I, the parent/guardian of the minor child listed on this application, for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever discharge Boys & Girls Clubs of Collin County, and Boys & Girls Clubs of America, 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.
Medical Treatment
I give permission to Boys & Girls Clubs of Collin County (BGCCC) to administer first aid to my child in the event of an injury. I give permission to BGCCC to seek emergency medical treatment from the nearest emergency facility for my minor child if I cannot be reached. I will be responsible for any and all costs of medical attention and treatment. I understand that it is my responsibility to keep all of my contact information current with BGCCC at all times.
Allergies and Medical Conditions
I give BGCCC permission to provide snacks and meals to my minor child. I understand that it is my responsibility to notify the Club in writing of my child’s food allergies, other allergies and/or medical conditions. I release, waive, acquit and forever discharge Boys & Girls Clubs of Collin County, and Boys & Girls Clubs of America, 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 the preparation or provision of any food or drink items for my child.
School Information
I give my permission to Boys & Girls Clubs of Collin County and my child’s school district to exchange information regarding the minor child listed on this application. The purpose of the exchange is to help both organizations do a better job of helping the student be successful in school, the Club, and in life. This release is valid for one year and may be revoked at any time by contacting the school district or BGCCC in writing.
Surveys and Questionnaires
I, the parent/guardian of the minor child listed on this application, give permission for Boys & Girls Clubs of Collin County to survey my child about his or her Club experience and behaviors, skills and attitudes using Boys & Girls Clubs of America’s Youth Development Outcome Measurement Tool Kit surveys or other survey instruments.
Technology
As a member of the Boys & Girls Clubs of Collin County, your child will have access to the Internet. While precautions are being taken, it is possible that s/he may access inappropriate sites. BGCCC will have rules and consequences at the Club for such behavior; however we will not be responsible for the consequences of such access.
Photo/Media Release
I give permission for my child’s picture, moving pictures, or any other graphic depiction or likeness, as well as their first name and age, to be used by the Boys & Girls Clubs of Collin County for programs, activities, public relations, marketing, fundraising or other purposes.
Transportation
I grant permission to Boys & Girls Clubs of Collin County to transport my child in a BGCCC vehicle. I, the parent/guardian of the minor child listed on this application, for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever discharge Boys & Girls Clubs of Collin County, 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 transportation owned or controlled by the above organizations.
Financial Eligibility Verification
I grant permission to BGCCC to verify my personal records including wages. It is understood that this authorization is granted for the sole purpose of certifying my eligibility for government assistance, financial aid and that all information acquired in this regard will remain confidential.
Miscellaneous
I understand that Boys & Girls Clubs of Collin County is not responsible for lost or stolen items. I understand that, as a drop-in facility, Boys & Girls Clubs of Collin County is not and does not claim to be a licensed day care center.
Non-Discrimination Policy
In accordance with Federal law, and U.S. Department of Agriculture and Texas Health and Human Services policy, Boys & Girls Clubs of Collin County does not discriminate on the basis of race, color, sex, age, gender, disability, religion, political belief, national origin, or any other protected status.
I have read the completed the BGCCC application and this form, understanding the rules of Boys & Girls Clubs of Collin County. I agree to the above specifications and releases, and I voluntarily request that my child be admitted into BGCCC membership.
