Boys & Girls Clubs of Weber-Davis
Summer  Annual  / New Membership
MEMBERSHIP APPLICATION
 Renewal Membership 
Paid membership fee: Yes  No  Amount: _________
First Name: ______________________ Middle: ___________________ Last Name: ____________________
Address: ______________________________ City: _____________
State___________
Zip: _________
Telephone: ______________________ Date of Birth: ____________________ Race: ______________
Gender: Male 
Female 
Hair Color: _____________________
Eye Color: _____________
What is your T-shirt size? (Youth) S__ M__ L__ XL__ (Adult) S__ M__ L__ XL__ Other__________
School Information
Current School: __________________________
Teacher: ______________________ Grade: __________
Medical Information
Doctor Name: _________________________
Phone: ________________ Hospital: _____________
Health Insurance: ______________________
Policy Number: _______________________
Health Problems:
Yes  No 
On A Regular Basis: Yes  No 
If Yes, Please indicate: _______________________________________________________________________
Does child take medications: Yes  No  If yes, what medication______________
Dosage: __________
Guardian/Parent 1
Guardian/Parent 2
Relationship: ___________________________
Relationship: ______________________________
Name: ________________________________
Name: ___________________________________
Employer: _____________________________
Employer: ________________________________
Phone 1: ______________________________
Phone 1: _________________________________
Phone 2: ______________________________
Phone 2: _________________________________
Phone 3: ______________________________
Phone 3: _________________________________
General Information
My child has permission to be used in public relations material for the Boys & Girls Club:
Yes  No 
Emergency Contacts and Names of Persons authorized to pick up your child:
Name: _________________________Relationship: _____________________Phone #: _____________________
Name: _________________________Relationship: _____________________Phone #: _____________________
Name: _________________________Relationship: _____________________Phone #: _____________________
Disclaimer
As parent/guardian of the child named above, I give my permission for my child to participate in the programs organized by the staff of the Boys &
Girls Clubs of Weber-Davis. As a part of these organized programs, I understand that some activities may take place away from the Boys & Girls
Club location. By signing below, I agree to hold the Boys & Girls Clubs of Weber-Davis; its paid and volunteer staff and governing Board of
Directors, harmless for any property damage or for personal injury that may occur in conjunction with program activities, transportation, or related
activities. If the staff of the Boys & Girls Club should need to contact me in an emergency, and for whatever reason were unable to do so, I authorize
the Boys & Girls Club staff to take whatever action is deemed necessary in their judgment for the health and welfare of the above named child.
Parent Signature: _______________________________________________________
Date: ______________________________________
Child Signature: ________________________________________________________
Date: ______________________________________
Boys & Girls Clubs of Weber-Davis
TRANSPORTATION RELEASE
Yes, my child, __________________________________ has permission to be picked up from
(Please print child’s name)
school or ride the bus on all Best Friends or Boys & Girls Club activities.
Bus Rules:
 Club will not re-pick up any late child that has missed the bus (even if a teacher keeps the
child after school).
 Child will obey all Club rules while riding in the bus.
 Child will not open bus door while the vehicle is moving.
 Child should not behave in any way to distract the bus driver.
 No food or drink allowed in the bus.
I understand that if the bus rules are not followed, then my child will have his/her “bus
privileges” terminated for a period of time.
_________________________________________________
Parent Signature
________________________
Date
_________________________________________________
Child Signature
________________________
Date
Staff Initials: _________________
Boys & Girls Clubs of Weber-Davis
Demographic Survey Form
SECTION 1: Household information: (There must be a dependent child under age 18 living in the home.)
Boys & Girls Club Member’s Name:__________________________________________
Family Name:________________________
Head of Household:
______Mother
______Father
______2-parent family
______Guardian
______Other
Size of Family:
______Number of males in the household
_____________________Ages of males
______Number of females in the household
_____________________Ages of females
Number of children in household who are:
African American
Alaskan Native
Asian
Caucasian (white)
Latin
Mixed Ethnicity
Native American
Pacific Islander
_________
_________
_________
_________
_________
_________
_________
_________
SECTION 2: Mark the services family is receiving.
_____CHIP
_____Free or Reduced Cost Lunch
SECTION 3: Income Guidelines:
(There is no excludable income)
