OCBGC Application Oscar Cross Boys and Girls Club

All children/youth must be at least in the 1st grade to be a club member

OCBGC Information: There is a $15.00 fee for the Year, and all snacks are provided free of charge. OCBGC will be located at OCBGC 2956 Park Ave Paducah. OCBGC will run from 2:30-6:00 pm, participants are expected to be dropped off and picked up on time. There will be a late charge of $1.00 added for every minute past 6:00 pm. Contact OCBGC for any additional questions: 270-444-9124 Membership Card – will be issued to each Club member – replacement cost $3.00

Student*

First Middle Last

Gender*

Male
Female

School Name

Current Grade

Birth date

Age (as of June 1, 2021)

Address

Street Address City State ZIP Code

Childs Home Phone

Parent/Guardian - Contact Information

Parent/Guardian #1

Prefix First Last

Parent/Guardian #1 Address

Street Address City State ZIP Code

Parent/Guardian #1 Home Phone

Parent/Guardian #1 Work Phone

Parent/Guardian #1 Cell Phone

Parent/Guardian #1 Email

Parent/Guardian #1 Occupation

Parent/Guardian #1 Employer

Parent/Guardian #2

Prefix First Last

Parent/Guardian #2 Address

Street Address City State ZIP Code

Parent/Guardian #2 Home Phone

Parent/Guardian #2 Work Phone

Parent/Guardian #2 Cell Phone

Parent/Guardian #2 Email

Parent/Guardian #2 Occupation

Parent/Guardian #2 Employer

Child lives with:

Transportation Release
Please list those people including in addition to parents / guardians who are permitted to pick up your child:

1:

2:

3:

Consent

I hereby give permission for the transportation of my child for official OCBGC activities by modes of transportation agreed to by the camp organizers (bus transportation) and by the individuals listed above.

Emergency Contact Information – Alternate Pickup/Release (If Parent/Guardian listed above unavailable)

Emergency Contact #1

First Last

Emergency Contact #1 Home Phone

Emergency Contact #1 Work Phone

Emergency Contact #1 Cell Phone

Emergency Contact #1 Email

Emergency Contact #1 Relation to child

Emergency Contact #2

First Last

Emergency Contact #2 Home Phone

Emergency Contact #2 Work Phone

Emergency Contact #2 Cell Phone

Emergency Contact #2 Email

Emergency Contact #2 Relation to child

Emergency Contact #3

First Last

Emergency Contact #3 Home Phone

Emergency Contact #3 Work Phone

Emergency Contact #3 Cell Phone

Emergency Contact #3 Email

Emergency Contact #3 Relation to child

Consent

I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.

Consent

I understand that the OCBGC will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.

*This section must be filled out for Boys and Girls Club statistics - Thank you

Annual Household Income:*

Below $5,000
$5,000 - $10,000
$10,001 - $15,000
$15,001 - $20,000
$20,001 - $25,000
$25,001 - $30,000
$30,001 - $35,000
$35,000+

Ethnicity*

Black
Hispanic
Asian
White
Multi

Income doesn't determine eligibility

Medical Release Information (ALL MEDICAL INFORMATION MUST BE COMPLETED)

Insurance Information

Policy Number

Name of Health Insurance Provider

Primary Physician

First Last

Address

Street Address

Phone

Hospital Preference

Please list any medical concerns, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).

List

Medical Problem	Required Treatment	Should paramedic be called?

Are there any food of environmental allergies that we need to be aware of?

Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?

Yes
No

If yes, explain:*

Is your child allergic to any type of food or medication?

Yes
No

If yes, explain:*

Does your child require a special diet?

Yes
No

If yes, explain:*

The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment. Is there any additional medical information that we may need to be aware of?

How did you hear about the OCBGC?*

After School Program
Website
School
Word of Mouth
Flyer
Other

Photo/ Media Release - I hereby give permission for my child to be photographed/media at and for the OCBGC. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of OCBGC and its affiliates.

Transportation Release

Consent

The Boys & Girls Club provides transportation to our facility and other regional locations after school.

OCBGC, and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. Children's’ photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician).

Guardian Signature*

First Last

Signature Date*

We need to fill out the attached Release /Inspection of Student Records form giving the Oscar Cross Boy and Girls Club authorization to look and monitor your child’s school records to help with homework, missing assignments and general studies. Thank you OCBGC Staff

Child's Name*

First Last

Date*

Parent's Name

First Last

School Attending*

Number*

Please enter a number from 1 to 12.

This is a release for the Oscar Cross Boys and Girls Club to have the ability to Release /Inspection of Student Records from the Paducah City Schools. This allows the OCBGC authorization to look and monitor your child’s school records to help with homework, missing assignments and general studies.

Approval*

Yes Approved
No Not Approved

Special sign up during COVID-19 Pandemic
Checklist for sign ups.

1. Are you an employee of an essential service industry and in need of childcare?*

Yes
No

Essential Service Employer*

WHAT ARE ESSENTIAL SERVICES?
Essential services are the services and functions that are absolutely necessary, even during a pandemic. They maintain the health and welfare of the municipality. Without these services, sickness, poverty, violence, and chaos would likely result.

Here are some examples:

Executive governance (the mayor, or his/her designee, who is in charge and has the authority to make executive decisions and enact policies)
Healthcare
Fire and police protection
Provision of clean water
Basic sanitation, including sewage and garbage removal
Maintenance of communication infrastructure (e.g., telephone system, radio, internet)
Maintenance of utilities (e.g., gas and electricity)
Provision of food and other essential goods (see below)
Transportation
Road maintenance/repair
Banking
Payroll departments
Tax collection

Essential goods are the food and other supplies that a municipality needs to survive, such as medical supplies and gasoline.
Essential workers are the personnel needed to maintain essential services.
Non-essential services are the services that are not essential to a municipality’s survival and can be stopped or closed down during a pandemic. Some examples are:

Tourism
Culture/entertainment
Libraries
Retail stores
Barber shops

2. Has your child tested positive for COVID?*

Yes
No

If so, when?*

3. Has your child been vaccinated?*

Yes
No

4. Has your child experienced any of the following symptoms or illnesses in the last 7-14 days:*

Yes
No

Fever
Diarrhea
Vomiting
Certain illnesses and rashes like chickenpox, measles or hand, foot and mouth disease
Vomiting
Certain illnesses and rashes like chickenpox, measles or hand, foot and mouth disease

5. Have you or your family traveled outside of the Country in the last 14 days and/or has had contact with someone who has (close contact)?*

Yes
No

6. Days child(ren) will attend:

7. Does your child have Asthma or other respiratory illnesses?*

Yes
No

Can you attest that the information provided on this application is true and correct to the best of your knowledge?*

Yes
No

Final Signature*

First Last

Final Date*

Oscar Cross Boys and Girls Club 2021-2022 Registration Form

All children/youth must be at least in the 1st grade to be a club member