If you are human, leave this field blank.
Emergency Contact Information (other than listed parent)
Emergency Contact Name (1)
Relation to Youth? (1)
Phone Number (1)
Emergency Contact Name (2)
Relation to Youth? (2)
Phone Number (2)
Other Important Youth Medical Information
Any other information
Youth Physician Name and Number (if they have one)
I acknowledge on behalf of myself, any other parent or guardian of youth participating in this program that I will indemnify and hold harmless Boys & Girls Clubs of Southeastern Michigan (BGCSM), their agents, officers, employees, partners and volunteers from any and all liability, claim, suits, demands, damages, costs, judgements, interests and expenses (including attorney fees, legal fees, medical fees, etc.) arising directly or indirectly from the youth’s participation in BGCSM programs and activities.
I also waive the right of myself, any participating youth and anyone picking that youth up from the Club to refuse a temperature check upon entering the building. Those with temperatures at or above 99.5 will not be allowed into the Club for seven days with the last three being symptom free (clock resets anytime symptoms persist or arise) I waive all claims against BGCSM to the fullest extent of the law and will not hold BGCSM, its agents, officers, employees, partners and volunteers liable if any participating youth, their fellow household members or extended family becomes infected or diagnosed with COVID-19 as a result of their participation in Club programming. In the event myself or any emergency contact cannot be reached in the event of an emergency, I hereby authorize BGCSM to allow any physician, medical facility or healthcare provider, including paramedics, to provide any emergency medical treatment deemed necessary by those professional in the event of injury or illness of the participating youth.
I agree with the above waiver information:
which can be used in anyway by BGCSM to support the mission of BGCSM. Ways include but are not limited to: our annual impact report. Social media posts, grant applications, special event programs, communication with donors and more. I consent for photographs and videography in which participants may appear, You can opt out by initialing below:
I consent for photographs and videography waiver:
Remind Phone App Authorization You give BGCSM Club sites permission to text me using the Remind App regarding club closing and hour changes, activities, announcements, etc. This will allow me stay in constant contact with my club. (Renewal will be every year to stay up to date!). If you do not sign or add a phone number you receive this free service
I give BGCSM Club sites permission to text me using the Remind App regarding Club closing and hour changes, activities, announcements, etc. This will allow me stay in constant contact with my Club. Renewal will be every year to stay up to date! (Permission is required for all Club member registration)
Phone number(s) to receive text messages at:
Boys & Girls Clubs of SE MI-Code of Conduct I will always be respectful and responsible to staff members, club members and overall, the Boys & Girls Club itself.
Bullying will not be tolerated! If I do have a problem with another member, staff member or outside person, I will let the staff know and not take it into my own hands.
I will always also keep my cell phone and electronic devices put away and use it in the office when I ask a staff member, only to contact my parents when needed. My phone/electronic device will be taken away until my parents come to pick me up if they are out and I am subject to disciplinary actions if I continue to bring it out.
Being a member of the Club, I am to set an example for my fellow members. If my attitude and behavior does not reflect that of a leader, my parents will be contacted, and I am subject to disciplinary actions. Attitudes and disrespect will not be tolerated!
I understand, if I exhibit any of these behaviors, I will be subject to disciplinary actions.
Once you hit submit, you will be routed to PayPal to complete your payment and finalize your registration.
$25 registration fee + 1 week ($75 total)
$25 registration fee + 4 days ($65 total)
$25 registration fee + 3 days ($55 total)
$25 registration fee + 2 days ($45 total)
$25 registration fee + 1 day ($35 total)
1 week ($50 total)
Submit & Make Payment