Mahomet Area Youth Club Membership Enrollment Form

#he MAYC membership $ear is %rom &eptember 1 to Au'ust 31 an! the annual membership %ee is (20)00) #his membership is %or $ear* &eptember 1, 20 to Au'ust 31, 20 )

Childs Information
Chil!+s Full ,ame* Male Female /irth 0ate* 1 1 ,i-.name* 2a-e* Yes ,o

3as he1she e"er been enrolle! in an a%ter s-hool pro'ram be%ore4 Chil!+s interests* Fa"orite Foo!s* Chil! %eels un-om%ortable 6hen* 5east Fa"orite Foo!s*

Family Contact Information

7arents18uar!ians* 3ome A!!ress*
Cit$ &tate 9ip

Email

3ome 7hone

Cell 7hone

:or.

Authorized Individuals
Please list the name, address, phone number, and relationship for each person authorized to pick up your child under the age of 14 . No child will be released to any individual not listed below or to any family or non-family member under the age of 1 . Any additions, deletions, modifications or request to list any family member authorized to pick up a MAYC member must be submitted in writing by the parents and/or legal guardians

1)
,ame A!!ress 7hone ,umber 2elationship

2)
,ame A!!ress 7hone ,umber 2elationship

3)
,ame A!!ress 7hone ,umber 2elationship

Youth and Family Information

!"#$ collects and submits data to our funding and grant sources. %nly the data is reported and no individual or family information is released. Please complete the following information when submitting this form.

Head of Household: &in'le 7arent 3ome #6o 7arent 3ome Foster 7arent 2elati"e Care'i"er
,on-relati"e -are'i"er

Household ize:

Complete Famil$ &i;e*

,umber o% &iblin's

,umber o% A!ults
&&= or &&0=

Financial Assistance < -he-. all that appl$ %or e"er$ member o% $our househol!*
=1:e !o not re-ei"e Finan-ial Assistan-e #A,F >#emporar$ Assistan-e %or ,ee!$ Families? Me!i-al Car! or @i!Care :=C 0CF& Foo! &tamps Free12e!u-e! 5un-h

Annual Combined Household IncomeParents&'uardians( )f you are seeking a reduced rate to *ualify for reduced fees or a
!"#$ +cholarship, you will be re*uired to report any changes in household size, financial assistance received or income levels.

Are $ou emplo$e!4 Are there unemplo$e! a!ults in the home4 Yes ,o 3o6 Man$* 0-4,999 5,000-9,999 10,000-19,000 20,000-29,000 30,000-39,999 40,000-49,999 50,000-59,999 60,000-69,000 0,000 an! abo"e 1 Mahomet Area Youth Club-Membership Enrollment Form

Medical and Emer!ency Contact Information

)n the event of a medical emergency, !"#$ staff will contact the parents immediately. )f the person is suffering from a back, neck, head, broken bone ,arm or leg-, or internal in.ury, !"#$ +taff will call /11. %N0# 123 P"43N1&'5"46)"N 7)00 6)43$1 +1"88 N%1 1% $"00 /11. )f the parent&guardian cannot be reached, staff will contact the individual listed as the 3mergency $ontact Person.

"lease list any health issues and#or problems:

Chil!+s 0o-tor an! 7hone ,umber Chil!+s Me!i-al =nsuran-e Compan$* A 7oli-$ ,umber1Me!i-ai! ,umber*

Emer!ency Contact "erson Information

)f there are any changes to the information provided below, please provide that information to !"#$.
,ame A!!ress 2elationship

