Page 1 of 3 2024-2025 MEMBERSHIP APPLICATION Expires August 31, 2025 Please mark “NA” for any field that is not applicable to your situation. Child / Youth INFORMATION First Name: Last Name: Preferred Name / Nickname: Gender: Date of Birth: Month: Day: Year: Age: School Attending: Grade: Alberta Health Care #: Who do you authorize to pick up your child from BGC Camrose programs and activities? Optional for ages 12+ Allergies / Dietary Considerations Medical / Physical Conditions or Disabilities and Support Requirements or Suggestions Emotional / Developmental / Behavioural Considerations and Support Requirements or Suggestions Family dynamics that may impact how we serve/support your child (i.e. shared custody, alternating living arrangement, no contact orders, etc.). S upporting documents may be requested/required. Do any of the following apply to your child? Disability English as a second language Foster Care New Canadian (5 years or less) Indigenous Low Income Homeless Lifejacket Use: Does your child require a lifejacket under any circumstances when swimming? Please describe.
Page 2 of 3 Please mark “NA” for any field that is not applicable to your situation. Parent / Guardian INFORMATION First Name: Last Name: Relation to Child: Cell #: Text Capable: Able to receive photos via text: Other contact #’s (i.e. work): Email: Address: City: Postal Code: Does the child live with this person? First Name: Last Name: Relation to Child: Cell #: Text Capable: Able to receive photos via text: Other contact #’s (i.e. work): Email: Address: City: Postal Code: Does the child live with this person? EMERGENCY CONTACT INFORMATION Who should we contact in the case of an emergency if we are unable to reach either parent/guardian listed above? First Name: Last Name: Contact Number: Text Capable: Other contact #’s (i.e. landline, work, etc.): MEMBERSHIP Information The following information is available to you on our website. www.camroseboysandgirlsclub.ca About Us Mission, Vision, Core Values Programs Purpose, Programs, Schedules Membership Overview, Code of Conduct Fees and Payments Policies, Procedures, Protocols Contact Us Location, Contact Information Office Hours 10:00 AM–3:00 PM, Monday-Thursday, September-June (closed on BRSD closures). Confidentiality BGC Camrose is committed to protecting the privacy and confidentiality of individuals who access our supports and services. All BGC Camrose staff and volunteer have sworn an oath to uphold this commitment. BGC Camrose staff and volunteers, will not disclose any personal or sensitive information to any third party without parent/guardian consent, unless legally obligated to do so. See Privacy Policy. Sunscreen & Insect Repellent Protocol If conditions could result in sunburn, children are required to wear sunscreen to participate unless special accommodation has been documented and agreed to by the parent/guardian and the BGC Camrose Program Director. The parent/guardian is expected to send sunscreen and insect repellent labeled for their child’s use when conditions for outdoor activities necessitate. If either are in a lotion form, staff will support application through verbal instruction. BGC Camrose will have sunscreen (minimum SPF 30) and insect repellent (both child friendly and spray form) available for participant use if the participant’s supply is not available (i.e. runs out, lost, forgotten). Please describe any Special Accommodation requests you have or mark NA if none. Use of Photo/Video Images BGC Camrose may use photo or video images of member’s participating in program activities for advertising or promotional purposes (i.e. media, website, brochures, BGC Camrose Facebook page). BGC Camrose will accommodate special circumstances that would limit or prohibit the use of photo images. Please describe any special circumstances or mark NA if none.
Page 3 of 3 MEMBERSHIP AGREEMENT I agree to participate in open productive communication with BGC Camrose, including: updating BGC Camrose, in a timely manner, of changes to the information I provided in this Member Application; communicating any concerns, as soon as possible, regarding my child’s participation in any BGC Camrose program or activity; and notifying BGC Camrose as soon as possible if I choose to withdraw my child from a program. I agree to notify BGC Camrose if I will be late picking up my child from the program. I understand that I may be billed for staff wages if late pick up becomes a recurring matter. I am aware that, if I am late picking up my child, and BGC Camrose is unable to reach a guardian or the emergency contact person, Child and Family Services will be contacted. I agree to take financial responsibility for any damages to BGC Camrose property caused by my child. I am aware that BGC Camrose will make every reasonable effort to safeguard my child's belongings, and understand that BGC Camrose is not responsible for lost, stolen, or damaged items belonging to my child. I am aware that BGC Camrose staff will supervise program activities and will take every reasonable precaution to ensure my child’s safety (i.e. first aid kit, cell phone, emergency contact numbers, appropriate supports and supervision, ongoing environmental risk assessments and adaptations, and adhere to relevant Alberta Health Services Guidelines). I am aware and acknowledge that participation in indoor and outdoor recreational, leisure, and sport activities, in person interactions with other people, and transportation via motor vehicle (i.e. BGC Camrose bus) in general involves inherent risks which expose participants to the possibility of injury that include, but are not limited to: transmissible contagions, skin abrasions, skin, nerve, bone, muscle, eye, spinal cord, skull and neck damage, pain, paralysis, brain injuries or even death. I understand, acknowledge and agree that choosing to permit my child to participate in BGC Camrose programs and activities brings with it the assumption of the risks outlined and I assume full responsibility to instruct my child about the risks and choices available to him/her relative to those risks. In addition, I understand that I am free to withdraw my child from any program at any time. I understand, agree and acknowledge that BGC Camrose and its staff cannot give consent for emergency medical treatment. I authorize the application of emergency medical treatment and undertake to be responsible for any hospitalization, medical and ambulance or other expenses incurred for my child. I understand that I will be informed of treatment as soon as possible and my permission will be sought for any follow up or additional treatment. I declare that I have read, understood, and agree to the contents of this Membership Application in its entirety, and relieve BGC Camrose, its employees and volunteers of any and all responsibility for injury, accident, or loss to my child during or by reason of participating in a BGC Camrose program or activity. I (parent/guardian name) give permission for my child (child’s name) to become a BGC Camrose Member and to participate in BGC Camrose programs and activities. Please identify the Program/s you would like your child to participate in (Programs section on our website). Membership Status: Member ID: BGC Camrose Representative:
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