Annual Gross Income $_________________
________________________________
Parent or Guardian Signature
______________________________
Date
BOYS & GIRLS CLUBS OF WEBER-DAVIS
CLUB RULES/BEHAVIORAL CONTRACT
“Zero Tolerance” rules: Parent/Guardian will be notified if and when these serious violations
occur and may be asked to come and pick their child up immediately. Serious violations and/or
endangerment to self or others may result in the notification of the police or other necessary
professional assistance.
1.
2.
3.
4.
5.
6.
7.
8.
No
No
No
No
No
No
No
No
physical harm or intimidation of other children or staff
sexual misconduct
stealing of Club supplies or equipment
destruction of property
repeated defiance or non-compliance of Club rules
weapons of any kind
use or possession of cigarettes, alcohol or illegal drugs
criminal or delinquent behavior
“Basic” rules: These rules apply to the day-to-day expectations regarding behavior and
cooperation.
1. Take turns with each other and cooperate when participating in group activities, games and
sports.
2. No name-calling, criticizing, swearing or rude remarks.
3. Keep your body in your own personal space. No pushing, hitting, or kicking others.
4. Participation! Everyone who comes here is expected to take an active part in discussions and
activities.
“Violations” will be dealt with on a “level” system:
Level 1: Warning: Staff member or adult volunteer will ask the child what rules are being violated.
Staff/volunteer will also suggest what is necessary to correct the problem.
Level 2: Time out/Cool down opportunity: Child will be taken aside by staff member/volunteer and
given an opportunity to correct the problem. Once the problem is corrected, the child may return to
the activity. If the child is unable/unwilling to correct the problem and return, the staff
member/volunteer may assign an alternative activity or task to complete in lieu of the group activity.
Level 3: Suspension: If the problem persists, the child’s parent or guardian will be called and
depending upon the severity of the incident, the child may be suspended from the Club for a period
of one day up to one week. The child’s parent/guardian will be advised of the date the child may
return to the Club. The Program Director or Executive Director may request that the child make an
apology or do an appropriate assignment as a condition of his/her return.
Level 4: Dismissal: Repeated violations may result in longer suspensions or permanent dismissal
from the Club.
Club rules/Behavioral Contract:
_______
Yes, I am in full agreement with the rules and expectations of the Boys & Girls Clubs of
Weber-Davis
_______
No, I am not in agreement with the rules and expectations of this program
Signed: __________________________________
Parent\Guardian
Date: _______________
Signed: __________________________________
Child participant
Date: _______________
As parent/guardian of the child named above, I give my permission for my child to participate in the
programs organized by the staff of the Boys & Girls Clubs of Weber-Davis. As a part of these organized
programs, I understand that some activities may take place away from the Boys & Girls Club location. By
signing below, I agree to hold the Boys & Girls Clubs of Weber-Davis; its paid and volunteer staff and
governing Board of Directors, harmless for any property damage or for personal injury that may occur in
conjunction with program activities, transportation, or related activities. If the staff of the Boys & Girls
Club should need to contact me in an emergency, and for whatever reason were unable to do so, I
authorize the Boys & Girls Club staff to take whatever action is deemed necessary in their judgment for
the health and welfare of the above named minor child.
Signed: __________________________________
Parent/Guardian
Date: _______________
Printed name of parent/guardian _____________________________________
***Periodically, data will be gathered in various forms to demonstrate the impact that the Boys & Girls
Club programs have on youth. Generally, information will be gathered in the form of observation and
written surveys completed by youth, staff and/or parents. Areas that will be assessed include; selfesteem, social skills, and academics (report cards).
Signed: ________________________________
Parent/Guardian
Date: ___________________
Printed name of parent/guardian _______________________________________
Boys & Girls Clubs of Weber-Davis
Terms and Conditions
For
NETWORK AND INTERNET USE
ACCEPTABLE USE POLICY
The Boys & Girls Clubs of Weber-Davis, in pursuit of meeting Club member’s educational needs, has
access to the Internet, a worldwide network connecting computers all over the world. This educational
opportunity has been made available to Club members. The Boys & Girls Club believes that the valuable
information and interactions available through computer network communication are effective ways to
introduce and educate students to global information.
To maximize the educational experience when using the Internet or local area network, the following
specific uniform practices and guidelines will be enforced.
System Security

