PARENT RELEASE FORM
I have read the completed application and this form, understand the rules of the Boys & Girls Club of Moorpark & Simi Valley and request that my child be admitted into membership.
Medical Treatment
I give permission to the Boys & Girls Club of Moorpark & Simi Valley 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.
Photo Release and Technology
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. As a member of the Boys & Girls Club of Moorpark & Simi Valley, your child may have access to the Internet. While precautions are in place, it is possible that s/he may access inappropriate sites. The Boys & Girls Club will have rules and consequences at the Club for such behavior; however we will not be responsible for the repercussions of such access.
School Information
I give my permission to the Boys & Girls Club of Moorpark & Simi Valley and Moorpark and Simi Valley Unified 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, at the Boys & Girls Club and in life. This release is valid for one year and may be revoked at any time by contacting Moorpark or Simi Valley Unified School District or the Boys & Girls Club in writing.
Surveys and Questionnaires
I, the parent/guardian of the minor child listed on this application, give permission for Boys & Girls Club of Moorpark & Simi Valley to survey my child about his or her Club experience, behaviors, skills and attitudes using Boys & Girls Clubs of America’s National Outcomes Survey or other survey instruments.
Miscellaneous
I am aware that there are additional fees required for non-school days, transportation, field trips, etc. and that there are scholarships available that I may inquire about. I understand that 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, unless registered in our after school transportation program. While all program areas are supervised, we are not responsible for Club members’ who leave the Club without their parents or staff member’s permission. I also understand that the Club is not, nor does it claim to be, a licensed day care center.
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 Moorpark & Simi Valley, 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.
I give my permission to the Boys & Girls Club of Moorpark & Simi Valley 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 Moorpark & Simi Valley, including data collected via surveys or questionnaires. All information provided to BGCA will be kept completely confidential.
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Additional Information:
PARENT RELEASE FORM
I have read the completed application and this form, understand the rules of the Boys & Girls Club of Moorpark & Simi Valley and request that my child be admitted into membership.
Medical Treatment
I give permission to the Boys & Girls Club of Moorpark & Simi Valley 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.
Photo Release and Technology
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. As a member of the Boys & Girls Club of Moorpark & Simi Valley, your child may have access to the Internet. While precautions are in place, it is possible that s/he may access inappropriate sites. The Boys & Girls Club will have rules and consequences at the Club for such behavior; however we will not be responsible for the repercussions of such access.
School Information
I give my permission to the Boys & Girls Club of Moorpark & Simi Valley and Moorpark and Simi Valley Unified 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, at the Boys & Girls Club and in life. This release is valid for one year and may be revoked at any time by contacting Moorpark or Simi Valley Unified School District or the Boys & Girls Club in writing.
Surveys and Questionnaires
I, the parent/guardian of the minor child listed on this application, give permission for Boys & Girls Club of Moorpark & Simi Valley to survey my child about his or her Club experience, behaviors, skills and attitudes using Boys & Girls Clubs of America’s National Outcomes Survey or other survey instruments.
Miscellaneous
I am aware that there are additional fees required for non-school days, transportation, field trips, etc. and that there are scholarships available that I may inquire about. I understand that 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, unless registered in our after school transportation program. While all program areas are supervised, we are not responsible for Club members’ who leave the Club without their parents or staff member’s permission. I also understand that the Club is not, nor does it claim to be, a licensed day care center.
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 Moorpark & Simi Valley, 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.
I give my permission to the Boys & Girls Club of Moorpark & Simi Valley 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 Moorpark & Simi Valley, including data collected via surveys or questionnaires. All information provided to BGCA will be kept completely confidential.
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Additional Information:
PARENT RELEASE FORM
I have read the completed application and this form, understand the rules of the Boys & Girls Club of Moorpark & Simi Valley and request that my child be admitted into membership.
Medical Treatment
I give permission to the Boys & Girls Club of Moorpark & Simi Valley 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.
Photo Release and Technology
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. As a member of the Boys & Girls Club of Moorpark & Simi Valley, your child may have access to the Internet. While precautions are in place, it is possible that s/he may access inappropriate sites. The Boys & Girls Club will have rules and consequences at the Club for such behavior; however we will not be responsible for the repercussions of such access.
School Information
I give my permission to the Boys & Girls Club of Moorpark & Simi Valley and Moorpark and Simi Valley Unified 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, at the Boys & Girls Club and in life. This release is valid for one year and may be revoked at any time by contacting Moorpark or Simi Valley Unified School District or the Boys & Girls Club in writing.
