Enroll Now | Atchison After School Club

1

Member Information

First Name *

Middle Name

Last Name *

Age *

Birth Date *

T-Shirt Size

Gender *

Nationality *

What sessions do you plan on attending? *

Before School

After School

Summer Camp

Winter Camp

Do you receive assistance from Atchison Housing Authority? *

Do you live in public housing? *

Street Address *

Address Line 2

City *

State *

Zip Code *

How long in Atchison area? *

2

Parent/Guardian Information

First Name *

Last Name *

Cell Phone *

Home Phone

Email *

3

Emergency Contacts

Emergency Contact #1

Full Name *

Phone Number *

Emergency Contact #2

Full Name *

Phone Number *

4

School Information

Name of School *

Grade *

5

Family Information

Child lives with *

Relationship to child *

Does this person have legal custody/guardianship? *

If no, who is the legal guardian?

Mother's Information

Mother's Name

Phone Number

Employer

Work Phone

Father's Information

Father's Name

Phone Number

Employer

Work Phone

Number of Brothers/Step Brothers

Number of Sisters/Step Sisters

6

Medical Information

Doctor's Name

Doctor's Phone Number

Does your family have health/accident insurance?

Insurance Provider

Group Number

Please indicate any medical issues *

Please indicate any medications presently taking *

Does your child have any allergies (including food allergies)? *

7

General Information

My child has permission to use the internet during scheduled computer lab time *

Yes

No

Has your child ever been a member of a Boys and Girls Club in the past? *

Yes

No

8

Confidential Information

We are required to provide statistical information to our national office for continued funding. All identifying information is removed when statistics are reported. The answers you provide are confidential.

Household Income *

Number of people in household *

Please select any assistance you receive *

SNAP/Food Stamps

TANF

Medicaid

WIC

Free/Reduced Lunch

None

Child's family setting *

9

Policies and Permissions

Please read all policies below carefully before signing.

Open Door Policy, Club Access

I (we) hereby give permission for my child to take part in the programs at the Atchison After School Club. I understand that the Club will make every effort to keep my child from leaving the club building without permission; however, I also understand that the Club is a voluntary club and not a daycare center. I understand that the club is not responsible for the time or manner in which my child may arrive or leave the club. If at anytime my child demonstrates that they do not want to be a part of the club program, I understand that I will be contacted and will then be responsible for making other arrangements.

Medical Treatment

I (we) permit and authorize the Atchison After School Club to allow necessary examination, anesthetic, medical diagnosis, surgery or treatment and/or hospital care to be rendered to the named physician or surgeon licensed to practice medicine. I understand that care for injuries that may occur during my child's active participation in Club programs are the responsibility of myself, my family, and/or my insurance. I understand that the Club does not supply insurance for my child.

Sick or Injured Children

Sick children will be sent home from the club due to any illness that keeps them from fully participating in the program. After notification, parents must pick up child within one (1) hour.

Emergency Procedures:

Parent will be contacted with the condition of the child.
Club staff will recommend whether a child is to be picked up.
Following an injury, an accident report will be written and kept on file. Parents will be provided with a copy as well.
In extreme emergency situations, an ambulance will be dispatched. Parents will be notified.

Field Trips

Field trips, when available, are one of the most exciting parts of the program. They are opportunities for vivid and memorable learning experiences. Children are eligible for field trips based upon behavior and participation.

Acceptable Use Policy

The Atchison After School Club adopts this policy to maintain a safe and secure environment for members, staff, volunteers and others. Members are expected to act responsibly and thoughtfully when using technology resources. Personally owned devices are to be put away in a secure location during Club time. The Club expressly prohibits the use of personally owned devices in locker rooms, restrooms and other areas where there is an expectation of privacy.

Any inappropriate use of a personally owned device can lead to disciplinary action including confiscation of the device, immediate suspension from the Club, termination of membership, or referral to local law enforcement.

Grievance Policy

Parents or children who have a grievance against AASC that they're not comfortable discussing with the program director can submit their complaint to the Chief Executive Officer at 913-367-3233.

Parent/Guardian Signature *

By signing below, you agree to all policies and permissions stated above.

Youth Signature *

By signing below, you agree to follow all Club rules and policies.

10

Health & Safety Acknowledgment

The Atchison After School Club has put in place preventative measures to maintain a safe environment. However, the Club cannot guarantee that you or your child(ren) will not become ill.

By signing this agreement, I acknowledge and voluntarily assume the risk that my child(ren) and I may be exposed to illness by attending the Club. I understand that the risk 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, illness, damage, loss, claim, liability, or expense of any kind that may occur in connection with my child(ren)'s attendance at the Club.

Parent/Guardian Signature *