Membership Form

Participant Information

MMS After school Programs

East Providence Boys and Girls Club 2022-2023 School Year

Dear Parent/Guardian:

Some of our programs will be using virtual elements. Boys & Girls Clubs of East Providence will use software, tools and applications provided by third parties that members, parents/guardians and/or staff will access via the Internet and use for purposes of communication and programming. These platforms include: Google Classroom and Google Meet.

This letter seeks consent for your child to utilize Google Classroom and Google Meet for distance-based, virtual Club program purposes. Please be aware that each application collects different information about its users and has its own privacy terms and conditions to which members must adhere. Please review these carefully before confirming your child’s participation.

We may use the online applications for the following program activities: Dungeons and Dragons, foreign language instruction and tutoring.

All of our program offerings will be accessible through google classrooms created by our Hennessey and Martin teachers. Therefore, all participants will only be able to access these online activities and meetings using their epschoolsri email address.

Our commitment to keeping the young people we serve safe is always our number one priority. Boys & Girls Clubs of East Providence will actively monitor member activity on Google Meet and will make every effort to protect member information by, among other things, maintaining control of, and access to, the data collected; prohibiting re-disclosure of member information; limiting the purposes for which the online platforms may use member information; ensuring there is no advertising and that no member information is collected for commercial purposes.

Further, all activities online must comply with Boys & Girls Clubs of East Providence’s safety policies, including the Code of Conduct, Acceptable Use Policy, Internet Safety Policy, Prohibition of 1:1 Contact Policy, which are available upon request. All of our one on one virtual lessons will have a Boys and Girls Club staff member present.

Transportation may be needed for some programming including but not limited to field trips and events away from MMS. When available we may also be able to transport students to and from home. These trips will be communicated in advance to parents and guardians.

First Name *

Middle Name

Last Name *

Nickname

Birth Date * +

Gender *

Home Address *

City *

State *

Zip *

Phone *

Email *

Ethnicity

School attending in September 2022 *

Grade in September 2022 *

Household / Contact Information

Primary Emergency Contact Name *

Emergency Phone Number *

Mother/Guardian First Name *

Mother/Guardian Last Name *

Mother's Occupation

Mother's Employer

Mother's Work Phone

Mother's Cell Phone *

Mother's Email

Father/Guardian First Name

Father/Guardian Last Name

Father's Occupation

Father's Employer

Father's Work Phone

Father's Cell Phone

Father's Email

Member Lives With *

Household Size - Please include all adults and children living in the household *

Annual Household Income: This information is kept confidential and is used to help us secure funding through Boys & Girls Clubs of America and other funders *

Is anyone in the household a member of the military or National Guard *

Yes

No

Does you child receive free or reduced lunch at school *

Yes

No

Health Information

Medical Problems/Allergies *

List ALL medications the child is taking *

Any restrictions of activity due to medical activity, if yes explain *

No

Yes Yes

Physician

Physician's Phone Number

Health Insurance Provider

Subscriber#

I would prefer that my child be taken to ________________Hospital. (Choice may be limited by local rescue service.) *

This health information is correct to the best of my knowledge and the person herein described has permission to engage in all prescribed activities, except as noted by me and the physician. I authorize the Boys & Girls Club of East Providence to arrange for medical examination and/or treatment of my child should an emergency arise in any Boys & Girls Club program. It is understood that every effort will be made to contact the emergency numbers provided before any medical action is taken. *

I agree

Individuals other than parents/guardians who are authorized to pick up child. Please include their phone number. Reminder anyone picking up should have their photo ID for staff to confirm their identity.

	First Name	Last Name	Phone Number	Emergency contact(Y/N)
Contact	First Name	Last Name	Phone Number	Emergency contact(Y/N)
Contact	First Name	Last Name	Phone Number	Emergency contact(Y/N)
Contact	First Name	Last Name	Phone Number	Emergency contact(Y/N)
Contact	First Name	Last Name	Phone Number	Emergency contact(Y/N)
Contact	First Name	Last Name	Phone Number	Emergency contact(Y/N)
Contact	First Name	Last Name	Phone Number	Emergency contact(Y/N)
Contact	First Name	Last Name	Phone Number	Emergency contact(Y/N)
Contact	First Name	Last Name	Phone Number	Emergency contact(Y/N)

Acknowledgements

I have read the completed application, understand the rules of the Boys & Girls Clubs and request that my son/daughter be admitted into membership. I have explained the rules to my son/daughter and agree that the Boys & Girls Club will not be responsible for any accident to the boy/girl while on the Club premises or while engaged in any of its activities away from the Club. I give my consent for photographs, in which my son/daughter may appear, to be used in any way by the Boys & Girls Club or its partners. The Boys and Girls Club reserves the right to revoke membership at any time. *

I agree