Music & Arts Center

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  • COVID-19 Updates
  • Virtual Classes
  • Virtual Music Lessons
  • Virtual Club
  • About
    • Staff
    • Parent Info
    • Calendar
    • Register
  • Contact

Music & Arts Center Member Registration Form

After enrolling in a class or camp, please fill out the below form to register your child as a member of the Boys & Girls Club Music & Arts Center.

  • Youth Information

  • The primary ethnicity of the youth
  • Youth's current school at the time of this submission, or school they will be attending if submitting during summer.
  • Youth's current grade level at the time of this submission, or grade they are entering if submitting during summer.
  • Does the youth reside with a single parent?
  • Number of people living in home, related or otherwise, including the youth.
    Please enter a number from 1 to 20.
  • Please check all that apply.
  • For example, are you wanting to expose your child to something new? Is your child already interested in the arts? Do you want them to improve upon already developed skills?

  • Second Youth's Information:

  • The primary ethnicity of the youth
  • Youth's current school at the time of this submission, or school they will be attending if submitting during summer.
  • Youth's current grade level at the time of this submission, or grade they are entering if submitting during summer.
  • For example, are you wanting to expose your child to something new? Is your child already interested in the arts? Do you want them to improve upon already developed skills?
  • Is the address and household information the same for both youth?
  • Does the youth reside with a single parent?
  • Does the youth reside with a single parent?
  • Number of people living in home, related or otherwise, including the youth.
    Please enter a number from 1 to 20.

  • Third Youth's Information

  • The primary ethnicity of the youth
  • Youth's current grade level at the time of this submission, or the grade they are entering if submitting during summer.
  • Youth's current school at the time of this submission, or school they will be attending if submitting during summer.
  • Youth's current grade level at the time of this submission, or the grade they are entering if submitting during summer.
  • For example, are you wanting to expose your child to something new? Is your child already interested in the arts? Do you want them to improve upon already developed skills?

  • Fourth Child's Information:

  • The primary ethnicity of the fourth child

  • Parent/Guardian Information

  • Name of the primary adult we will interact with.
  • Only complete if different than the Primary Parent/Guardian's address.
  • This person will also be allowed to pick the child up.
  • This contact will also be able to pick the child up.
  • A copy of the court order is required.
  • This information is required for grant and reporting purposes and will be kept confidential.

  • Release & Fine Print

    I agree to abide by the terms and conditions of the Boys & Girls Clubs of Benton and Franklin Counties (BGCBFC) Parent Handbook. Available upon request, is the Policies and Procedures Manual including the Health Care Plan, Pesticide Policy, Safety Management Plan and Disaster Plan (licensed programs). I agree to permit my child to participate in field trips or other activities sponsored by the BGCBFC. This permission is given with the understanding that transportation, if needed, will be provided by the BGCBFC by Club vehicle, school buses, public transportation, or other approved and regulated methods of transportation. I certify that my child is covered by medical insurance as listed on the above Membership/Emergency Form. I understand that I am solely responsible to provide such coverage. I agree to abide by all the rules of the BGCBFC pertaining to the health and safety of the members and to inform the Club immediately of any change in my child’s health, health care insurance, or medical provider. In case of serious accident or illness to my child, I hereby authorize the staff of the BGCBFC, my children’s physician, dentist, emergency personnel, and those individuals named on the Membership Form to give any necessary treatment to my child, including emergency surgery, at my expense. I understand that there is a certain amount of risk involved in even the simplest of children’s games, sports and activities, and I give permission for my child to participate in Club activities and programs. I agree that the BGCBFC, its employees, Board of Directors and affiliated agencies, shall not be liable for any claims, demands, injuries, damages, or actions to me or to my child as a result of my child’s involvement in BGCBFC programs or activities. By signing my permission below, I give permission for the BGCBFC to use photographs and other types of media of my child for promotional purposes. If I wish to revoke this permission, I will specifically request a Public Relations Denial form. I understand that the BGCBFC works with officials, staff, teachers, and other interested parties in my child’s school district for the express purpose of ensuring the Academic Success and well-being of my member. I give the BGCBFC, and its agents, permission to contact these individuals directly to discuss the attendance, grade progression, academic progress, disciplinary issues and other matters not specifically referenced of my child. I also hereby provide the School District with release to such documents that contain information regarding the learning assessment, reading level, homework status, behavior and other cognitive and skill-related determinations. BGCBFC may share information about the child(ren) 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 child’s school or school district, and other information collected by the BGCBFC. All information provided to BGCA will be kept confidential. I understand the implication of this Permission and Statement of Release. I certify that I am legally capable of executing this agreement, and that I have so of my own free will on the date indicated below, on behalf of myself, my spouse, if not signed separately, and our child for whom this form was prepared. I further certify that all information provided is the most current and understand that it is my duty to update this information should anything change.
  • By entering your first name, last name and date, you are agreeing to the above terms.
  • By entering your first name, last name, and date, you are acknowledging that you have received a copy of our Parent Handbook, that you have read or will read it, and that you understand and agree to the guidelines and terms outlined in the handbook.
  • By entering your first name, last name, and date, you are granting permission for your child (6th – 12th grade only) to leave the MAC on their own, giving them coming and going privileges as they chose without your presence. *This is optional. If you do not want your child to having coming and going privileges, leave this blank.
  • Date Format: MM slash DD slash YYYY
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