3ome 7hone

Cell 7hone

:or. 7hone

MAYC A!reements
!"#$ offers several different activities that re*uire that certain conditions, policies, rules and regulations be understood and adhered to by parents&guardians and our members. Please carefully review the following information and if you permit your child to participate in and&or use the following !"#$ resources, please sign and date the space provided near each item. MAYC $ate "ar$ A!reement 1) Bse o% the MAYC &.ate 7ar. is %or enrolle! MAYC members onl$) 2) A parent1'uar!ian must ha"e a si'ne! this portion o% the MAYC Membership Appli-ation an! MAYC &.ate 7ar. a'reement on %ile be%ore usin' o% the &.ate 7ar.) 3) #he &.ate 7ar. is %or s.ateboar!s onl$) ,o s-ooters or inline s.ates 6ill be permitte! in the s.ate par.) 4) 3elmets must be 6orn at all times 6hile in the &.ate 7ar.) 5) Members are en-oura'e! to ha"e their o6n helmets) MAYC 6ill pro"i!e a limite! number o% helmets %or s.ate par. use) 6) All helmets must be 6orn in a sa%e manner) ) Appropriate %oot6ear >har! sole shoes? must be 6orn in the s.ate par.) C) Members are en-oura'e! to suppl$ an! 6ear their o6n sa%et$ pa!s) 9) &.aters must eDer-ise appropriate -aution 6hen $oun'er or less eDperien-e! s.aters are present, an! must respe-t the ri'hts o% all s.aters) 10) MAYC members 6ill be as.e! to -lean an! maintain the s.ate par. prior an! a%ter use) 11) #he MAYC &.ate 7ar. 6ill not be open %or use unless a MAYC sta%% member or Euali%ie! a!ult "olunteer is a"ailable to super"ise the s.ate par. a-ti"ities) 12) #he s.ate par. 6ill not be open a%ter !us.) 13) =n!i"i!uals 6ho enter the s.ate par. 6hen the -lub is -lose! 6ill be -onsi!ere! trespassin') 14) MAYC is not responsible %or an$ members+ lost, stolen or bro.en eEuipment) 15) &houl! an$ MAYC members 6ill%ull$ or purpose%ull$ !ama'e or !estro$ MAYC propert$, the$ 6ill be as.e! to reimburse MAYC %or the a-tual repla-ement -ost o% an$ eEuipment or item !ama'e! or !estro$e!) 16) MAYC 6ill emplo$ all reasonable e%%ort to super"ise an! -ontrol a-ti"ities -on!u-te! in the &.ate 7ar. to minimi;e the ris. o% inFur$, ho6e"er, MAYC members use the $ate "ar$ at their o%n ris$& MAYC %ill not be responsible for any in'ury or dama!e incurred %hile usin! the MAYC $ate "ar$& Appro"e! b$ parent1'uar!ian* &i'nature o% parent1'uar!ian ,ot appro"e! b$ parent1'uar!ian) A--ess to the MAYC s.ate par. is !enie!) 1 1 0ate

MAYC Computer (ab A!reement 1) Bse o% the MAYC Computer 5ab is %or enrolle! MAYC members onl$) 2) A parent1'uar!ian must ha"e a si'ne! this portion o% the MAYC Membership Appli-ation prior to the MAYC member usin' the -omputer lab) 3) ,o !i'ital !ata, me!ia, "i!eo or photo'raphi- material o% an$ t$pe 6ill be !o6nloa!e! to or %rom an$ -omputer or -omputer relate! eEuipment o6ne! b$ the Mahomet Area Youth Club) 4) #he Mahomet Area Youth Club 6ill assume no -ontrol o"er sites "isite! nor assumes an$ responsibilit$ %or the sites the member "isits on the internet) 5) =% the member "isits an$ site o% a -ontro"ersial nature, in-lu!in' porno'raph$, obs-enit$, eD-essi"e "iolen-e, in%lammator$ an! or !an'erous nature an! or material, the member ma$ be suspen!e! or eDpelle! %rom the Mahomet Area Youth Club) 6) ,o member is permitte! to "isit an$ t$pe o% so-ial me!ia pa'e o% an$ nature 6hile at the Mahomet Area Youth Club) ) &houl! an$ member post an$ t$pe o% !i'ital !ata >photo'raphs, "i!eo, !o-uments, et-),? ta.en 6hile at or about the Mahomet Area Youth Club sta%%, members or "olunteers 6ithout prior 6ritten appro"al, the member ma$ be suspen!e! or eDpelle! %rom MAYC) C) ,o inappropriate in%ormation 6ill be eD-han'e!, %or6ar!e! or share! 6ith an$ Mahomet Area Youth Club sta%% or MAYC members) 9) Members are responsible %or the sa%e an! appropriate use o% MAYC -omputer eEuipment) =% an$ member !ama'es or !estro$s an$ eEuipment, the %amil$1'uar!ian 6ill be responsible %or the -ost o% repair an! or repla-ement) Appro"e! b$ parent1'uar!ian* &i'nature o% parent1'uar!ian ,ot appro"e! b$ parent1'uar!ian) A--ess to the MAYC Computer 5ab is !enie!) MAYC "o%er House A!reement 1) Bse o% the MAYC 7o6er 3ouse is %or enrolle! an! pai! MAYC members an! in!i"i!uals 6ho ha"e an appro"e! 6ai"er %orm) 2) All MAYC Members 6ill be instru-te! on the appropriate use o% all eEuipment) Members are to use eEuipment G,5Y =F the$ un!erstan! ho6 to use it -orre-tl$, pre"entin' the ris. o% inFur$) Members must eDer-ise appropriate -aution 6hen usin' the eEuipment in the 7o6er 3ouse) 3) MAYC members use the 7o6er 3ouse at their o6n ris.) MAYC !oes not assume an$ responsibilit$ %or an$ inFur$ sustaine! b$ an$ member utili;in' the 7o6er 3ouse) 4) Appropriate %oot6ear >in-lu!in' so-.s? an! -lothin' must be 6orn in the 7o6er 3ouse at all times) 5) Athleti- shoes must be -lean in or!er to enter the 7o6er 3ouse) 6) All 6ei'hts an! eEuipment must be put ba-. an! -leane! be%ore eDitin' the 7o6er 3ouse) ) Members must lea"e the 7o6er 3ouse in a -lean an! sa%e -on!ition) C) #he 7o6er 3ouse an! 7o6er 3ouse eEuipment are to be use! %or the inten!e! purposes onl$) 9) #he MAYC 7o6er 3ouse 6ill be a"ailable %or use onl$ 6hen a MAYC sta%% member or Euali%ie!1appro"e! MAYC a!ult "olunteer is a"ailable to super"ise a-ti"ities) 10) 7arents1'uar!ians are reEuire! to !is-lose an$ health or health relate! -on!itions o% the member prior to use o% the 7o6er 3ouse) MAYC 6ill emplo$ all reasonable e%%ort to super"ise an! -ontrol a-ti"ities -on!u-te! in the 7o6er 3ouse to minimi;e the ris. o% inFur$, ho6e"er, MAYC members use the 7o6er 3ouse at their o6n ris.) MAYC 6ill not be responsible %or an$ inFur$ or !ama'e in-urre! 6hile usin' the MAYC 7o6er 3ouse) Appro"e! b$ parent1'uar!ian* &i'nature o% parent1'uar!ian ,ot appro"e! b$ parent1'uar!ian) A--ess to the MAYC 7o6er 3ouse is !enie!) 1 0ate 1 1 0ate 1

