2015 Membership Application - Boys & Girls Clubs of North Georgia

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T h eC l u ba t P C M S( P i c k es CountyMiddleSchool)706-253-1830
T h eC l u ba t J M S( J per MiddleSr:hool)
706-253-1760
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R o p e rP a r kC l u b7 0 6 - 2 5 3 - 06 5 ( H a r m 6 p 'Ty a
(HillC:ityElernerrt,arry)
W e s tE n dC l u b@ t h e L u d v i l l e mmunityCenter706-253-8973
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T h r e eR i v e r sC l u b
(AllGilrnerCountySchools)
276--2582
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POBox649 . la ;rer,GA 301,+3' 7(16"253-CLUB(2582)
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WEIL OMETOTIIIEBO\/S& GIRLS
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I3OYS & GIRLS CLUBS
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OF NOR]IHGEORGIA
D e a rP a r e n t / G u a r d i a n :
y o u rt r u s tt n u s
Welcome
t o t h e B o y s& G i r l sC l u b so f N o r t hG e a " B G C N Gf a" m i l y .W e a r ee x c i t e dt h a ty o r .hr a v ep l a c e d
to providea :;afeandpositiveplacefor yourr:h d t o a t t e n dw h e r n
o u t o f v ' o u cr a r e .W e t a k ep r i d ei ln t h e f a c tt h a t o u r c l u b s
a r eo p e ne v e r yd a ya f t e rs c h o o-l a n da t s o m e I u b s- d u r i n gt h e s u m m e m
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tandingof the services
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l e a rP r o g r a m . . . n of ot r b o t h .
pay,we ne:ed
I n o r d e rf o r o u r d o o r st o s t a yo p e na n de n s u r e\/veserveany childwho nr:edsus regardl,ess
of their abilil,.y'to
a d e q u a t ef u n d i n gf r o m m a n y s o u r c e s , O n e : r i t i c a lf u n d i n g s o u r c ei s t h e D e p a r t m e n to f H u m a n l i e r r , ' i c e(sD H S ) . I h i s
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s t t o k e e oo u r i d o o ros o e n .
We havereceived
noticefrom DHSthat in ord r f o r o u r o r g a n i z a t i ot on c o n t i n u er e c e i v i ntgh i sg r e a tf u n d i n ragn d p a s , s i n g
a l o n gt h i s l o r r um e m b e r s h irpa t et o o u r
s, we will needto haveall parents/guardians
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, u r c h i l dw i l l b e e l i g ; i b lteo p a r t i c i p a t ei f s p a c ep e r n r i t s
l f y o u r c h i l di : sn o t d e e m e de l i g i b l ea c c o r d i n g t h e D H Sg u i d e l i r r e ys o
. o um a y ,h o w e v e rb, e c h a r g a monthly program participationfee. lhis hrasyet to berdeterrninr:rlllLrt
i n t h e p r o g r a mY
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e t l e a s at o n em o n t hn o t i c eo f u c h . L e t ' sb e s u r et o d o c u m e ni tf y o uq u a l i f y !
I n a d d i t i o n ,w e w a n t t o e n s u r ey o u t h a t r e c
c o n f i d e n t i aal n d n o t s h a r e dw i t h a n Vo u t s i d e
a u d i t - a n d B o v s& G i r l sC l u b so f A m e r i c a .A l
a r e k e p t p r i v a t e ,s o p l e a s eb e a s s u r e dt h a t y o u r i n f o r r n a t i o nu , , i lrl e r n a i n
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Executive
Director
MicheleL.Crawford-Brackin,
B o y s& G i r l sC l u b so f N o r t hG e o r g i aI,n c .
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g o u t hi n P i c k e n&s G i l m e rC o u n t i e s
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OF NORTHGEORGIA
2014-2015Memhership Applicati,or
Y
NI
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N
No Fc,ster? \'
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Clubat JMS I\4edical/AtlergiesAlert?
Yes Nc, Internet? \'
N
ParkUnit
R.oper
14ernbermay leave on own? Yes No S-J\4oves?\'
N
lnrmunization
Docs'/
Yes No AC:D-AR? \'
N
WICI,COMBTO THE BOYS& GIII.LSCI,U
Yes Nrr PI-JI/VDR? \'
N
WestEndUnit
ThreeRiversClub lE Incomet)ocs?
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First Name:
MI
E t h n i c i t y ( p l e a s er e v i e wa l l c h o i: e st h e nc i r c l eo n e )
Native ,{rr erican
(not ol' l " l i s p a n icc, r i g i n )
White/Caucasian
fl'lack/Aflicarr
Anrerican(nct o f I { i s p a n i co r i g i r r )
Hispani
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STAFFUSE ONLY
N/A
IF]:I
'feen?
