I give this member permission to attend and participate in activities sponsored by the Boys & Girls Clubs of Northeastern Pennsylvania. I hereby release the Club, its employees, associates, and contributors from liability from any injury or loss incurred by this member while participating. Furthermore, I hereby authorize medical examination and emergency treatment for this member by a qualified licensed physician in the event of an accident. I further understand that the Club has an “Open Door” policy, which means that this member may come and go at will. Further, I give permission for this member’s picture to be used in any Club publication. The Club is not responsible or liable in any way in the event of harm or injury occurring to the member. It is agreed that the parent or guardian will not hold the Club responsible for the welfare or whereabouts of the member. If the Parent or Guardian does file a complaint against the Club the Parent or Guardian agrees to pay for the Club legal fees.
I give my permission to the Boys & Girls Club of Northeastern Pennsylvania to collect information via online or written surveys, questionnaires, interviews, and focus groups from the minor child listed on this application. Any and all information received will be kept strictly confidential. Data gathered through these means 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 understand that the Boys & Girls Club of Northeastern Pennsylvania may share information about the minor child listed on this application with Boys & Girls Clubs of America (BGCA) for research purposes and/or to evaluate the program’s effectiveness. Information that will be disclosed to BGCA may include the information provided on this membership application form, information provided by the minor child’s school or school district, and other information collected by Boys & Girls Club of Northeastern Pennsylvania, including data collected via surveys or questionnaires. All information provided to BGCA will be kept confidential.
My signature indicates that I completely understand the above statement.
My signature indicates that I have received a copy of the Club’s Membership Handbook and I will review it with my child/children.