Authorization
1) = 'i"e m$ -onsent %or MAYC to release photo'raphs in 6hi-h m$ -hil! appears to the me!ia a'en-ies an! to !ispla$ or use photo'raphs in promotional materials relate! to MAYC 6ithout an$ %uture monetar$ -onsi!eration or -ompensation) 2) #o pro"i!e the best en"ironment %or m$ -hil! an! help stren'then m$ -hil!+s positi"e in"ol"ement an! su--ess in s-hool an! non-s-hool a-ti"ities, = 'rant permission %or MAYC to obtain -opies o% m$ -hil!+s s-hool report -ar! an! share that in%ormation bet6een an$ or'ani;ation !eeme! appropriate b$ MAYC a!ministration) #hose a'en-ies ma$ in-lu!e but not be limite! to s-hool !istri-ts, poli-e !epartments, &-outin' or'ani;ations, health ser"i-es, et-) 3) = 'i"e permission %or m$ -hil! to be transporte! in a MAYC o6ne! or operate! "ehi-le %or transportation to1 %rom home i% appli-able an! on MAYC %iel! trips) 4) = un!erstan! that no MAYC sta%% member ma$ transport m$ -hil! at an$ time in a pri"atel$ o6ne! "ehi-le) 5) = un!erstan! that MAYC -annot pro"i!e transportation %or m$ -hil! outsi!e o% MAYC authori;e! a-ti"ities an!1 or %iel! trips) 6) = un!erstan! that m$ -hil! must be si'ne! out b$ m$sel% or an authori;e! person as i!enti%ie! on the enrollment %orm) =% m$ -hil! is bein' transporte! home in a MAYC "ehi-le, a MAYC sta%% member must si'n m$ -hil! out) ) = un!erstan! that members a'e! %ourteen >14? $ears or ol!er ma$ lea"e the -lub an! he1she 6ill not be permitte! to -ome ba-. to MAYC !urin' same !a$ 6ithout prior appro"al %rom a MAYC A!ministrati"e &ta%% person) C) = un!erstan! an! a'ree that the Mahomet Area Youth Club 6ill not be hel! liable %or m$ -hil! i% he1she lea"es MAYC %a-ilities or an o%%-site a-ti"it$ o% his1her o6n %ree 6ill) = %urther a'ree that MAYC 6ill not be hel! liable i% m$ -hil! su%%ers an a--i!ental inFur$ 6hile on MAYC propert$, or 6hile en'a'e! in a MAYC sponsore! a-ti"it$ o%%-site) 9) = un!erstan! that i% m$ -hil! reEuires me!i-ation !urin' a%ter s-hool pro'ram hours, a H7ermission %or Me!i-ationsH %orm must be -omplete! an! in%ormation re'ar!in' !ose an! time o% a!ministration must be pro"i!e! to MAYC sta%% an! that the me!i-ations 6ill be .ept in -learl$ labele! ori'inal -ontainers) = un!erstan! that no over the counter medications will be given such as 1ylenol, cough li*uid, etc. without written consent from my child 9s physician. 10) = ha"e re-ei"e! an! re"ie6e! the Mahomet Area Youth Club 7arent an! Member 3an!boo. 6ith a MAYC sta%% member) 11) = un!erstan! that the Mahomet Area Youth Club is not responsible %or an$ lost, stolen, bro.en or mispla-e! propert$) 12) = un!erstan! that i% membership in the Mahomet Area Youth Club is terminate! b$ either MAYC an!1or m$sel%, membership %ees are not re%un!able)

=16e ha"e rea! an! a'ree to the poli-ies, rules, re'ulations an! -on!itions o% this a'reement an! an$ !o-ument re%eren-e! in the a'reement) 7arent18uar!ian &i'nature 0ate

Member &i'nature

0ate

MAYC &ta%% Member &i'nature

0ate