To prevent the spread of computer viruses you will follow established guidelines.

You will immediately notify a Club staff member if you have reason to believe that there is a
security problem.
Respect for Privacy

You will not post or repost private information pertaining to individuals or entities.
Inappropriate Language

You will not use obscene, profane, vulgar, inflammatory, racist, threatening, or disrespectful
language.

You will not harass another person.

You will not post personal attacks including but not limited to prejudicial, discriminatory, or
defamatory statements.
Illegal Activities

You will not attempt to gain unauthorized access.

You will not use the system to engage in illegal activities.
Personal Safety

You will inform the Club staff immediately if you have received any inappropriate messages.

You may not use the system to set up private meetings.

You may not post personal information about yourself or other people i.e. addresses, phone
numbers, school, etc.
Respecting Resources Limits

You will use the system only for educational and career development.

You will not subscribe to discussion groups, mailing lists or chat groups that have not been
formally approved by the Club staff.
Plagiarism and Copyright Infringement

You will not plagiarize information found on the Internet.

You will follow copyright guidelines and not reproduce work that is protected by copyright. If
you are unsure of copyright guidelines or what constitutes plagiarism ask a Club staff member for
further understanding.
Inappropriate Access to Material

You will not use the system to access material that is profane or obscene.

You will not use the system to access material that is directed toward discrimination, hate
literature, or acts of violence.

You will immediately notify a Club staff member if you mistakenly access inappropriate
information.
Purchases

You may not make purchases from the Internet.

The Club will not be held responsible for purchases made by Club members.
*** RIGHTS AS A USER ***
Search and Seizure
There is no privacy pertaining to the contents of your files on the system.
Routine monitoring and maintenance of the system may lead to the discovery that you have violated the
Acceptable Use Policy.
Parents/guardians have a right to request to see the contents of your e-mail and files at any time.
Due Process
The Boys & Girls Club will cooperate fully with local, state, or federal officials in any investigation
related to illegal activities conducted on the system.
You have the right to be heard by a neutral Club staff member if there is a claim that you have violated
this policy.
BOYS & GIRLS CLUB RIGHTS
The Club reserves the right to restrict access to any Club member that is suspected to be in violation of
the Acceptable Use Policy until that violation can be resolved.
The Club will not be held responsible for unauthorized use of the system to purchase products or services.
The Club has the right to maintain a history of a Club member’s Acceptable Use Policy violations.
Member Acceptable Use Agreement Section
Member Name _______________________________________________ Grade ___________
School _____________________________________________________ Age _____________
My Parent/Guardian has reviewed and explained the Acceptable Use Agreement with me, and I have read
the Boys & Girls Clubs of Weber-Davis’ Acceptable Use Policy. I agree to follow the rules contained in
this Policy. I understand that if I violate the rules my computer use rights can be terminated and I may
face other disciplinary measures.
Member Signature ____________________________________________ Date ____________
Parent/Guardian Section
I have read the Club Acceptable Use Policy. I hereby release the Club, its’ staff, and any institution with
which it is affiliated, from any and all claims and damages of any nature arising from my child’s use of,
or inability to use, the Club system, including, but not limited to claims that may arise from the
unauthorized use of the system to purchase products or services.
I will instruct my child regarding any restrictions against accessing material that are in addition to the
restrictions set forth in the Club Acceptable Use Policy. I will emphasize to my child the importance of
following the rules for personal safety.
I give permission for my child to use the computers and certify that the information contained in this form
is correct.
Parent/Guardian Signature ______________________________________ Date ____________
Parent/Guardian Name ___________________________________________________________
Home Address _______________________________________________ Phone ___________
Boys & Girls Clubs of Weber-Davis Internet Acceptable Use Policy for Club Members:
APPLICATION PORTION OF DOCUMEMT [ ] Accepted
[ ] Denied
User’s Full Name (please print): ___________________________________________________
Home Address: _________________________________________________________________