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Boys & Girls Clubs of the Pee Dee Area JES 21st Century Membership Application
This application must be completed in full and signed by parent/guardian.
A large portion of the Clubs’ funding comes through grants. Much of the following information will only be used for statistical data on the overall program and will be held in confidence.

Johnsonville Elementary School 21st Century Membership Application
First Name *
Middle
Last Name *

Signatures are required on these forms. Typing your full name below is considered a legal signature.

Gender
Race
Describe who the youth lives with
Annual Family Income (Check One)
Does Family Receive Public Assistance?
Other Organizations Your Child receives services from
Is there an Active Duty, National Guard, Reserve, or Veteran in the household?
Prefix
First Name *
Last Name *
Prefix
First Name *
Last Name *
In Case of Emergency Information

Please provide the following information in case an emergency arises and we can not get in contact with you at any of the phone numbers listed on the front page of this application. Experience shows it is best for you to list 2 individuals, other than parents, that do not live with you.

Prefix
First Name *
Last Name *
First Name *
Last Name *
Medical Release

I give permission to the Boys & Girls Clubs of the Pee Dee Area to seek emergency medical treatment for my minor child 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. (Typing your name below is considered a legal signature.)

Medication Used of Needed?
School Information Release

I give my permission to the Boys & Girls Clubs of the Pee Dee Area and my child’s school or respective 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, in the 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 the Boys & Girls Club in writing.

School Information Release
Publicity Release

I hereby consent to the reproduction, publication and use of photographs or video taken of my child by the Boys & Girls Clubs of the Pee Dee Area, 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.

Publicity Release
Data Release

I, the parent/guardian of the minor child listed on this application, give permission for Boys & Girls Clubs of the Pee Dee Area to survey my child about his/her Club experience, behaviors, skills and attitudes using Boys & Girls Clubs of America’s National Outcomes Survey or other survey instruments. 

I also give my permission to the Boys & Girls Clubs of the Pee Dee Area to share information about my 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 Clubs of the Pee Dee Area, including data collected via surveys or questionnaires. All information provided to BGCA will be kept confidential. 

In our reporting, we will NEVER name ANY CHILD individually. We will use the information ONLY in combination with information from other Club members. ONLY a limited number of authorized Club staff will have access to this information AT ANY TIME.

Data Release
Memorandum of Agreement

I/we, the parent(s)/guardian(s) of

First Name *
Last Name *

understand that the Boys & Girls Clubs of the Pee Dee Area 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 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 understand the Boys & Girls Clubs of the Pee Dee Area operates in partnership with Johnsonville Elementary School and Florence School District 5.

I/we understand it is my/our responsibility to insure my/our child adheres to the school's rules and the club's rules and follow 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 that 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 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.

My signature below signifies my acceptance of this memorandum of agreement.

(Typing your name above is considered a legal signature.)

Survey Question
Transportation Release and Indemnity Agreement
Additional Details

I, the parent/guardian, of

First Name *
Last Name *

hereby give permission to the Boys & Girls Club to transport my child(ren) home daily from the 21st Century Community Learning Center’s after school program. Please check with the after school program director as to the after school’s days and weeks of operation. 

I understand the Boys & Girls Club will contract with Florence School District 5 to provide this service. 

I understand this transportation service is a privilege, not a right, and the privilege may be taken away due to misbehavior on the bus, in the after school program or during the normal school day.

I understand that if my child is suspended or expelled from the after school program or the normal school day he/she will not be able to ride the bus home that day. 

I understand if my child misbehaves on the bus, he/she may be suspended from riding the bus home, as well as possibly being suspended from the after school program.

I understand if the school closes early because of inclement weather, or other safety issues, my child will be transported home by the school district’s normal transportation program. This means your child may be dropped off at home significantly earlier than normal.

Release:

I/we, the parent(s)/guardian(s) of the above named child(ren) understand that the Boys & Girls Clubs of the Pee Dee Area makes this transportation service available for its’ members. I/we understand that there are always dangers and risks connected in transportation and, as Parents/Guardians of the child named above, I/we hereby give my/our approval of his/her transportation home from the after school program. I/we understand the responsibility for any and all such risks and dangers and I/we do hereby release, indemnify and hold harmless the Boys & Girls Clubs of the Pee Dee Area, Florence School District 5, 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. 

Transportation Release

(Typing your name above is considered a legal signature.)

Country
Address Line 1
City
First Name *
Last Name *

Our Impact This Year

  • Days Open a Year

    252

  • Youth Served

    3,000+

  • Club Sites

    8

  • Healthy Meals Served

    160,500+

Our Partners & Designations

  • Gold Transparency 2026
    Gold Transparency 2026
  • Best of South Carolina
  • CompliAssure
  • Verified by Viking Cloud
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