Where

Geyserville Club on the Geyserville Elem. Campus

21485 Geyserville Ave
Geyserville, CA 95441

Event Address Map
Driving Directions

Contact

Jenny Meeker
Boys & Girls Clubs of Central Sonoma County
707-857-3214
csilva@bgccsc.org

2017-18 Geyserville Club School Year Registration

* Required information

Parent/ Guardian Information

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  • Fee

    Type Fee
    $12.00

Household Information

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    Do you Receive Any of the Following? Check all that apply

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Member Information

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Member Information

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Emergency & Medical Information

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Agreements & Waivers

  • Medical Consent: I hereby give my consent to have my child treated by a physician or surgeon in case of sudden illness or injury while participating in a Boys & Girls Clubs of Central Sonoma County program. It is understood that the cost thereof will be at my expense. To protect the safety of staff and our members and reduce liability, Boys & Girls Clubs of Central Sonoma County staff does not dispense or store medication of any kind for our members.

  • Acknowledgement & Consent: I approve of my child’s application for membership to Boys & Girls Clubs of Central Sonoma County. In consideration for allowing my child to become a member of the Club, I hereby agree that the Club, its’ officers, employees, volunteers, directors, and agents shall not be liable for any injury to my child, or for any loss, injury, or damage to my child’s property, which occurs during my child’s participation in any activities at, or sponsored by the Club. I further agree that my child, my child’s heirs, executor, successors in interest, and legal representatives will not make a claim against, sue, or attach the property of the Club or the Club’s representatives for the injury or damage resulting from negligence or other acts caused in any way whatsoever by the Club or the Club’s representatives.

  • (Acknowledgement & Consent, continued): I hereby release the Club and the Club’s representatives from any and all causes of action and claims that I, my child, my heirs, successors in interest, executors and other legal representatives may have arising from these matters.

  • School Information: I give permission to Boys & Girls Clubs of Central Sonoma County and local schools to exchange information regarding the child listed on this application. The purpose of exchange is to help both organizations do a better job of helping the student be successful in school, at the Club & in life. This information will only be shared within state & federal guidelines.

  • Surveys & Questionnaires: I, the parent or guardian of the minor child listed on this application, give permission for Boys & Girls Clubs of Central Sonoma County to survey my child. Surveys gather information about what has been done in the after school & summer program, attitudes towards it, and behaviors related to learning, safety, positive youth development, and health. The surveys may include questions about physical activity and nutritional habits, alcohol, and other drug use, violence and bullying, and environmental assets. This data will help improve program services and demonstrate effectiveness of after school programs. This includes participation in the National Youth Outcomes Initiatives through Boys & Girls Clubs of America. Copies of surveys may be requested at any time.

  • Media Release: I hereby consent to the use of my/my child’s name, likeness and speech in any audio tape, video tape, film or photograph made in any Club activity for the business or publicity purposes of Boys & Girls Clubs of Central Sonoma County & its partners. I understand that any participation offers no remuneration and that my/my child’s name, likeness and speech may be edited, produced, recorded for duplication and distribution throughout the United States and abroad. I expressly release Boys & Girls Clubs of Central Sonoma County & its partners, its licensees, assignees, affiliates and successors from any privacy, defamation, or other claims having arisen out of broadcast, exhibition, publication, or promotion of this program.

  • Behavior Policy: Boys & Girls Clubs of Central Sonoma County has a discipline policy that gives positive guidance, allows for redirection and sets clear behavior limits. The discipline policy has been designed to assist members in developing self-control, self-respect, respect for others, and consideration for the rights and property of others. Members that do not follow set policies may receive a phone call home, suspension from the program, or they may be dropped from the program.

  • I hereby give my permission to my child to become a member of Boys & Girls Clubs of Central Sonoma County. I understand that the Club is not responsible for the time or manner in which he/she may arrive at or leave the Club. Attendance is contingent upon member's following Clubhouse expectations and exhibiting positive behavior. Clubhouse staff reserves the right to suspend or terminate attendance and/or membership at any time if those guidelines are not followed and I understand that no fees will be returned to me. I understand that I am responsible for attending an orientation with my child before he/she receives his/her full-time membership card.

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    Check each box below to acknowledge your agreement to the above statements & releases to complete your registration.

Optional Supply Donation

Item Qty. Max Limit Price

Optional Program Supply Donation

Your supply donation will go towards purchasing sports equipment, art supplies, and other items needed to run amazing Programs each day.

5 $40.00 each
$9,999.99

Payment

Payment Method

Payment Summary


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