'Yes
N
L a s tN a m e :
Doesyour chiildreceivefnee
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l N a n r e / R c ' l a t i oinps, :l r
M y c h i l d r n a yp a r t i c i p a t ei n a c t i v i t i e si n o r a d j a c e n t o t h e C l u b b u i l d i n gw i t h s t a f f a n d / o r v o l u n t e e rs u p e r v i s i o n ?
Yes
No
l s y o u r c h i l d p e r r n i t t e dt o l e a v et h e I I G C p r e m i s e s i t h o u t a s t a f f r n e r n b e rp, a r e n t / g u a r d i a no, r a u t h o r i z e da d u l t ?
Yes
No
l f y c s ,p l e a s ew r i t c y o u r p r i n t e d n a m e h e r e : .
anrd the sign hert::r
As an affiliarte
o f B o y s& G i r l s C l u b s o f A m e r i c ar e h a v eb e e na s k e ctlo s h a r eC l l u l bm e m b e rr e g i i s t r a t i , oann d p r r r g r a mp a r t i c i J r a t i o r r
n i t i a l h e r e: _ - * _
i n f o r m a t i o n .N a m e sw i l l n o t b e u s e d .o n l v t C l b rm e m b e r s h i pn u m b e r s . P l e a s ri e
T h i s i r ;n , Da' tn o p t i o r r : )
S i n g l eP a r e n t H o u s e h o l d '
Farnily Income Level: T'hisinformationis MANDATC)R''Yfbr grant
Yes No
r e l a t n dp u r l l o s e(sw i l l L r ek e p tc o r r l r d e n t i a l )
*",\lI infirrmation
Is this nelv member a fostenc itd?
2 Persons:
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S
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is requirerl
3 Pensons:
the response
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5 Persons:
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a n d t h e nw r i t e
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rvrll reniainshictly'
FosterParent
8 Pensons:
S
1'earlyincome.
9 Pensons:
S
Other:
conlldcnti al**
Yes
No
Statusi: Guard FLeserrve ,\ctiric
I s t h i s m e m b e ra c h i l d o f M i l i t a r y p e r s o n n enl o t l i v rigon a N,llilitaryBase?
If yes,pleasecircle one: MarineCorps Air Force l\rmy Navy CoastGuard NationalGuard Duty iStation:
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BOYS & GIRLS CLUBS
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iatlSGCNG.
l'his certainlly
helpsus to keeprr ur memhershipdueslorwand alFfordable
for everyonerl
All Clubrnemberswill be assigned
a staffrn 'nber/menrtor
whrowill helprthsrylin crneor rnoreareasas notedbelow.
l f a n a r e r ias n o t c h e c k e di ,n f o r m am
l entori Ep
s i l l t a k ep l a c ew h i l l ey o u rc h i l di s a t t h e rC l u b .
j r o g r a r nasn d a c t i v i t i ew
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OJPMENI'ORING
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NEEDSPEROURGRAI{TAGREEME]VT
PAIRENT/GUARDIAN
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l \ n t i s o c i aBl e h a v i o(rd e f i n e db e l o w )
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C i P A( l o w ,m a i n t a i no r t o i m p r o v e )
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WI"THYOU!
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CLUB MIEMIBER
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* S o c i aCl o m p e t e n c(ed e f i n e db e l o w
*'*hntisocia
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F a m i l yF i e l a t i o n s h i p s
G a n gI n v o l v e m e n t
A l c o h oal n d D r u g s
Schooll\ttendance
GPA(low,maintainor to improlrel
Other:
Other:
. l , t h ( 3p a r e n to. r l e g a l g u a r d i ahne, r e b yg i v em y p , : r m i s s i of n
r l "/ e n t c l r i n g
o r m y c h i l dt o p a r t i c i p r aitnet h e f o r m a l" i n d i v i c l u ; N
P r o g r a ma t t h e B o y s& G i r l sC l u b .
. I f u l l yu n d e r s t a ntdh a t t h e p r o g r a mi n v o l v e m
s e r 1 [ o rw
s ,h o s h a l lb e s e l e c t e c l f r o n r t hceo m n r u n i t b
y ru t p r i m a r i l yt ] G Cs t a f f ,
t h a t v v i l bl e s c r e e n e(di n c l u d i nagc r i m i n abl a c k g rr.rnd
< checl:)and trainedbeforebr:ginning
the program.A m{rntorwill b,e
e x p e r : t etdo s p e n da m i n i m u mo f o n e h o u r p e rw r ,erk
with rnychrildon-siteat th,eBGC.The mentor is not allo'vved
to take or
m e e t m y c h i l cbl e y o n dt h e C l u bf a c i l i t y .
. I u n d e r s t a ntchl e i m p o r t a n coef m y c h i l da t t e n d1gthe wer:klymr:ntoringsessions
and will makeeveryatternptto have,r
h i m / h e ri n a t t e n d a n c eT. h i sp r o g r a mi s p l a n n e dt l l a s to n e l y e aar n dc o n t i n u a t i om
n a yt h e n b , ed i s c u s s e d .
