Paper form to download – English Form

PARENTAL AUTHORIZATION

I, parent, adult participant, or guardian of the above named participant fully understand that the participation in the Boys & Girls Clubs of Edinburg RGV and Teen Court Programs may result in serious injury or illness. Risk involved, getting hurt playing basketball, weight lifting, volunteering to work with concessions and concession equipment, travel, and more serious injuries may result from participating in a Boys & Girls Club program. Although I fully appreciate those risks, I desire to participate without regard to the consequence. I assume all risks and hazards incidental to such participation and do hereby waive, release, absolve, indemnify and agree to hold harmless the Boys & Girls Clubs of Edinburg RGV, City of Edinburg, Edinburg Teen Court, the organizers, supervisors, participants, volunteers, or any other individuals, firm or organization resulting in whole or part from any participation in the Boys & Girls Club programs and Edinburg Teen Court. This Waiver shall be binding on my heirs, legatees, administrators and assigns. Further, I hereby grant full permission to any and all of the forgoing to use any photograph, video tapes, motion pictures, recordings or any other record of my participation in these programs for any legitimate purpose.

No refunds granted under any circumstances.

I, also grant permission to managing personnel or other representatives to authorize and obtain medical care from any licensed physician, hospital or medical clinic should a participant become ill or injured while participating in activities away from home, or at any times when neither available to grant authorization for emergency treatment. I will furnish a certified birth certificate of the above named upon request by sponsors or supervisors.

Expectations of Conduct

Respect others. Respect yourself. Respect your Boys & Girls Club and what it represents.

Please read the following and sign indicating agreement:

I hereby give permission for my child (or ward) to become a member of the Boys & Girls Clubs of Edinburg RGV (the “Club”) and to participate in all programs and activities. I understand that the Club is NOT regulated as a licensed daycare by the State of Texas and that an open campus policy is in effect at all times. I further understand that the Club is NOT responsible for the time or manner in which my child (or ward) may arrive at or leave the facility.

I understand and agree that my child (or ward) must be picked up by closing time or a fee will be charged that must be paid before my child (or ward) can return to the Club. The charge for late pick-up is $5 per hour or partial hour.

I understand and agree that the Club cannot and will not administer prescription or over the counter medications of any kind to my child (or ward).

In the event of an emergency I authorize Club staff to secure medical treatment for my child (or ward) and that I, as the legal guardian, will assume any and all responsibility for paying medical expenses associated with such treatment.

I understand and agree that the Club does not refund memberships and that my child (or ward) must obey all standards of conduct. I further understand that behavioral problems that cannot be resolved may result in my child (or ward) being suspended from the Club without monetary refund.

I understand and agree that the Club or the City of Edinburg are not responsible or legally liable for any personal property losses or for any bodily injuries incurred and suffered by the applicant on any Club property or in connection with any activities at any of its facilities, or while engaged in any Club activities away from the Club.

I understand and agree that the Club does not provide medical insurance for my child (or ward).

I give consent for my child’s (or ward’s) picture or any reproduction thereof (while he/she is engaged in Club-related activities) to be used for publicity/fundraising purposes. I give permission for the Club to use my child’s (or ward’s) name or any fictitious one for publicity/fundraising purposes.

I give permission for my child (or ward) to participate in all BGCE Health and Life Skills Programming, such as, S.M.A.R.T. Moves (Skills Mastery and Resistance Training) a national prevention program that helps young people avoid alcohol, tobacco, other drugs, and teen pregnancy, Street S.M.A.R.T. a national program on gang and violence prevention and conflict resolution, valuing differences and positive peer helpers, S.M.A.R.T. Girls a national program that offers age-specific activities designed to build character and instill the values of integrity, self-discipline and mutual respect and Passport to Manhood a national program that instills in young boys the values and moral compass that will assist them in their journey from adolescence to manhood. I understand that topics of discussion may include physical, emotional and social changes in our bodies, dating and sexual issues such as HIV and other diseases, nutritional habits including eating disorders, healthy exercise, communication skills, taking care of your body, ethics, wellness, respect to authority and employment exploration and careers.

I give permission for the Club to administer occasional anonymous surveys to my child (or ward) for purposes of better understanding the needs of my child (or ward) and the impact of the Club on my child (or ward).

I give permission for the Club to obtain age verification of my child (or ward) from their current school.

I give permission for the Club to make and retain copies of my child’s (or ward’s) report cards and/or progress reports or to be given access to ECISD/ IDEA records pertaining to my child (or ward) in order to better understand the academic needs of my child (or ward) and to better assist him/her in his/her educational pursuits.

I understand that copies made of report cards and/or progress reports will remain confidential and will only be viewed by Boys & Girls Club staff.

I affirm that I have received and will read the Club’s Parent/Member Orientation Handbook.

I affirm that I have received and will read the Club’s Acceptable-Use Policy/Parent Permission Form.

The undersigned represents that he/she is the parent and/or legal guardian of the minor named above, and represents that he/she has the legal authority to execute this consent and release. If the child/applicant is signing for him or herself, the undersigned warrants that he/she has reached the age of legal majority according to the State of Texas.

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