THERE ARE NO REFUNDS

Please complete the form and print clearly. This information is confidential and the required data is for self-certification and contact purposes.

Parent/Guardian Information:

Ethnicity/Race

This information is only used for government reporting purposes to monitor compliance with equal opportunity laws.

Please note that self-identification of race/ethnicity is voluntary.

Malvern Magnet Cove Glen Rose Poyen Ouachita

Internet agreement:

The Boys & Girls Club of Malvern and Hot Spring County is established solely for the use and benefit of students in grades K-12.

Acknowledgement and Consent:   I understand the conditions under which the Boys & Girls Club of Malvern and Hot Spring County operates and that it is not a day care facility. I understand the “open door” policy which allows children to come and go as they please. Staff supervision will be provided for children at the Club’s facility only. I understand that no loitering is allowed outside the club entrance. For both internal and external use, I acknowledge that the Boys & Girls Club of Malvern and Hot Spring County may utilize photographs or videos of my child that may be taken during involvement in the Club’s activities. I consent to such uses and hereby waive any rights of compensation. The Club offers educational programs such as SMART Moves. The Club also has my permission to obtain school records such as report cards, benchmark scores, progress reports, and computer software reports, etc. that will help the club personnel to assist my child academically if the need arises. My child has permission to participate in classroom discussions which teach youth the dangers of drugs, alcohol, life skills/options and negative peer pressure.

Waiver of Liability & Disclaimer: In consideration of my child’s membership, and any participation in the activities and special programs or events of the Club, on behalf of me and my child and any heirs or assigns of me or my child, waive, release, and agree to defend and hold harmless the Boys & Girls Clubs of Malvern and Hot Spring County, and its sponsors, staff members, board of directors, and any other affiliated persons and/or vehicle drivers from any and all claims, injuries, death, damages, and

demands arising or in any way resulting from or connected to any Club-related event, activity, program, or property. I attest and verify that I have full knowledge of the risks involved in Club-related events, activities, programs, and properties and that I will, on behalf of the my child, assume and pay any medical or emergency expenses. I further acknowledge that my child is physically fit to participate in the programs or other activities of the Club.

Emergency Authorization:     I, the undersigned, as parent/guardian of my child, hereby authorize the staff of the Club, its sponsors, and vehicle drivers as my agents to consent to medical, surgical, dental examination or treatment of my child. In case of emergency, I hereby authorize treatment or care at any hospital or by any licensed medical personnel.

NOTE: YOUR SIGNATURE BELOW ACKNOWLEDGES THAT YOU HAVE READ AND ACCEPT THE

POLICIES/CONDITIONS OF THE BOYS & GIRLS CLUBS OF MALVERN AND HOT SPRING COUNTY AS DESCRIBED

ABOVE.

1. Members should sign in DAILY.
2. Members are expected to keep all areas of the Club clean and neat
3. All personal items must be placed in a cubical.
4.  Members will be held responsible for their behavior
5. The club phone is for emergency use only
6.  Members may only eat and drink in the gym ONLY.
7. Members are permitted in designated areas only
8. Respect yourself and others, do not use foul language
9. Contrabands, i.e. alcohol, drugs, tobacco, knives or weapons of any kind are not allowed at the Club.
10. Cell phones, Ipods, and other electronic devices are not allowed at the club at any time. 
11. Late fees will apply after 6:00 p.m. daily at a rate of $1.00 per minute after 6:05. 

BGC- Office Use Only – Do Not Fill In