. I u n < i e r s t a nt hcal t d u r i n gt h e c o u r s eo f t h e m e n tl r i n g p r o g r a mt h e r em a y b r :s p e c i a l g r o uepv e n t :(;i n c o r p o r a t i n g lrar lel n t o ' r s
a n dy ' o u t ha) n df a m i l ye v e n t sp l a n n e d .I u n d e r s t a
td that tlrr::staffrcfthe Clubr
will provideongoingmonitoringof tthe
m e n t c l r i nagc t i v i t i e s .
. W e l ' e etl h a t m e n t o r i n gh a p p e n a
yoLr1o
s t a l l t i m e st h a 'yourchilr:l
attendthe Boys;
& GirlsClubprogramr.We enr:or,irage
h a v ey o u rc h i l da t t e n da s o f t e na s p o s s i b l eb,u t i n ;rarticular,
de:;ignated
weel<ly
sessions.
o -*--*Yes .---No
give
p re r m i s s i otno o b t a i r m
I
the Boys& GirlsClu r M e n t o r i n gP r o g , r a C
mo o r c l i n a t o
, r y c : h r i l cal c' sa d e r n i c
a n d a t t e n d a n cree c o r d fsr o m m v c h i l d ' ss c h o o l .
r ----Yes
I permitBoys& GirlsClub o f N o r t hG e o r g i aI ,n c .t o u t i l i z ep h o t o g r a p hasn dv i d e oo f n r r /c h r i l tda k e n
.--No
d u r i n gh i s / h e ri n v o l v e m e ni nt t h i sm e n t o r i n gp r o 5r i a ma n d v r a i v ea l l r i g h t so f c o m p e n s a t i o n .
Signatureof Parent/Guardian:
Date:
*SocialCompetenceis definedas the ability to achievepersr
a n d a c:rosssituotions,
gools in :tociolinte,ractionwhile mointoining positiverelationshipswith others over t,ime
+*AntisocialBehctvior:A pervosivepottern of behovior that
deceitftrlness,irritobility, consistent irresponsibility, lock of r
loys disre,qord
for and violation ol the rights of others,societolmores,(,,rthe law (:;uchos
rse, failure to conJ'ormto socio,lnctrm:;),
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OF NORTH GEORGIA
r O u rC l u bi s t a k i n gp a r ti n a n a n n u aSl U
t h a t w i l l b r eusedtr ) tr ackthe wellbeingof r ne r y r b€)i nr sBoy sIi; .
G i r l sC; l u b sn a t i o n a l l yO.u r C l u bi s o n e of g r o u pc r fC l u b sacr ossthe r :ountr ypar ticipating
in thi :;s ur v e'ythat
a s k sh o w m e m b e r sf e e l a b o u t t h e a c vi ties ar r d tinr e t h e y s p r e n da t t h e C l u r be, d u c a t i o np l a n s ,d n r C
i n v o l v e m e ni nt c o m m u n i tsye r v i c e
a n dW rk.
I l t d d i t i o n a l l yt h, e s u r v e ya s k sa b o u t h e attitr .r der
and
s healtl' rbehavior sof Club men nber si ,i nc l udi ng
q u e r s t i o nasr b o unt u t r i t i o na n d p h y s i c a l rctivity.l[-eenmembers;,
iaged]-3 arrd older, arel;r:;kr:daddition;rl
q u e : s t i o nasr r o u n a
d l c o h o lt,o b a c c oa n d ther dr ug r .r se,
fighting,ar r ests,and whetherteens ar e s ex uar l l y
actlive.
r lv le m b e rw
s i l l b e a ske dto co mp l e teo
3 0 4 5 m i n u t e st o c o m p l e t ea, n dw i l l b e
P a r t i c i p a t i ri n
r gt h i ss u r v e yw i l l c a u s en o r
m i g h tf i n dc e r t a i nq u e s t i o ntso b e s e n s i t
r €sl u r V € ! ' i n
t h e s p r i n gd u r r i n rge g u l a C
r l u bh o u r sl.i - h es u r v e yt a l : c s
m i n i s t r : r eedi t h e ro n l i n eo r v i a p a p e r& p e n c isl c a n n a l obl e
o o k : tl se ; .
k to your child.T' heor r lypotentialr iskis that somr teen
r nr :r nbr :r s
e
pr i v ac 'y
, Thesur veyl"r as
beender signed
to pr oter :tyour ch i i l d':;
M e m b e r sw i l l t put tlreir nameson the survey,and
n o m e m b e rw i l l e v e rb e enticlnedby namein a report,of the results.
guardians;
Clubstaff and pa
do not seethe resultseither,
r A ll in f o r r n a t i ofnr o m th e su rve yi s b e i usedto assess
the wr ellbeing
of $6r ys& Gir lsClu [:sr nem ber sanr C
hn
at is
w i l l b e k e p t c o m p l e t e lcyo n f i d e n t i aO
l . n t h e B r c , y&s G i r l sC l u b so 1 ' A m e r i cnaa t i o n aol r r g a n i ; r a t ti o
s ser eonly r epor ts;
of the infor mati c lcnr :m bi nc ,C
c o n d u c t i ntgh e s u r v e yw i l l h a v ea c c e stso he data Other rwill
f o r g r o u p sc l fy o u t hi n t h e s t u d yo r a l ly o u 1 rat a Clr .r b.
