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Fall Program Registration

Register for Florence Club Fall Programming

Use this form to register up to three children living at the same address with the same guardians
First Name
Last Name
Club Member(s) Information
First Name
Last Name
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Male/Female
Race
School Status
First Name
Last Name
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Male/Female
Race
School Status
First Name
Last Name
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Male/Female
Race
School Status
Describe who the youth lives with:
Medical Release
I give permission to the Boys & Girls Clubs of the Pee Dee Area to seek emergency medical treatment for my minor child(ren) listed above if I cannot be reached. I hereby authorize the attending physician, in an emergency situation, to perform whatever acts that is his/her professional opinion are in the best interest of my child. I will be responsible for any/all costs of medical attention and treatment.
By entering your name, you agree to the terms and conditions set forth, and your name will serve in place of a signature
First Name
Last Name
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Publicity Release
I hereby consent to the reproduction, publication and use of photographs or video taken of my child(ren) listed above, items (artwork, photos, videos, etc.) submitted to the Boys & Girls Clubs of the Pee Dee Area can be used for advertising, educational and/or publicity purposes in any and all publications, advertisements and publicity materials, without limitation or reservation. I also consent to any use of testimony or copy written by or about my child that may accompany said photographs or stand alone in any and all publications, advertisements and publicity materials, without limitation or reservation.
By entering your name, you agree to the terms and conditions set forth, and your name will serve in place of a signature
First Name
Last Name
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Memorandum of Agreement

I/we, the parent(s)/guardian(s) of the child/children listed above understand that the Boys & Girls Clubs of the Pee Dee Area, Inc. makes available organized educational and recreational activities for its’ members.  I/we understand that there are always dangers and risks connected in participation in such activities (particularly athletics) and, as Parents/Guardians of the child named above, I/we hereby give my/our approval of his/her participation in all activities of the club.  I/we understand that responsibility for any and all such risks and dangers (including any risks associated with the transportation to or from the Club or any club activity) and I/we do hereby release, indemnify and hold harmless the Boys & Girls Clubs of the Pee Dee Area, Inc. and Boys & Girls Clubs of America, the organizers, sponsors, supervisors and staff of all its’ activities, from any and all liability in connection with any injury (including any injury caused by their own negligence) to the child named above.  I/we likewise release and hold harmless from liability any person transporting him/her to or from any club activity.

I/we agree to adhere to the policies and procedures of the Boys & Girls Clubs of the Pee Dee Area, Inc. which are in place for staff, youth, parents, and visitors. 

I/we understand it is my/our responsibility to insure my/our child adheres to the club rules and follows staff instructions.  Inappropriate behavior, not following rules and staff instructions can result in my child’s suspension or expulsion from the Club.  If suspended or expelled, I agree to pick up my child immediately from the Club.  I also understand any fees paid will not be refunded if my child is suspended or expelled.

I/we agree to be financially responsible for any property damage or loss caused by my child from inappropriate behavior.

I/we understand that the Boys & Girls Club has a non-refundable membership fee.

I/we understand a late fee of $5.00 every 15 minutes will be charged for any child left after the club closes and this fee must be paid before a child returns to the club.

I/we understand my/our child’s successful participation at the Club can be enhanced with my active participation at the Club.  If I have a question, concern or comment about the Club or my child’s behavior I will direct my question to the Club’s director.

By entering your name, you agree to the terms and conditions set forth, and your name will serve in place of a signature
First Name
Last Name
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School Information Release

I give my permission to Boys & Girls Clubs of the Pee Dee Area and my child's school or respective School District to exchange information regarding the minor child(ren) listed on this application. The purpose of the exchange is to help both organizations do a better job of helping the student succeed in school, in Boys & Girls Club, and in life. This release is valid for one year and may be revoked at any time by contacting the School District or Boys & Girls Club in writing. 

By entering your name, you agree to the terms and conditions set forth, and your name will serve in place of a signature
First Name
Last Name
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**Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19**

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.

            Boys & Girls Clubs of the Pee Dee Area has put in place preventative measures to reduce the spread of COVID-19; however, the Club cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending the Club could increase your risk and your child(ren)’s risk of contracting COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending the Club and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Club may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Club employees, volunteers, and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the Club or participation in Club programming (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless the Club, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Club, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Club program.

By entering your name, you agree to the terms and conditions set forth, and your name will serve in place of a signature
First Name
Last Name
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**PLEASE NOTE PRIOR TO SUBMITTING** PART II OF APPLICATION WILL BE EMAILED TO YOU FOR COMPLETION

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