MEMBERSHIP APPLICATION 2024-2025.pdf
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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.
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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.
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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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