No reportswill be sha
lthatshlowy/ourchilld"sianswerlion the survey.
par t in thr e:tur vey.
ey
r ,r r ihr
l l :l p
The r esultsof tl' r is:;unv
;
r Y r c ucr h i l dw i l lg e t n o b e n e f i tr i g h ta w fr om tar king
y o u rc h i l d; r n do t h e rr n e m b e rosf B o y s& l i n lC
s l u b si n t h e f u t u r eb y a s ; s i s t i a
n lgl n a t i o n aBl o y s&, G i r l sC l u b st , o
s e w o u l dl i k ea l l m e r n b e ras t o u r t l l l u bt o 1 [ a kpr :a r l
h a t b e s tm e e t sm r n b e r s ' n e e d W
d e v e l o pp r o g r a m m i nt g
i n t h rr:s u r v e yb, u t t h e su rve yi s vo l u n ta ry. o a c t i o nw i l l l l e t a k e na g a i n stth e C l u b y, o u ,o r y o u rc h i l di f h e t s h c
an,C
r
su rve y rticipar r ts
canskipanVqu€) stions
thr eydo not wis l rto an:;ur er
do e sno t t a k e p a r t .Ad d i ti o n a l l y,
n th e su rve ya t a n pointwiithoutpenalty.
ma ys t o pp a r t i c i p ati ni g
I giverpermissionfor my childto
I do not givepermissionfor my ch
Parernt/Guarrdian
Signature:
Survey.
rticipatein the BGCAl\lationalYoutlrOutcomesIniitiative
Survey.
NationalYouthOutcorrne:s
in the BGiCA
to parllicipate
NEW MEM BR S'[ART.UPSiLIPPLY
LIST
A N DM E D I C AINF()RMATIONI
lrage6 of 14
NEW ME
I t i s " s u g g e s t e d "n, o t r e q u i r e d ,f o r a l l n e w
b e r sa n c l / o rf i a m i l yu n i t st o d o n a t ea n a d d i t i , o n a$l 2 5 u p o n r e g i s t r a t i o nr l o
help offsetthe supply cost(s)required to
t l v n e e d e da n d
Iland PLrrrrp
Hilnd Soap
F i r s tA i d S u L p p l i e s
D i s p o s a b lCe L r p s
BER SIIART.UPSUPPLYLIST
C
pport your chrildfor the vearrlOll donate 8 of the items listetl trelow.
ConstructionPaper
LooseL,eafPaper
l-ysolDis;infectant
TP o' Kleenex
Haindlianilizer
Nn p k i r r s
DICAL INF'ORMATIONI
P l e a s en o t et h a t s t a l Tm e m b e r sc a n n o t c l m i n i s t e p
r r e s c r i p t i o na n d / o r o v e r - t h e - c o u nr :l r n r e d i c a t i o nusnf t ; s s
i n a L ne m e r g e n c l ' s i t u a t i o nA. p a r e n t / g u a n m u s t m a k e a r r r a n g e m e r rttos a d m i n i s t e ra n y a r n da l l m e d i c : a t i o n s .
Y o u t hM A Y
l F i r s (N a m e :
LastNamc:
D o c : y; o u r c h i l d h a v c
Yes
h e a l t hi n s u r a n c c o \ e r a g c ?
l ) o e sv o u r c h i l d h a v ea n y a l l e r g i e s ? Y c s
I f v o u r c h i l d h a sl b o d a l
l D o e ys o u r c h i l d h a v ea n y o t h e r
n n e d i c aclo n d i l i o n s( d i s a b i l i t i e s , Y e s
i n f e c t i o n sv, i r u s e s e
, tc.)?
ls your childcurrcntlytaking
any medications Yes
( p r e s c r i b e do r n o n - p r e s c r i b e d ) ?
I n t h c o ' e n t o f c m e r g c n c ya n d f i r s t a i d
i s r c q u i n c do n - s i t c ,m a y w e a d m i n i s t e r Y e s
B e n a d r y la n d / o r N e o s p o r i n ?
