1615 Illinois Street Bloomington, Illinois 61701

Registration For Membership

Member Information

Parent/Guardian Information - Primary Contact

Parent/Guardian Information - Secondary Contact

The following information is completely confidential. This information enables us to provide the best possible services for our members, as well as statistical data for funding resources.

Household Information

Member Medical Information & Special Needs

Emergency Contacts & Persons Authorized for Member Pickup

Only those persons listed will be authorized to pick-up member in case of emergency please list individuals other than primary and secondary contact.

I. Membership Release Form

EMERGENCY: I understand that in the event of a medical emergency, every effort will be made to contact me. In the event I cannot be reached, I authorized the Boys & Girls Club of Bloomington-Normal and its agents and/or employees to secure emergency transportation and to secure and consent to any and all medical care and treatment for my child as deemed necessary by a qualified medical care provider.

LIABILITY: I understand that The Boys & Girls Club of Bloomington-Normal is not responsible or liable in any way in the event of harm or injury occurring to my child. It is agreed that I will hold The Boys & Girls Club of Bloomington-Normal harmless for the actions of my children or the action of other children that result in the harm of others or damage to property, including activities outside of the Club. I authorize The Boys & Girls Club of Bloomington-Normal to seek medical attention for my child should the need arise.

TRANSPORTATION: I am giving permission for my child to be transported in the Boys & Girls Club of Bloomington-Normal van/bus or the bus from another agency from school and/or to/from any field-trips relating to program activities that are within or outside the Bloomington-Normal area and held during regular program hours.

PHOTO/VIDEOS: I am giving consent for photographs, videos and/or like materials, in which my son/daughter may appear, to be used in any promotional materials The Boys & Girls Club of Bloomington-Normal may care to use them.

RELEASE OF INFORMATION: I am giving permission for the school my son/daughter attends to share attendance information, quarter and semester grades, suspension information and standardized test information with the staff of the Boys & Girls Club of Bloomington-Normal. This information will be used only by the staff in aggregated data reports and will not be used in any way that could identify an individual student.

COMMUNICATIONS: I also consent to being added to the Remind.com database to receive updates from the club via text.

COMPUTER LAB USE POLICY: I understand and will abide by the Computer Lab Use Policy of The Boys & Girls Club of Bloomington-Normal as stated in the Membership Application. If I commit any violation, I will respect the decision of the Boys & Girls Club staff as to the consequences of my actions. I have read the Computer Lab Use Policy of The Boys & Girls Club of Bloomington-Normal as stated in the Membership Application. I understand that this access is designed for educational and entertainment purposes and precautions have been taken to eliminate controversial material. I also recognize, however, that it is impossible for the Boys & Girls Club to re-strict access to all controversial materials. I will not hold the Boys & Girls Club responsible for unintentional exposure to such material while on the internet. Further, I accept full responsibility for all intentional harm caused by my child to computer resources of The Boys & Girls Club of Bloomington-Normal or any other affected parties.

As the parent/guardian, I DO NOT GIVE PERMISSION for my child to use the computer resources at Boys & Girls Club of Bloomington-Normal.

II. Club Rules

  1. All members must immediately sign-in upon arriving at the Club.
  2. Members must keep their hands and feet to themselves at all times (including play fighting, rough housing, and public displays of affection).
  3. All cell phones, other electronic devices or excessive currency must be kept in backpacks unless otherwise permitted by a staff member for a specific circumstance.
  4. The club phone is reserved for emergencies only.
  5. Vandalism or destruction of property will not be tolerated.
  6. All gum and candy must be kept in backpacks or it will be thrown away upon entering the building.
  7. Foul language, profanity, and name-calling will not be tolerated.
  8. Once you leave the building, you may not re-enter until the next day.
  9. Food and drinks may only be consumed in designated areas. Please note outside food policy.
  10. Gym shoes must be worn in the gym at all times.
  11. Members must be in a supervised area at all times; wandering the halls is not allowed.
  12. Members and visitors may not loiter outside the building.
  13. Members are expected to listen and respect staff and volunteers at all times.
  14. Tobacco, alcohol, and other drugs are not permitted on Club property or in the surrounding neighborhood. Anyone suspected to be under the influence may be asked to leave.
  15. Members in K – 5 must be picked up inside the Club by an authorized party.
  16. All members must follow bathroom expectations of their specific site.
  17. Bullying, in any shape or form, will not be tolerated.
  18. We don’t allow members to sell any items (i.e. fundraiser items-chocolates, shirts, etc.) during program hours.

III. Policies & Procedures

It is the policy of the Boys & Girls Club of Bloomington-Normal to operate primarily during out-of-school time or when school is not in session.

Transportation Policy: The Boys & Girls Club of Bloomington-Normal works with the schools to provides transportation to the Club by picking up at designated locations as well as contracts with local bus companies to provide transportation home for select members (Please see supervisor for current locations), and for local field trips. All members that ride the bus must understand and follow all the rules. If a member chooses to break a rule, they will not be able to ride the bus. Please understand that transportation at the Club is a privilege.

