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Membership Application Form

Make sure you have filled out the Summer Camp 2020 registration form BEFORE continuing with this page. You should have received notice of a timeline (a start date of June 15 or June 29). If you have not, you cannot continue with this page.

Note that the summer membership cost, depending on your start date, is a non-refundable $50-$70. Our annual school-year membership is still $25.

Choose a Club by using the DROP-DOWN MENU by clicking the down arrow icon to open more options.
Click the date in the pop-up calendar. Make sure the month and year are correct!
Type the age by number only. Example: "8".
Please, use the DROP-DOWN MENU by clicking the down arrow icon to open more options.
Please, use the DROP-DOWN MENU by clicking the down arrow icon to open more options.
XXX-XXX-XXXX format.
Please, use the DROP-DOWN MENU by clicking the down arrow icon to open more options.
Specify the name with Elementary, Middle/Intermediate, or High School. Example: "Blue Doors Middle School".
Example: "Indianapolis Public Schools (IPS)".
Name of primary parent/guardian.
Example: "Mother".
Type "NONE" if this does not apply.
To contact at work, if necessary. XXX-XXX-XXXX format.
XXX-XXX-XXXX format.
If it is the same as "Home Phone Number", type it again. XXX-XXX-XXXX format.
In case of an emergency, this person will be contacted first of all parents/guardians.
Relationship of Emergency Contact to child/Member. Example: "Grandmother".
Work phone number of Emergency Contact. If it is the same as before, please type it again. XXX-XXX-XXXX format.
Home phone number of Emergency Contact. If it is the same as before, please type it again. XXX-XXX-XXXX format.
Cell phone number of Emergency Contact. If it is the same as before, please type it again. XXX-XXX-XXXX format.
Please, use the DROP-DOWN MENU by clicking the down arrow icon to open more options.

CONFIDENTIAL

The following information is REQUIRED for the Club to obtain funding as a Non-profit Agency. Names are never used and the information is completely confidential. Your cooperation in providing this information is both appreciated and necessary.
Type the amount by number only. Example: "5".
Click your total annual household income.
Type their name; leave blank if it doesn't apply.

HEALTH HISTORY AND PERMISSION FORM

Type "NONE" if this does not apply.
Name of your child's doctor.
Phone number of your child's doctor. XXX-XXX-XXXX format.

PARENTAL PERMISSION AND RELEASE AND INDEMNITY AGREEMENT

I hereby give permission for my child, named above, to join the Boys & Girls Clubs of Indianapolis (“The Club”) and permission for my child to participate in the Clubs’ programs, activities, field trips and to visit and use the Clubs’ facilities and to be photographed and/or videographed. It is understood that Club programs and activities may include Internet access, surveys, interviews, and focus group discussions.


Any and all information received will be kept strictly confidential. The data will be summarized in the aggregate and will exclude all references to any individual responses. The aggregated results of these analyses may be shared with Club staff, Boys & Girls Clubs of America (BGCA), funders, and other community stakeholders to evidence program effectiveness and/or Club impact on our members. I give further permission for the Club to share information about my child with BGCA and United Way of Central Indiana (UWCI), including the information on this application form, the information provided by the child’s school and/or school district, and other information collected by the Club, including data collected via surveys or questions. The information shared with BGCA or UWCI will be used for research purposes and/or to evaluate program effectiveness. All information provided to BGCA and/or UWCI will be kept confidential.


I am the natural parent or legal guardian having custody of the said child. In consideration of my child being accepted for membership and participation in the Club and activities, I hereby voluntarily release and agree to hold harmless and indemnify the Boys & Girls Clubs of Indianapolis and each of its directors, officers, employees, volunteers, and agents from and against any and all liability, claims, demands, actions, damages, expenses, and costs, including attorney’s fees, losses and judgments of whatsoever kind and nature which may result from or arise out of my child’s membership in the Clubs, participation in the Clubs’ programs, activities and field trips and the Clubs’ facilities, whether or not resulting in whole or in part from negligence, acts or omissions of the Boys & Girls Clubs of Indianapolis or its directors, officers, employees, volunteers, or agents, or of said child.


The Health History and Permission Form is correct so far as I know, and the person herein described has permission to engage in all Club activities except as noted. Authorization for Treatment: I hereby give permission to the Club Director to order x-rays, routine tests, treatment, to release any records necessary for insurance purposes, and to provide or arrange necessary related transportation for my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician or nurse selected by the Club director to secure and administer treatment, including hospitalization, for the youth listed above. I do hereby agree to hold free from any and all liability all respective officers, employees, and members. I hereby on behalf of my child(ren) waive, release, and forever discharge any and all rights and claims for damages which my child(ren) may have or may not have accrued arising out of or connected with my child(ren) in any of the activities of the Club.

Click and drag with the mouse to sign. If you have a touchscreen device, simply sign with your finger or stylus.
Click the date in the pop-up calendar. Make sure it is today's date!

RELEASE OF ACADEMIC (SCHOOL) INFORMATION

I give permission to the Boys & Girls Clubs of Indianapolis (“The Club”) and the school named below (and the associated school district) to exchange information regarding my child for the purpose of helping both organizations to do a better job of helping my child be successful in school, in the Club, and in life. I specifically give permission to my child’s school to release to the Club the following data covered by the Family Educational Rights and Privacy Act (FERPA): ILEARN scores, benchmark & summative assessment scores, midyear & final course grades, high school credit accumulation, grade point average, school attendance records, behavioral records (including suspensions/expulsions), my child’s state testing number, and whether my child was promoted to the next grade level. I also give permission for my child’s teachers at said school to share information with the Club about my child’s academic progress and to complete a survey about my child’s academic and behavioral performance.
Click and drag with the mouse to sign. If you have a touchscreen device, simply sign with your finger or stylus.
Click the date in the pop-up calendar. Make sure it is today's date!

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 Indianapolis 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 (“Claims”). 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.


This includes and is not limited to a waiver of all claims for any and all of the following: Boys & Girls Clubs of Indianapolis, Inc. disclosure of HIPAA information, Boys & Girls Clubs of Indianapolis, Inc. safety protocols relating to ensuring the health and safety of its staff and child participants, other notification measures, the right to privacy, the right to confidential communications, and any and all other potential claims arising under what is commonly known as HIPAA and any/all related statutes both state and federal.   I understand that it is my duty to report any symptoms, exposure or positive diagnosis of COVID-19 to my Club Director and I understand that shared information will be made available to the Marion County Health Department, State Board of Health, and any and all individuals that my child(ren) may have come into contact with through the Boys & Girls Clubs of Indianapolis.

If you are on a phone or touch-capable device, use your finger or stylus to sign. If you are on a computer without touch capabilities, use the mouse,
Click the date in the pop-up calendar. Make sure it is today's date!

LIABILITY AND SUBMISSION

After you hit “Submit” above and see the completion notice, pay below!

PAY FOR SUMMER MEMBERSHIP NOW!

Hitting the “Donate” button below will take you to a secure page to either pay for your 7-week (starts June 15th) or 5-week (starts June 29th) summer membership. Please ignore the “Other” option and only select your approved summer timeline.