STAR Leadership Training • Boys & Girls Clubs of Sarasota County Florida

Student Information

Student's First Name *

Student's Middle Initial

Student's Last Name *

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Session You're Applying For:

Summer 2019 Session (Venice)

Fall 2019 Session (Sarasota)

Spring 2020 Session (North Port)

Tell us about yourself. Include hobbies, interests, ways you spend your free time, anything that is important to know about you.

Who do you look up to? Why?

What are three things you would like to get from participating in the STAR Leadership Training?

How did you hear about the STAR Leadership Training?

Parent / Guardian Information

First Name *

Last Name *

Rules, Waivers and Regulations *

I agree to the above conditions *

I request my child be admitted to membership in the Boys & Girls Clubs of Sarasota County. It is expressly understood and agreed by the undersigned that the Boys & Girls Clubs of Sarasota County is not liable for the loss of property or injury unless such loss or injury results directly from Boys & Girls Clubs of Sarasota County negligence or the willful act of an employee of the organization. I also grant the Boys & Girls Clubs of Sarasota County permission to authorize and obtain medical care in case of illness and injury when neither parent/guardian is available to grant permission for emergency treatment. Under the open door policy, it is understood and agreed that all members may come and go, as they desire. Therefore the Boys & Girls Clubs of Sarasota County will not be held liable for your child leaving the building and or/grounds. I fully understand and agree to all of the conditions stated on this form and have counseled my child to conform to these rules and the authority of the employees of the organization. I understand that my child’s membership may be suspended or cancelled any time, the sole decision resting in the judgment of the Director. If my contact information (home phone, cell, address, etc.) changes I will let the Boys & Girls Clubs know immediately. This is a very important safety issue. I understand that if the Boys & Girls Clubs staff contact me regarding my child being sick or hurt that I will pick up my child immediately or make arrangements for them to be picked up. I understand that access to Boys & Girls Clubs’ network and the Internet are designed for educational purposes and the Boys & Girls Clubs have taken precautions to educate members on appropriate educational materials. However, it is understood that no matter how much supervision and monitoring that the Clubs can utilize, there will always be the possibility of my child coming in contact with inappropriate material, and I will not hold the Boys & Girls Clubs responsible for materials acquired on the network.

Member Assessment Permission *

Yes

Member to participate in assessments including but not limited to: Surveys for outcome measurements, schools, household demographics, and customized surveys built for specific programs (i.e.STAR Leadership and SRQ Volunteen). For valuable consideration I, the undersigned, hereby irrevocably consent to and give authorization for my child to participate in Member Assessments used by Boys & Girls Clubs of Sarasota County.

Media Permission *

Yes

Use of Name, Photograph and Identity in Connection with Advertising and/or Promotion of the organization For valuable consideration I, the undersigned, hereby irrevocably consent to and authorize the unrestricted use by Boys & Girls Clubs of Sarasota County of my child’s name, photographs, works of art and identity in various BGCSC website, social media and collateral material, as well as miscellaneous print publications and other media outlets, and any personal information that I supply to the Companies, in connection with advertising and promotion of the Companies and/or their products in any media, form or material selected by the Companies, without any right of prior review or further approval, whether such advertising and promotion is to the public, to the trade, or both, and in the corporate releases, newsletters and other communications of the Companies; and I hereby waive, and release and discharge said Companies and all agents, employees and officers of the Companies, including their agencies, media producers and customers from, any claims, liabilities and demands, past, present or future, including any that I do not now know of or anticipate arising in the future, none of which would affect my execution of this release if known to me, and waive all rights with respect to such use of my name, photograph, identity, and personal information including but not limited to publicity, privacy, psychological injury and libel.

School Data Release *

Yes

The Boys & Girls Clubs of Sarasota County will maintain all member files in a confidential manner. I give permission for pertinent information (i.e. all academic information, report card information, state testing i.e: FCAT or tutorial information) may be shared professionally with a Boys & Girls Clubs staff member.

Application Fee *

I agree to pay the non-refundable $25 application fee online (You will be redirected on submission of form)

There is a non-refundable $25 STAR application fee. If paying the application fee would cause a hardship for your family, please request a fee waiver (please send a short letter to the address listed above or an e-mail to skhong@bgcsarasota.com asking us to waive your fee). Do not let this fee prevent you from applying!

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STAR Program Success

Student Information

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