I f 1 , s 5;,1 r ,n a n r eo f i n s u r a n c ep r o v i d e r :
lf ),es,;rleaselist them:
in snaclkson a dailv/week.lvbasis(we will store vour childl'ssrnachs).
l f 1 ' e sp, l e a s el i s t t h e m :
l f 1 , e sp, l e a s el i s t t h e m :
lf l,esp
, l e a s ec i r c l eo n eo r b o t h . . . . . . . . . B e n a d L r y l
thcn initialin the box.
Pleasebe sure to noti y C l u b S t a f f i f a n y o f t h e a b o v ec h a n g e s . . . t h a : n k s !
I t i s r e c o m m e n d etdh a t a l l p a r e n t s / g u a r d i a nds a t e f i r s t a i d s u p p l i e si,n c l u d i n r g
b u t n o t l i m i t e dt o B e n a d r y l& l \ e o s p o r i n ,
i f y o u w o u l d l i k e f o r u s t o a d m i n i s t e rt
medications in tlte event of emergency. Not required - just rec()murended*
l n t h e e v e n to f a n e
rgency and a parent/guardiancantt be reachred,
Club staff will malie an attempt to get in
h with tlrr,renrerg;encv
contactsa s l i s t e d o n t h e m e r n b e r s h i p a p p l i c a t i o n .
*Pleasebe sure to notify
your
b staff iif any o'f
emergencycontactscha
By sig,ninghelow, I certi/v the above inJr
North ()eorgia (BG(-I\G) to contuct me if'my
is lrue to tlte best of trtlt l1v1o1s1etlge.
I aulhotrize Boys & Girls Clult:so./
ild is ittjured unal/or hurnrcd'in an.ywq). I also aulhorize BGCI\lll to seeA
nrcrlical attentiotr.frcrm)t cltilil if he or she is
iured anal.,/or
l'tarmed untl ne'ed;simntediate medical assistuncrzu,/ u lot'ul
hosltitul or emergenq) cure cenler. I certifl,
I urrtl/or our.funtil.lt's ittsurance'prttyitler will be resportsibt!e.lbrun.1;
./itruncial nredical cosls thil nruy be u
t:ottsitlerotiott of their granting nry
releuse,indeuni.fj' uttd ltoltl
lYorth Georgia./'rom ony Iiability,
assisluncetlrsl ntav be rteededsnd
L e g a l N a m eo f P a r e n t / G u a r d i a n
:iuted witlt all medicul attention und treatnrent given to nty clrild. ln
t'lte opportu,tit.yto participnte itt'tlte Afterscho'rtl Progrum, I hereb.y
llte Deparl'ntent o-flluman Resourcesund Bo1,s& Girls Clubs oJ
or lenrunil resultingfrom unlt legal medic'ttl attettttinnund
u:; a resulll oJ un injury or harmful inctident t'o my cltiltl.
Parent/GurlrdianSignature
AGADtsMIGREL
SE A,l'.lD
PHOT(CTVIDEO
IRELEASI:
Page7 of 14
AUTHORIZATtrON
F( )R RELI|]ASEOF ACA]DEMICINFOIRMATION
Boysli GirlsClubsof NorthGeorgiais a p ivate,not'l'or-prol'it,
youthdeverloprment
organization
servinr;youthin both
Pickerns
& GilmerCounties.We prideourselvesi t developing
proglrams
centererd
on AcademicSuccess/Job
Fleradiness,
Healthy
Lifestyles,
and Character
& Leadership
Developnent. Holt'dowe provideour sr:rvices
withsuchlow annualmembershin
dues'?
Glad you asked!
Individuals,
businesses
and civicgroupsar( our locall'undingl
sourceserndwe reallyapprreciate
theirfinarrcial
supportl
Hrcwever,
the majorityof our fundingcomesfron grants, T'hesegrantscomr-a
v7i[[objectives/goals
thatwe needto meetanrj ir
turnhaveto follow-up
witheithera monthly,quartrrrlyor annualreports.we haveto proveto themthatwe are makingan imprac;t
- our academicprogramsin supprrt of the localschoolsysterns.We also undergoa yearlyIIGCAevalualion.
in particular
lf uresucceedin documenting
the impacton our rnembers......wethenbecom,e
eligiblefor erdditional
and/orsustained
fun,lingl
We mu€t havetheseqrantsto cr)ntinuesen/ices! 'fhrisis wherrewe need \/orurheln!
We needI'oryouto giveBoys& GirlsClubsof N rrth Georgiaautl"rorization
b get il copyof yourcl"rild's
proglrersrs
reports,rerport
cards,test sr:ores,# of behavior/disciplinary
referrerlsand attendancerecordsi.\/ve,the staffilnd parents/guarclians
together,cian
-l-his
thentargetyourchildfor helpin academics,
behzvior,and/crr
help'yourchildbe betterpreparedfor school.
is rruhat
tfreClub
is all abcrut!**Wewant to ensureyou that rec rrdsare keptprivateso pleiase
be assuredthatyourinformation
willremain
confidential
and notsharedwithanv outsidesour:el"Namelris)
are notsubmittecl
in grantreports-we use mr:n,hrersrhip
numbelrrs.
