves the right to regulate that forum for valid educational reasons. The Club will not restrict your
speech on the basis of a disagreement with opinions you are expressing. You should expect only
limited privacy of the contents of your personal files on the system. This situation is similar to the rights
you have in the privacy of your locker. An individual search will be conducted, if there is a reasonable
suspicion that you have violated these Guidelines.
Disciplinary Actions
Members who violate the Responsible Use Guidelines may be denied future Internet and/or network
privileges for a defined period of time, or be subject to other disciplinary measures as set forth by the
Boys & Girls Club staff.
This Section Must Be Signed By a Parent or Guardian for All Members under Age 18
As a parent or guardian of this student, I have read the Boys & Girls Club Responsible Use Guidelines.
I understand that access to the Boys & Girls Club Network and the Internet is designed for educational
purposes and the Boys & Girls Club has taken available precautions to educate members on
appropriate educational materials. However, it is understood that no matter how much supervision and
monitoring that the Club can offer, there will always be the possibility of my child coming into contact
with inappropriate material, and I will not hold the Boys & Girls Club or Union College responsible for
materials acquired on the network.
Parent/Guardian Signature Date

10. Report Card Release
To better serve our members, we want to play a strong role in their education. We partner with several
schools in order to help our Club members excel academically. We do this by tracking grades and
attendance, discussing Club members' academic obstacles and goals with their teachers, and obtaining
user information for web-based programs that are designed to accelerate learning (such as Study
Island). To accomplish this, we need permission from you. By signing this release, you are giving
permission for your child's report card to be given to the Club's Area Director.
I give permission for my child's school to release their report card to the Boys & Girls Clubs of
Appalachia every nine weeks.
Childs Name
Parent Signature

11. Boys & Girls Clubs of Appalachia Membership Application
Date Member Type
☐ New Member
☐ Renewing Member
UNIT: Cawood Ledford Union College 21CCLC
PRIMARY CONTACT INFORMATION
Role in Household ☐ Mother
☐ Father
☐ Step-Parent
☐ Aunt/Uncle
☐ Sister
☐ Brother
☐ Cousin
☐ Grandparent
☐ Foster Parent
☐ Guardian
☐ Other Relative
First Name
Last Name
Employer / Organization
Email Address
Home or Primary Phone
Mobile Phone
Employer or Neighbor #
Address
City, State and Zip Code
Military Status
Current /
Former
Military
☐ Yes ☐ No Status ☐ Active Duty
☐ Reserve/Guard
☐ Veteran
Branch ☐ Air Force
☐ Army
☐ Coast Guard
☐ Marine Corps
☐ National Guard
☐ Navy
Dept. of Defense ID
Number
CurrentlyDeployed
(or deploy ed within the next 6 months)
☐ Yes ☐ No
MEMBER DETAILS
Member Information
Total past years of membership with Boys & Girls Clubs
First Name
Last Name
Preferred Name
Email Address
Home or Primary Phone
Mobile Phone
Birthday
Address
City, State and Zip Code

12. Gender
☐ Male
☐ Female
☐ Choose Not to Answer
Racial / Ethnic
Identity
☐ American Indian or
Alaska Native
☐ Asian
☐ Black or African
American
☐ Hispanic or Latino
☐ Middle Eastern or
North African
☐ Native Hawaiian or
other Pacific Islander
☐ White
☐ Bi-racial
☐ Multi-Racial
☐ Other
☐ Choose Not to Answer
Foster Care ☐ Yes ☐ No Kinship Care ☐ Yes ☐ No
School Lunch
☐ Free/Reduced
☐ Entire School is Free
☐ Not Eligible
School Information
Grade (Fall 2019)
School Name
Teacher
School ID Number
Allergies
Food Allergies ☐ Peanuts
☐ Tree Nuts
☐ Dairy/Lactose
☐ Soy
☐ Gluten
☐ Seafood/Shellfish
☐ Eggs
☐ Other _______________________
Environmental
Allergies
☐ Bee Stings
☐ Pollen
☐ Dust
☐ Mold
☐ Grass
☐ Other _______________________
Medicine Allergies ☐ Penicillin
☐ Aspirin
☐ Amoxicillin
☐ Other _______________________
Other Allergies ☐ Latex
☐ Perfumes/Colognes
☐ Lotions
☐ Other _______________________
Medical Information
Diagnosed Medical
Conditions
☐ Asthma
☐ Diabetes
☐ Hearing
Impairment
☐ Visual impairment
☐ ADD/ADHD
☐ Autism
☐ Seizures
☐ Anxiety/Depression
☐ Oppositional Defiance Disorder
☐ Other
___________________
Please list any other physical, mental or medical limitations.
Does the member use an
inhaler? ☐ Yes ☐ No Does the member use insulin? ☐ Yes ☐ No