Surveys and Questionnaires
I, the parent/guardian of the minor child listed on this application, give permission for Boys & Girls Club of Moorpark & Simi Valley to survey my child about his or her Club experience, behaviors, skills and attitudes using Boys & Girls Clubs of America’s National Outcomes Survey or other survey instruments.
Miscellaneous
I am aware that there are additional fees required for non-school days, transportation, field trips, etc. and that there are scholarships available that I may inquire about. I understand that 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, unless registered in our after school transportation program. While all program areas are supervised, we are not responsible for Club members’ who leave the Club without their parents or staff member’s permission. I also understand that the Club is not, nor does it claim to be, a licensed day care center.
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 Moorpark & Simi Valley, 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.
I give my permission to the Boys & Girls Club of Moorpark & Simi Valley 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 Moorpark & Simi Valley, including data collected via surveys or questionnaires. All information provided to BGCA will be kept completely confidential.
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Additional Information:
PARENT RELEASE FORM
I have read the completed application and this form, understand the rules of the Boys & Girls Club of Moorpark & Simi Valley and request that my child be admitted into membership.
Medical Treatment
I give permission to the Boys & Girls Club of Moorpark & Simi Valley 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.
Photo Release and Technology
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. As a member of the Boys & Girls Club of Moorpark & Simi Valley, your child may have access to the Internet. While precautions are in place, it is possible that s/he may access inappropriate sites. The Boys & Girls Club will have rules and consequences at the Club for such behavior; however we will not be responsible for the repercussions of such access.
School Information
I give my permission to the Boys & Girls Club of Moorpark & Simi Valley and Moorpark and Simi Valley Unified 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, at the Boys & Girls Club and in life. This release is valid for one year and may be revoked at any time by contacting Moorpark or Simi Valley Unified School District or the Boys & Girls Club in writing.
Surveys and Questionnaires
I, the parent/guardian of the minor child listed on this application, give permission for Boys & Girls Club of Moorpark & Simi Valley to survey my child about his or her Club experience, behaviors, skills and attitudes using Boys & Girls Clubs of America’s National Outcomes Survey or other survey instruments.
Miscellaneous
I am aware that there are additional fees required for non-school days, transportation, field trips, etc. and that there are scholarships available that I may inquire about. I understand that 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, unless registered in our after school transportation program. While all program areas are supervised, we are not responsible for Club members’ who leave the Club without their parents or staff member’s permission. I also understand that the Club is not, nor does it claim to be, a licensed day care center.
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 Moorpark & Simi Valley, 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.
I give my permission to the Boys & Girls Club of Moorpark & Simi Valley 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 Moorpark & Simi Valley, including data collected via surveys or questionnaires. All information provided to BGCA will be kept completely confidential.
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Additional Information:
PARENT RELEASE FORM
I have read the completed application and this form, understand the rules of the Boys & Girls Club of Moorpark & Simi Valley and request that my child be admitted into membership.
Medical Treatment
I give permission to the Boys & Girls Club of Moorpark & Simi Valley 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.
Photo Release and Technology
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. As a member of the Boys & Girls Club of Moorpark & Simi Valley, your child may have access to the Internet. While precautions are in place, it is possible that s/he may access inappropriate sites. The Boys & Girls Club will have rules and consequences at the Club for such behavior; however we will not be responsible for the repercussions of such access.
School Information
I give my permission to the Boys & Girls Club of Moorpark & Simi Valley and Moorpark and Simi Valley Unified 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, at the Boys & Girls Club and in life. This release is valid for one year and may be revoked at any time by contacting Moorpark or Simi Valley Unified School District or the Boys & Girls Club in writing.
Surveys and Questionnaires
I, the parent/guardian of the minor child listed on this application, give permission for Boys & Girls Club of Moorpark & Simi Valley to survey my child about his or her Club experience, behaviors, skills and attitudes using Boys & Girls Clubs of America’s National Outcomes Survey or other survey instruments.
Miscellaneous
I am aware that there are additional fees required for non-school days, transportation, field trips, etc. and that there are scholarships available that I may inquire about. I understand that 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, unless registered in our after school transportation program. While all program areas are supervised, we are not responsible for Club members’ who leave the Club without their parents or staff member’s permission. I also understand that the Club is not, nor does it claim to be, a licensed day care center.
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 Moorpark & Simi Valley, 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.
I give my permission to the Boys & Girls Club of Moorpark & Simi Valley 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 Moorpark & Simi Valley, including data collected via surveys or questionnaires. All information provided to BGCA will be kept completely confidential.