AI]TIIORIZATION F( IITRELII]ASEIDFACADEMIC TNFO!3WIQN
Mychild,
__, is currrentlyenrolled in an after
s c h o o l p ro g ra msp o n so re d b y Boysl& Gir ls Clubs r cfNor th Geor g[a( BGCN G) .
I autlhorizemy local school syst€rn to relklaseinformationcontained in rmychild's school
record 1lothe BGCNGleadershiptei rn on a ,quartrerly
basis and at the close of thersc;hoolyear.
.This informationwill includegrades,
tes : scores, lt of behavior/disciplinaryreferrialsanrdattendancer,ecord!;*
P a re n U G u a r d i aPri
n n te dN a me
P- n enUGuiar dian
Signatur e
Diate
C l hi l d'sSc hool
;\UTHORIZATION FOR REL ]ASEOT'PHOTOS/VIDEOFOR PUI}LIC RELATIONIJ
Th s;portionof the membership
application
yourpermission
requ,rs;ts
for Boys{i GirlsClubsof NorthGeorgia,ernclthe
r.ieorglra
Department
of HumanServices(oneof our mair f undingscurces,l,
to takeand use photographs
and/orvideoof yourc;hild
arrd
otherprogranrstaff. When we tellothersthe storr ilboutour organization
(prirnarily
to potentierl
mennbers
and fr:ndingsourc(3{j),
it
wou d be helpfulto sharephotographs
of the parti;ipants.Picturescan enhancepeople'sunderstandrng
abcutvrlhois irrvolveci
n
the pro5;ram
and what activitiesand servicesare beinglonducted.lf you havemorethanone r:hild,thisforrnshouldlcer
connpleted
for eachchildparticipating
in the prog'erm.lf yolragreefor us to t,akr:
and use the,sephotographr;
and/orvideos,our
use of themwillinclude,butwillnot necessarily
b : limitedta,thefollowing:publications
aboutthe program;rec.uitrnent
activities
to rr:achadditionalyouth
who mightparticipate
in the futurer;
and/orreportsaboutthe programto supportersand otherswho iarr:
intenested
in the program's
outcomes.The local 'rewspaper
and our websitewillbe keyto marketing
our programs lf you lrave
anyquestions
regarding
thisreleas:r,pleasecontactMicheleL. Crawford-Brackin
@706-253-2532.
1\UTHORI.ZATIONFOR REL l.N_aE qIoTosA/rDEo [oR pur]Lrc RELA:frc)NIi
t------- l
l , t h e p a r en t/g u a rd i aIn , OO tl DO NOT giveconsentthat stillphotographs
arrrd/crr
videosmay be taken of my hildanclusedfor Boys& GirlsClub i&Departmentof
H u ma nS e rvi c)s marketingpurposeaLsstatedabor,'e,
f y o u D O c o n s e n tp, l e a sel i sta n y l i mi ta ti,nSher e:
ParenU G u a r d i aPri
n n te dN a me
P i renucurardilan
Siqnature
Date
Child's Namrer
C L U BP O L I C I E SR,U ES AND EIXPECT,ATIONS
Page8 roli'1rl
CLUBPOLIClE:S,Rl-lrLHS
AND EXIPHCTATIION$
Club Operatiion
Hours: The Clubclosesat 5:45 :.m. (unlessotherrwise
notederttheClubUnit). Youthmustbe picrked
up ncr
pick-uptime. Pleasedo not requels;t
laterllhanthe designated
sprecial
exceptions;
for your chilcl A latefee will be imposedif you
are lateon repeatedoccasions Repeatedlatear ivalscan and willresultin yourcl'rild's
membership
beingrevr:ke<jThanksin
advancefor erdhering
to thispolicy Pleasenotetl erpostednotices,/handouts;
for changesin regularCluboperationhours
En<Jof Day Youth Pick-up: Pleasecome inside h e b u i l d i ntro3 r e c e i v e
a n d s ; i g n - o u t y o u r c h iW
l d r. er e Q u € s l t h a t y o uot fh€ r 3 t
askerdto wiaitby the frontdoorsto "look-out"for p rents/guatdians
iand/ortostandin the parkinglot. Pleasedo not useVourc3ll
phonr:to callin to the Clubrequesting
Clubstafft sendyoilr cl'rildout to you. \A/e'recountingon parents/guiardirans
to review
noticesand havecontinual
contactwithClubStaf \lVe'dlil.u,l
to see voul
Transportationof youth bv ISGCstalFlland
volunteersis NOTpermittedat any tiime!