13. Does the member use an
EpiPen? ☐ Yes ☐ No
Does the member self-
administer medication? ☐ Yes ☐ No
Does the member receive additional
support in the school/community?
☐ Individualized Education Plan (IEP)
☐ 504 (accommodation)
☐ Speech Coach
☐ Meets with school or private counselor
☐ Other ___________________________
Insurance
Insurance Carrier
Group Number Member/Policy Number
Policy Holder Phone Number
Physician Name Physician Number
Hospital Name Hospital Number
AUTHORIZED CONTACTS
Authorized Contact 1 Authorized Contact 2
Full Name Full Name
Phone Phone
Mobile Phone Mobile Phone
Work Phone Work Phone
Emergency Contact ☐ Yes ☐ No Emergency Contact ☐ Yes ☐ No
Relationship ☐ Caseworker
☐ Child
☐ Grandchild
☐ Grandparent
☐ Neighbor
☐ Other
☐ Other Relative
☐ Parent
☐ Stepdad
☐ Stepmom
Relationship ☐ Caseworker
☐ Child
☐ Grandchild
☐ Grandparent
☐ Neighbor
☐ Other
☐ Other Relative
☐ Parent
☐ Stepdad
☐ Stepmom
NON-AUTHORIZED CONTACTS
Please list any individuals that are restricted from picking up the member.
Non-Authorized Contact 1 Non-Authorized Contact 2
Full Name Full Name
Phone Phone
Relationship ☐ Parent / Step Parent
☐ Grandparent
☐ Other Relative
☐ Neighbor
☐ Friend
☐ Caseworker
☐ Other
Relationship ☐ Parent / Step Parent
☐ Grandparent
☐ Other Relative
☐ Neighbor
☐ Friend
☐ Caseworker
☐ Other
Start Date Start Date
End Date End Date

14. Household Support
Number of adults in household Number of children in household
Household Composition
☐ Single Adult Household
☐ Two + Adult Household
☐ Self (emancipated / 18)
Who are the adults
living in the
household? (Check
all that apply)
☐ Mother
☐ Father
☐ Parents
☐ Step Father
☐ Step Mother
☐ Grandparent(s)
☐ Foster Parent(s)
☐ Joint Custody
☐ Legal Guardian(s)
☐ Sibling(s)
☐ Uncle
☐ Aunt
☐ Other Relative(s)
☐ Other Adult(s)
Assistance
Programs
☐ Childcare Assistance
☐ Food Stamps/SNAP
☐ Medicaid
☐ Medicare
☐ Social Security
☐ SSI (Supplemental Security Income)
☐ SSDI (Social Security Disability Insurance)
☐ WIC (Women, Inf ants, and Children)
☐ TANF (Temporary Assistance
for Needy Families)
☐ Veteran’s Compensation
☐ Housing Assistance
☐ Other (please explain below)
☐ Choose Not to Answer
☐ None
Please describe
other income
sources:
Housing Type ☐ Permanent (Own or Rent)
☐ Public Housing
☐ Group Home
☐ Foster Family
☐ Transitional Housing
☐ Homeless
Household
Income
Range
☐ $0 - 10,000
☐ $10,001 – 15,000
☐ $15,001 – 20,000
☐ $20,001 – 25,000
☐ $25,001 – 30,000
☐ $30,001 – 35,000
☐ $35,001 – 40,000
☐ $40,001 – 45,000
☐ $45,001 – 50,000
☐ $50,001 – 55,000
☐ $55,001 – 60,000
☐ $60,001 – 65,000
☐ $65,001 – 70,000
☐ $70,001 – 75,000
☐ $75,000 – 80,000
☐ $80,001 – 85,000
☐ $85,001 – 90,000
☐ $90,000 – 95,000
☐ $95,001 – 100,000
☐ $100,001 – 105,000
☐ $105,001 – 110,000
☐ $110,001 – 115,000
☐ $115,001 – 120,000
☐ $120,001 – 125, 000
☐ $125,001 – 130,000
☐ $130,001 – 135,000
☐ $135,001 – 140,000
☐ $140,001 – 145,000
☐ $145,001 – 150,000
☐ $150,001 – 155,000
☐ $155,001 – 160,000
☐ $160,001 – 165,000
☐ $165,001 – 170,000
☐ $170,001 – 175,000
☐ $175,001 – 180,000
☐ $180,001 - 185,000
☐ $185,001 - 190,000
☐ $190,001 - 195,000
☐ $195,001 - 200,000
☐ $200,000+

