OF THE SANDHILLS
Club Member Consent to Release Information Form
My Child, ___________________________________, is enrolled as a member of the Boys & Girls Clubs of the Sandhills.
In order to assure that he/she receives the full benefit of the program, relevant background information is required. My
permission is hereby granted for the following information to be released to the Boys & Girls Clubs of the Sandhills for the
2014-2015 academic school year:
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Name
Legal Status
Report Card
Attendance Record
Discipline Referrals
Test Scores
Reading Level
It is understood that this information is being used in grant reporting to assure continued funding for the Club programming,
to evaluate the Club programs and ensure its effectiveness, as well as to record my child’s academic progression
throughout the school year. This information will be the property of the Boys & Girls Clubs of the Sandhills and will be
confidentially preserved for a minimum of 5 years. I (we) reserve the right to have access to this data upon written request.
Please select appropriate program location:
o Southern Pines Club
o Aberdeen Club
Please select appropriate school:
o Southern Pines Primary
o Southern Pines Elementary
o Aberdeen Primary
o Aberdeen Elementary
o Southern Middle
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Pinecrest
The Academy of Moore
Sandhills Farmlife
Sandhills Theater Arts Renaissance School
Club Member National Program Participation Consent
I understand the priority that the Boys & Girls Clubs of the Sandhills places on academic success, good character and
citizenship, and healthy lifestyles and therefore, support my child’s participation in the Club’s National Programs, such as:
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Project Learn
Power Hour
SMART Moves
Triple Play
Career Launch
Money Matters
SMART Girls
Passport to Manhood
Healthy Habits
Goals for Graduation
I agree to allow Club youth development professionals to implement the programs listed above with my child. I understand
that if my child fails to participate or is disruptive to the learning process of others, they will be removed from the program for
the day and/or the duration of the program depending on my child’s behavior.
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Parent/Guardian Name
Parent/Guardian Signature
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Date
Revised 7/2014