BGCYN After School Program

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Located at the Yakama Nation Community Center

2:30-6:30 Monday-Friday

Fees vary, various scholarship opportunities available

Transportation for Yakama Nation Tribal School & Toppenish School District students provided to the club after school. No transportation provided home.

Email *

Record my email address with my response

Participant First and Last Name *

Participant's Nickname (if applicable)

Gender *

Male

Female

Other:

Required

Birthdate *

YYYY

Age *

Grade *

Please list any allergies/medical conditions below. *

School Attending *

Toppenish High School

Toppenish Middle School;

Kirkwood Elementary School

Lincoln Elementary School

Garfield Elementary School

Valleyview Elementary School

Other:

If attending from another school district other than Toppenish, please list the district and school

Will club member ride the bus from school to BGCYN?

(Bus only available for Toppenish School District and YNTS)

Yes

Ethnicity *

African American

Native American

Native Hawaiian

Asian

White

Other:

Required

Tribal Affiliation (if applicable)

Club member agrees *

To follow all club rules regarding safety, harassment, bullying to ensure a safe, inclusive environment for all club members

To follow all rules and regulations regarding technology, both club appointed technology, as well as any personal technology that I have with me

To be respectful of the club, club materials, club members, etc.

To abstain from using or possessing any drugs, alcohol, or illegal substances

To be encouraging and positive of other club members

Required

List any other members in your household attending BGYCN after school program. If none, write n/a *

Do you or anyone in your household utilize these services? *

Amerigroup

UnitedHealthcare

Coordinated Care

Molina

Community Health Plan (ages 6-18)

Other:

Primary Contact Name *

Relationship *

Emergency Phone *

Secondary Contact Name *

Secondary Contact Relationship to Member *

Secondary Contact Phone Number *

Names of individuals with permission to pick up member *

Names of individuals that are NOT to pick up member *

I, the parent/guardian of the minor child listed on this application, for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever discharge the Boys & Girls Club of Yakama Nation and Boys & Girls Clubs of America, their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organizations such as staff, directors or volunteers, from all liability, claims, demands, or causes of action for any and all loss, damage, injury or death and any claim of damages resulting from use of facilities owned or controlled by the above organizations, or participation in activities of said organizations either at or away from the Club.

Medical Treatment: I give permission to the Boys & Girls Club of Yakama Nation to seek emergency medical treatment for my minor child if I cannot be reached. I will be responsible for any/all costs of medical attention and treatment.

Data Collection: I give my permission to the Boys & Girls Club of Yakama Nation 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.

School Information: I give my permission to the Boys & Girls Club of Yakama Nation and my child’s school district to exchange information regarding the minor child listed on this application. The purpose of the exchange is to help both organizations do a better job of helping the student be successful in school, in the Boys & Girls Club and in life. This release is valid for one year and may be revoked at any time by contacting the school district or the Boys & Girls Club in writing.

Data Sharing: I understand that the Boys & Girls Club of Yakama Nation 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 Yakama Nation, including data collected via surveys or questionnaires. All information provided to BGCA will be kept confidential.

Misc.:I understand The Boys & Girls Club is not responsible for lost or stolen items. Parents and Club members are responsible for their own transportation to and from the Club.

Misc.I give permission for my child’s picture, moving pictures, or any other graphic depiction or likeness, to be used by the Boys & Girls Club and its activities. I understand my child may be pictured in the paper and on social media sites like Facebook, bgca.net, etc. I also understand the Club is not, nor does it claim to be, a licensed day care center. I have read the completed application and this form, understand the rules of the Boys & Girls Club and request my child be admitted into membership.

Misc.I give my permission to the Boys & Girls Club of Yakama Nation to 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 Yakama Nation, including data collected via surveys or questionnaires. All information provided to BGCA will be kept confidential.

Required

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