Discripline:I understand
thatmy childmustadhe'ertoall Boys8i GirlsClubrulesand directions,
bothverbalandwritten In the
evenlof repeatednegativebehaviors,
I understari thatmy c;hild's
rnembership
can and willbe revoked,ther,afr:lre
s/hewillno
longerbe abk:to participerte
in Clubprogramsan( activities.I underrstand
that mv c;hild's
membership
fee and/r:rsummerferer;
willnot be re,funded.
POWERHCll,JR
HomeworkClub: Membersare erquired
to cornpletehomevrork8, schoolass;ignrnents
beforeparliciparting
rrr
- in writingy
programsand activities.lf you prefertr do homelvork;
recreation
withyourchild,plerase
informus uponregistration
F r o u l l a n g u a g e ( i n c l u d i n gn a m e c a l l i n ga
rcswearins,t,
di:;respectto stalT,and stealinq will not be llolerated.
Snracksmust be prorrded by ltheparenUguiardian
on a clailybasis.
Phone Usagr::All youthshouldhavepre-arrange
I transoortation
homebeforearri'val
to the Club. Clubohoner;arertobreused
for r:nrergen,cies
ONLY. lf a middleor highschoo Clubmernberhas a cellphone,it may be us;edduringdesignatecl
timesas
tSlubs.
direcledby the individual
Rulesfor accessirg the Inh=rnet,
texting,ernail,ancl/orsocialnetworking
are es;t:rblishec
at thil
youthshouldnot bringa cellplrone1lothe C;lub(if s/hehars
CIublevelanrlapprovedkryBGCNGadministratio
r. Elementary-age
one,it mustbe leftin theirpersonalbookbag at a t i m e s ) .
Membersare responsiblefor "intentionalhr"lost or danraqedequipmentand supplies.
Persionallterms:Youthshouldnot bringpersona"play"itentsto the Club. We are not responrsible
for lostor stolenitems s;c,
pleasedo not allowyourc;hildto bringthem. All b rokbags,jack,ets,
umbrellas;,
ertc.shouldbe clearlylabeled
Bikes/Scoollers/Skateboards:
lf yourchildridesa bike,sc;ooter
or skateboard
to the Club,it rnustbe securedoutside.Youtl-r
prcperty
mav not bringtheseitemsinside Pleasenotetha ,d/eare not responsible
for lostor stolenproperty(even
ifsecur,ed
outctocrs)
Absolutelv
no fiqhtinqor horseplay.At no I tnne
Awav'!
mavermemberhit another- in anqeror "iust plavinq''----Walk
MembersNreeding
SpecialCare: PleaseinformC;lubstaflfif yourchilclneedsspecialassistance
in a mid to largc'
to participate
grouprps6ps;rtion
your
provid,a
We
setting.
will make everyatte npt to acr:r:mnroclate clhild,however,wr3?[e unableto
on(:]-rlr-r-crne
superrvision
and assistanc;e
on a continualbasis. :'arents/guardians
are welcomre
tclcomeand playl
Parernt
Volunteers:We inviteyou to comeout a ,:lplay,however,if you planto spendmorethanan lrhour, prerwreekthe
you willhavecontactwithr:hildrerr
willneedto be con rletedanclapproved.Sincer
BGC:l{G
Volunteer
Application
otlrerthanyour
*ti
'n
policy
pertairLs
investigation
own,thisinc;ludes
a background
confidenl)/ouv/illunderstand
this
as it
to the safet)/of you',ohilcl
as well.
(includinq
premises.
This Facilitvis a Druq-FreeZone AbsolutelvINOdruqs
smokino)onrthe
prograrTr
tlre
SMA'RTMovres:The SMARTMoves(SkillsMastrryand Resistance
Training)prev'ention/education
addresses,
prololems
uses;
decisions.Basedon proventechniques,
the prr:granr
of smoking,drugand alcoholabuse,an, makingprositve
assertiveness,
disc;ussion
and role-playing,
as youthlearnresistalce and r,efusarl
skills,to delrrslop
sllrengthen
drrr:isir:n-rnal<irrg;
sess;ions
m e d i aa n d p e e ri n f l u e n c eA. l l a :rtivities
and lvillbe held in specificage groupr
s k i l l s ; a nadn a l y z e
arc)age-atppnrpriate
in tlrisprograrn
T h e ur l t i m a t e r g oTaO
T
My'child(circte
one)CANor CA'NNO'[participate
l : P R O M O T ER E S P O N S I B L13EHAVIOR.