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Additional Information:
PARENT RELEASE FORM
I have read the completed application and this form, understand the rules of the Boys & Girls Club of Moorpark & Simi Valley and request that my child be admitted into membership.
Medical Treatment
I give permission to the Boys & Girls Club of Moorpark & Simi Valley 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.
Photo Release and Technology
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. As a member of the Boys & Girls Club of Moorpark & Simi Valley, your child may have access to the Internet. While precautions are in place, it is possible that s/he may access inappropriate sites. The Boys & Girls Club will have rules and consequences at the Club for such behavior; however we will not be responsible for the repercussions of such access.
School Information
I give my permission to the Boys & Girls Club of Moorpark & Simi Valley and Moorpark and Simi Valley Unified 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, at the Boys & Girls Club and in life. This release is valid for one year and may be revoked at any time by contacting Moorpark or Simi Valley Unified School District or the Boys & Girls Club in writing.
Surveys and Questionnaires
I, the parent/guardian of the minor child listed on this application, give permission for Boys & Girls Club of Moorpark & Simi Valley to survey my child about his or her Club experience, behaviors, skills and attitudes using Boys & Girls Clubs of America’s National Outcomes Survey or other survey instruments.
Miscellaneous
I am aware that there are additional fees required for non-school days, transportation, field trips, etc. and that there are scholarships available that I may inquire about. I understand that 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, unless registered in our after school transportation program. While all program areas are supervised, we are not responsible for Club members’ who leave the Club without their parents or staff member’s permission. I also understand that the Club is not, nor does it claim to be, a licensed day care center.
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 Moorpark & Simi Valley, 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.
I give my permission to the Boys & Girls Club of Moorpark & Simi Valley 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 Moorpark & Simi Valley, including data collected via surveys or questionnaires. All information provided to BGCA will be kept completely confidential.
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Additional Information:
PARENT RELEASE FORM
I have read the completed application and this form, understand the rules of the Boys & Girls Club of Moorpark & Simi Valley and request that my child be admitted into membership.
Medical Treatment
I give permission to the Boys & Girls Club of Moorpark & Simi Valley 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.
Photo Release and Technology
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. As a member of the Boys & Girls Club of Moorpark & Simi Valley, your child may have access to the Internet. While precautions are in place, it is possible that s/he may access inappropriate sites. The Boys & Girls Club will have rules and consequences at the Club for such behavior; however we will not be responsible for the repercussions of such access.
School Information
I give my permission to the Boys & Girls Club of Moorpark & Simi Valley and Moorpark and Simi Valley Unified 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, at the Boys & Girls Club and in life. This release is valid for one year and may be revoked at any time by contacting Moorpark or Simi Valley Unified School District or the Boys & Girls Club in writing.
Surveys and Questionnaires
I, the parent/guardian of the minor child listed on this application, give permission for Boys & Girls Club of Moorpark & Simi Valley to survey my child about his or her Club experience, behaviors, skills and attitudes using Boys & Girls Clubs of America’s National Outcomes Survey or other survey instruments.
Miscellaneous
I am aware that there are additional fees required for non-school days, transportation, field trips, etc. and that there are scholarships available that I may inquire about. I understand that 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, unless registered in our after school transportation program. While all program areas are supervised, we are not responsible for Club members’ who leave the Club without their parents or staff member’s permission. I also understand that the Club is not, nor does it claim to be, a licensed day care center.
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 Moorpark & Simi Valley, 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.
I give my permission to the Boys & Girls Club of Moorpark & Simi Valley 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 Moorpark & Simi Valley, including data collected via surveys or questionnaires. All information provided to BGCA will be kept completely confidential.
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Additional Information:
PARENT RELEASE FORM
I have read the completed application and this form, understand the rules of the Boys & Girls Club of Moorpark & Simi Valley and request that my child be admitted into membership.
Medical Treatment
I give permission to the Boys & Girls Club of Moorpark & Simi Valley 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.
Photo Release and Technology
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. As a member of the Boys & Girls Club of Moorpark & Simi Valley, your child may have access to the Internet. While precautions are in place, it is possible that s/he may access inappropriate sites. The Boys & Girls Club will have rules and consequences at the Club for such behavior; however we will not be responsible for the repercussions of such access.
School Information
I give my permission to the Boys & Girls Club of Moorpark & Simi Valley and Moorpark and Simi Valley Unified 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, at the Boys & Girls Club and in life. This release is valid for one year and may be revoked at any time by contacting Moorpark or Simi Valley Unified School District or the Boys & Girls Club in writing.
