Important: Additional children in the same age category (Youth or Teen) can be added using the same application. If you have both a Youth and a Teen they must be submitted on separate applications.
(Based on 2021-22 School Year grades)
Member Information
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School Information
Medical Information
Child 2 - Member Information
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Child 2 - School Information
Child 2 - Medical Information
Child 3 - Member Information
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Child 3 - School Information
Child 3 - Medical Information
Child 4 - Member Information
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Child 4 - School Information
Child 4 - Medical Information
Parent/Guardian Information
All parents/guardians listed are allowed to pick-up the child(ren) named above unless access is prohibited or restricted by a court order (provided to Club).
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Other Parent/Guardian (optional)
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Military Involvement
Emergency Contact/Authorized Pick Up
These individuals must be people other than the parent/guardian who also has authorized pick up permission
You can choose to require that your child only be allowed to leave the Club under the supervision of individuals you have authorized by selecting ‘yes’ to the authorized pick up option. Only contacts listed on this application or the Authorized Pick Up form, will be allowed to pick up your child from the Club. These contacts will be verified at time of pick up. Or you may choose to allow your child to walk home from the summer program. Specific communications from a parent/guardian will be required for Club staff to release your child to walk home should you select this option. These requirements will be communicated by the Unit Director.
Youth Only: Summer Program Attendance
Summer Program Drop Off / Pick Up Times:
- - Morning drop off between 7:30-9:30am
- - Mid-day drop off/pick up between 11:45am-12:45pm
- - Afternoon pick up between 3:00-5:30pm
If you are applying for multiple children and attendance answers are different for each child, please explain here.
Youth Only: Summer Program Fee Assistance
Financial assistance is available based on 2021-22 School Year eligibility for Free/Reduced lunch.
| Cost per Child | Cost per Family (max) |
| Standard Rate | $200 | $540 |
| Discounted Rate | $100 | $240 |
| Special Circumstances* | Based on ability to pay |
| Summer Program Fee waived for youth under the age of 7 years old. |
Provide important information regarding any sudden income loss or financial hardship.
Policy and Waiver Information
PLEASE READ CAREFULLY
OPEN DOOR POLICY:
I understand the Boys & Girls Clubs of Sheboygan County has an “open door policy”. It is my responsibility as the parent/guardian to instruct my child as to whether or not he/she may leave the Club.
SUMMER ORIENTATION:
I understand I am REQUIRED to complete the summer orientation BEFORE my child(ren) can attend the summer program. I understand it is my responsibility to complete all required steps of orientation. I understand that I will be responsible for following additional requirements for summer program, listed in the Summer 2022 Program Handbook, which will be reviewed at orientation.
SUMMER PROGRAM COMMUNICATIONS:
The Boys & Girls Clubs of Sheboygan County uses the Remind app to communicate important messages about summer program. I agree to receive these text message/email notifications.
MEDICAL EMERGENCY:
In the event of an emergency, I understand that every attempt will be made to contact me. If I cannot be reached, I hereby give my permission to the physician selected by the Boys & Girls Club staff to secure proper treatment for my child.
Liability:
I understand that the Boys & Girls Clubs of Sheboygan County is not responsible or liable in any way in the event of harm or injury occurring to my child. It is agreed that I will hold the Boys & Girls Clubs of Sheboygan County harmless for the actions of my children or the action of other children that result in the harm of others or damage to property, including activities outside of the Club.
PHOTOS/VIDEOS:
I give consent for photographs, videos, artwork and/or like materials, in which my child may appear, to be used in any promotional materials the Boys & Girls Club may care to use them. I understand it is my responsibility to inform the director, in writing, if my child cannot be in photographs, videos, artwork, and/or like materials.
LATE PICK-UP POLICY:
I understand my child cannot be left at the Boys & Girls Club earlier than the Club’s established hours of operation and my child must leave the Club’s property or be picked up at or before closing time. I understand that I will be charged a fee for late pick up. I understand that if my child(ren) remains at the Club and the Club does not receive any communication within 30 minutes after closing, the police will be contacted.
TRAVEL:
I authorize my child to participate in walking field trips, under proper staff supervision, within the local city limits. No additional permission slips will be required for walking trips.
PROGRAM PARTICIPATION:
I understand that my child will be participating in activities scheduled for his/her group and that participation is required. I understand my child’s participation is based on his/her ability to follow expectations of the Club and to respect staff, property and other Club members. Membership may be suspended or terminated at any time for misbehavior without a refund of fees.
DATA COLLECTION & SHARING:
I give permission to the Boys & Girls Clubs of Sheboygan County to use this membership information provided, as well as information obtained via surveys and questionnaires, to compile aggregate results that may be shared with Club staff, Boys & Girls Clubs of America, funders, school districts and other community stakeholders to assess and communicate program effectiveness and Club impact. I understand that my child’s responses will remain confidential. Included in, but not limited to these surveys are: NYOI survey, individual program surveys (SMART Moves, SMART Girls, Passport to Manhood, etc.)
SCHOOL INFORMATION:
I give permission to the Boys & Girls Clubs of Sheboygan County and the member’s school district to exchange information regarding the minor child listed on this application.
TECHNOLOGY:
As a member of the Boys & Girls Club, your child will have access to the internet and electronic devices designed for educational and enrichment programming. Precautions have been taken to maintain a safe electronic presence here at the Club, however it is impossible for the Boys & Girls Club to restrict access to all controversial materials. I will not hold the Boys & Girls Club responsible for unintentional exposure to such material while on the internet. I understand that my child is expected to follow all technology expectations of the Club, as listed in the parent handbook. I accept full responsibility for all intentional harm caused by my child to computer resources of the Boys & Girls Clubs of Sheboygan County or any other affected parties.
ASSUMPTION OF THE RISK AND WAIVER OF LIABILITY RELATING TO CORONAVIRUS/COVID-19:
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.
Boys & Girls Clubs of Sheboygan County has put in place preventative measures to reduce the spread of COVID-19; however, the Club cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending the Club could increase your risk and your child(ren)’s risk of contracting COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending the Club and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Club may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Club employees, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the Club or participation in Club programming. On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless the Club, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Club, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Club program.
I HEREBY CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION.
I hereby certify that all above information is true, accurate and complete to the best of my knowledge. I am also aware that it is my responsibility to notify the Boys & Girls Clubs of Sheboygan County of any change of information.
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This field is for validation purposes and should be left unchanged.