Bus Rules

  1. No eating or drinking allowed.
  2. Members must keep hands and all body parts inside the windows.
  3. Members must remain seated until the bus stops.
  4. Members must follow all Club rules while riding the bus.
  5. Members may not open or attempt to exit through the emergency door.

Late Fee Policy: Please be sure to make arrangements for your child to depart the Club by closing time. You will be charged $10 & Safe Passage of $5 for the first 15 minutes past our close time per family and $1 for every additional minute. If you are charged a late fee, your child may not return to Club activities until all fees have been paid or prior arrangements have been made. The Boys & Girls Club of Bloomington-Normal reserves the right to contact the appropriate authorities for assistance when members are not picked up by a reasonable time AND after all emergency contact alternatives have been exhausted.

Code of Conduct: One of the Club’s core beliefs is to provide a safe place to learn and grow. Positive attitudes keep the Club fun. Below are some simple guidelines members are expected to follow:

  • Respect yourself
  • Resolve disagreements in a positive way
  • Play fairly and honestly
  • Listen during appropriate times
  • Applaud the efforts of others
  • Be respectful of other members and their property
  • Avoid inappropriate language
  • Tobacco, drugs, alcohol, and weapons are prohibited at all times
  • Dress appropriately at all times
  • Participate only in program areas open to your assigned group
  • Running is reserved for athletics
  • Avoid lingering in areas without staff members
  • Say only good things about others
  • Take care of your Boys & Girls Club facility, property, and equipment
  • Bring your membership card everyday
  • Be respectful of the Boys & Girls Club Staff

Guest Policy: For security and safety reasons, we don’t allow members to bring guests that are not BGCBN members during normal program days nor during vacation or non-school days.

Food Policy: To prevent issues with allergies the Boys & Girls Club of Bloomington-Normal will not allow outside food to be eaten at the Club. Every day, all members are given the opportunity to eat hot, nutritious, and balanced meals from our kitchen. If your child has a food allergy, please request the separate Food Allergy form from the director. The form must be completed by a doctor.

IV. Illinois Alliance of Boys & Girls Clubs

21st CCLC & Teen REACH Program Parent Release of Information As the legal parent/guardian of my son/daughter, I authorize the School District and /or the educational institution my child attends to release the following information to the Boys & Girls Club of Bloomington-Normal on a quarterly basis: grade point averages, photocopies of report cards, school attendance rates, grade advancement information and graduation information.

Photocopies of this form shall be considered a valid release for all information.

V. Parent/Guardian Consent Form

I understand that the operations of the programs of the Boys & Girls Club of Bloomington-Normal are not regulated by child care licensing requirements.

As part of the optimal club experience your child will be participating in Boys & Girls Club of Bloomington-Normal’s SMART Moves program. The SMART (Skills Mastery and Resistance Training) Moves program is a nationally acclaimed prevention program originally developed in the 1980s with the help from prevention specialists and Clubs around the country. Newly revised in 2011, the program incorporates the latest information and approaches that BGCA has learned about effective prevention. Participants will be exposed to various activities designed to hone their decision-making and critical thinking skills, as well as learn how to avoid and/or resist alcohol, tobacco, other drugs and premature sexual activity.

As part of the optimal club experience your child will be participating in Boys & Girls Club of Bloomington-Normal’s SMART Girls program. SMART Girls is a program of prevention that educates girls about healthy attitudes and lifestyles. The program will address positive, healthy body images; healthy lifestyles including diet, exercise, and personal hygiene; physical and emotional growth associated with puberty including but not limited to sexually transmitted diseases, sexual truths and myths, menstruation, and the importance of regular exams; other questions girls have will also be addressed with a female staff member and/or brought to your attention when appropriate.

As part of the optimal club experience your child will be participating in Boys & Girls Club of Bloomington-Normal’s Passport to Manhood program. Passport to Manhood promotes and teaches responsibility in Club boys ages 11-14. Areas addressed by the program include healthy lifestyles including diet, exercise, and personal hygiene; physical and emotional growth associated with puberty including but not limited to sexually transmitted diseases, sexual truths and myths; other questions boys have will also be addressed with a male staff member and/or brought to your attention when appropriate. Passport to Manhood represents a targeted effort to engage young boys in discussions activities that reinforce positive behavior.

In addition, as part of all SMART programs, we will be administering a pre and post survey to assess your child’s knowledge and understanding of some of these topics.

The Club reserves the right to terminate this membership if deemed necessary, for the sake of any child’s well-being. I have read all of the above information and agree to the terms set forth by The Boys & Girls Club of Bloomington-Normal. PARENT & MEMBER: I have read and agree to abide by all items in the Membership Application. MEMBER: I will attempt to be safe, legal, reasonable, respectful, and responsible while at the Club or participating in Club activities.