Surveys and Questionnaires
I, the parent/guardian of the minor child listed on this application, give permission for Boys & Girls Club of Moorpark & Simi Valley to survey my child about his or her Club experience, behaviors, skills and attitudes using Boys & Girls Clubs of America’s National Outcomes Survey or other survey instruments.
Miscellaneous
I am aware that there are additional fees required for non-school days, transportation, field trips, etc. and that there are scholarships available that I may inquire about. I understand that 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, unless registered in our after school transportation program. While all program areas are supervised, we are not responsible for Club members’ who leave the Club without their parents or staff member’s permission. I also understand that the Club is not, nor does it claim to be, a licensed day care center.
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 Moorpark & Simi Valley, 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.
I give my permission to the Boys & Girls Club of Moorpark & Simi Valley 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 Moorpark & Simi Valley, including data collected via surveys or questionnaires. All information provided to BGCA will be kept completely confidential.
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Additional Information:
PARENT RELEASE FORM
I have read the completed application and this form, understand the rules of the Boys & Girls Club of Moorpark & Simi Valley and request that my child be admitted into membership.
Medical Treatment
I give permission to the Boys & Girls Club of Moorpark & Simi Valley 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.
Photo Release and Technology
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. As a member of the Boys & Girls Club of Moorpark & Simi Valley, your child may have access to the Internet. While precautions are in place, it is possible that s/he may access inappropriate sites. The Boys & Girls Club will have rules and consequences at the Club for such behavior; however we will not be responsible for the repercussions of such access.
School Information
I give my permission to the Boys & Girls Club of Moorpark & Simi Valley and Moorpark and Simi Valley Unified 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, at the Boys & Girls Club and in life. This release is valid for one year and may be revoked at any time by contacting Moorpark or Simi Valley Unified School District or the Boys & Girls Club in writing.
Surveys and Questionnaires
I, the parent/guardian of the minor child listed on this application, give permission for Boys & Girls Club of Moorpark & Simi Valley to survey my child about his or her Club experience, behaviors, skills and attitudes using Boys & Girls Clubs of America’s National Outcomes Survey or other survey instruments.
Miscellaneous
I am aware that there are additional fees required for non-school days, transportation, field trips, etc. and that there are scholarships available that I may inquire about. I understand that 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, unless registered in our after school transportation program. While all program areas are supervised, we are not responsible for Club members’ who leave the Club without their parents or staff member’s permission. I also understand that the Club is not, nor does it claim to be, a licensed day care center.
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 Moorpark & Simi Valley, 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.
I give my permission to the Boys & Girls Club of Moorpark & Simi Valley 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 Moorpark & Simi Valley, including data collected via surveys or questionnaires. All information provided to BGCA will be kept completely confidential.
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Additional Information:
PARENT RELEASE FORM
I have read the completed application and this form, understand the rules of the Boys & Girls Club of Moorpark & Simi Valley and request that my child be admitted into membership.
Medical Treatment
I give permission to the Boys & Girls Club of Moorpark & Simi Valley 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.
Photo Release and Technology
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. As a member of the Boys & Girls Club of Moorpark & Simi Valley, your child may have access to the Internet. While precautions are in place, it is possible that s/he may access inappropriate sites. The Boys & Girls Club will have rules and consequences at the Club for such behavior; however we will not be responsible for the repercussions of such access.
School Information
I give my permission to the Boys & Girls Club of Moorpark & Simi Valley and Moorpark and Simi Valley Unified 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, at the Boys & Girls Club and in life. This release is valid for one year and may be revoked at any time by contacting Moorpark or Simi Valley Unified School District or the Boys & Girls Club in writing.
Surveys and Questionnaires
I, the parent/guardian of the minor child listed on this application, give permission for Boys & Girls Club of Moorpark & Simi Valley to survey my child about his or her Club experience, behaviors, skills and attitudes using Boys & Girls Clubs of America’s National Outcomes Survey or other survey instruments.
Miscellaneous
I am aware that there are additional fees required for non-school days, transportation, field trips, etc. and that there are scholarships available that I may inquire about. I understand that 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, unless registered in our after school transportation program. While all program areas are supervised, we are not responsible for Club members’ who leave the Club without their parents or staff member’s permission. I also understand that the Club is not, nor does it claim to be, a licensed day care center.
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 Moorpark & Simi Valley, 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.
I give my permission to the Boys & Girls Club of Moorpark & Simi Valley 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 Moorpark & Simi Valley, including data collected via surveys or questionnaires. All information provided to BGCA will be kept completely confidential.
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