15. WAIVERS & RELEASES
Data Collection
☐ Yes ☐ No I give my permission to the Boys & Girls Clubs of Appalachia (BGCAPP) 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, BGCAPP, funders, and other
community stakeholders to evidence program effectiveness and/or Club impact on our
members. This release may be revolved at any time by contacting the BGCAPP in writing.
Medical
☐ Yes ☐ No I give permission to the BGCAPP to seek emergency medical treatment for my minor child
if I cannot be reached. I will be responsible for any/all costs of medical attention and
treatment.
Technology
☐ Yes ☐ No As a member of the Boys & Girls Club, our child may have access to the internet. While
the Boys & Girls Club has rules prohibiting such conduct and precautions are taken by the
Club to prevent such access, it is possibly your child may access inappropriate sites. The
Boys & Girls Club will not be responsible for such unauthorized access.
Transportation
☐ Yes ☐ No Parents and Club members may be responsible for their own transportation to and from
the Club, unless otherwise specified.
Data Sharing
☐ Yes ☐ No I give my permission to the Boys & Girls Clubs of Appalachia to share information about
the minor child listed on this application with Boys & Girls Clubs of America for research
purposes and/or to evaluate the program’s effectiveness. Information that will be disclosed
to Boys & Girls Clubs of America 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 Clubs of Appalachia, including
data collected via surveys or questionnaires. All information provided to Boys & Girls
Clubs of America will be kept confidential. This release may be revoked at any time by
contacting the Boys & Girls Clubs of Appalachia in writing.
Press / Media
☐ Yes ☐ No I give my permission for my child’s picture, video image, or any other graphic depiction or
likeness, to be used by Boys & Girls Clubs of Appalachia, Boys & Girls Clubs of America
and its affiliates or donors and acknowledge neither my child nor I will receive payment for
same.
Miscellaneous
☐ Yes ☐ No I understand that the Boys & Girls Club is not responsible for lost or stolen items. Each
Club has the right to make membership decisions based on the resources and capacity of
their facility and staff. Boys & Girls Clubs of Appalachia reserves the right to decline the
application, rescind the enrollment of, or suspend any youth that cannot successfully
associate with other club members.

16. APPLICATION APPROVAL
I understand the Boys & Girls Clubs of Appalachia has an open door policy where members are
allowed to come and go as they please. Should a member leave the Club, they will not be granted
return access unless approved by the Club Director. We assume no responsibility for members
who choose not to attend on a particular day or who choose to leave early.
I, the parent/guardian of the minor child listed on this application, on behalf of the minor child listed
herein and for ourselves, our heirs, executors and administrators, hereby release, waive, acquit
and forever discharge the Boys & Girls Clubs of Appalachia (BGCAPP) and Boys & Girls Clubs of
America (BGCAPP), their representatives, successors, insurers, assigns or any other person or
entity associated with any of the above organizations such as staff, directors or volunteers, from all
liability, claims, demands, or causes of action for any and all loss, damage, injury or death and any
claim of damages resulting from use of facilities owned or controlled by the above organizations, or
participation in activities of said organizations either at or away from the Club.
Your signature below confirms that all information above is true and accurate.
Parent/Guardian Signature Date