Policy".,.
meaning,it is the parent/guardian's
Open-DoorFolicy: Pleasekeepin mindthattha we havean "Open-Door
person.
responsibility
to informthe staff,and child, thats/ re shouldremainon the Clubpremisesuntilreceivedby an a;thcltized
rlc
property,
so ,An
we
are
not
legally
responsibl,o
to
child
to
stay
in
the
.llub
on
BGC
although
We willstrorr5;ly
encourage
the
and
truithoul:
premises
parenVguardian
leav'e
willbe mac: in the eventthata Clubrnemberdecidesto
the
atternptto contactthe
providesan after-scl"rool
permission.Pleasekeepin mindthatthe Boys& )irls Clubs;of l\or1hGeorgier
educ;atirr:rn
& recrr:ati,rtr
yourchild permiss;ion
to go to ancjfrom the Cl.tbr
for yourchild,not a daycareand/or b llbysittingseruic;e.lf you gyive
experrience
time,s/he may not rer-enter.
at his/herleisure.oleasenotethatoncea membe leavesfor the sercond
.staff mentttetr.
We are not responsible for ANY child tha /eayes the Clutt without prior permission fram a BGCIUCi
Pare,nt/Guard
ian Signature:
Club Memlrer'sSignature:
C O M P U T E RIENTEiIR
A1{DINT'ERNET
USAGE
Parqe9 of 14
CENTE:IR
ANIDINTERNI=T
USAGE
**C L U BME MB E R SA R E R E
Youthmust havewrltten
NSIBIL.E
FORTHEIROONDUCTI\ND ACTIVITIIEi S* *
permisrsion
renUguardian
to userthe internert.
Abscllutely
NO downloa of any kin<jwithoutprionpermissiolr
frornstaff.
p
ri
n
t
P l e a sed o n o t
a rnaterials
unlerss
approveld
by a staffmember.
A b so l u te l N
y O fo o d , inks,cernrdy,
or gumin the computer
centers.
Alwaysremember
th youareresponsible
forwhatyoudclonline.
Members
shouldn changt,l
anyof tlhecontrolpanelsettings.
Neveragreeto m
in pensonwith anyorteyou meet online
N e ve rg i veo u t
I inforrnation
o\/erthe Internet.
\/our
S h a reco mp er tim ewith
fellowmember sl
Have fun urfing llheNET hut d,ornotvisit
any of
restric;tedlsites liste,dbe,low.
GOC) II]
JUDGEMENT!
l\lliddle{t High School Members On : Club member cell phrcneswith lnterrnetaccesiiri,
texting,
email, anrJ/orsocial networking capa ilities may berused drrrriing
designatedtimes as dirrectedb'y
p
e
rmi
t h e C l u h . . . a n do n l y A F T E Ra
ion fornnis siignedby the parenUguardian.Tlririiis not thr-.
ission form---please uestthis form fromtVourClub'sUnit Director.
TI.IEFOLLO\ruING
ARE RESTR TED SITES]TORALL.OF THE BGCNGCOM PU'T ER S
Any websitethat asks r user information
beforeaccessingthe site.
,Allpornography
site to includeall sexuallysuggestive
m ater i;al.
Any sitewith ch or lM carpabilityregardlessof conternt.
productioninl'ormation
A l l d ru gw e b si contiaLining
.
l n sta n t
saginglliite,s
iandPersonral
Email
M u s i cs i or sitest1'rat
containranylyrics
Anya All Sorpial
Nretworking
Siitels
NoF
*Members who intentionally
I D O g i v e p e rmi ssi o nfo r my
child to use the Internet.
C l u b M e mb e rP ri n te dN a me
C l u b Me mb e rS i g n a tu n e
Pa r e n U Gu a n d i aPnri n te dN a
i a n S i g n a tu re
Pa r e n UGu a rd
-lwitter,
k, li4yS;pace,
ellc
y and ,t\ll"hette"sites
Y'r:uT'uhre
fhese.sifes will hav<>t,heirintern,et privileEet; re:vokecf.
I DO NOT girr,epermissi<lnlFon
child to rusethe Internrert.
Club M embr erPr intetjNa m e
Club MemrberSignaturrc:
Far enUGuar dian
Pr intedNi am e:
ParenUGuard
ian Siqnature
AFTERSC}{OOL
RAMINISfUIEELIGIBILITYFORFJI Pagel{} sf l4
-29-2014
?014lMnh{gf; iltp YEAn.UPFATED,f
Ilol's & Girls Clubsof lrlortlrGeorgia, ng i,vith the Georgi* Deparfinentof ${umanSerlsices{Dl,lti}. airc
partnering
to providevaluableand exci ing out-of-schaolprcgsam$fbr youth in tieorgia. T'he in{i:rrnlrri{}fr
providedon the following fqnmslvill
i en$ursthat $ligible youth are ber:efiting lrom the partnership.\\iu
re'ceivef'undsfor each incomeeligihle ld that ws $effe---this is how ws rran qrfTera uominal f**e i'irl
membership.
Knowthatilris,stilldoesnot coverwhat is raquiredto serueyour child .* but it doqshelpl lf ycr.rtlo
notqualily',wewill nrakeeveryattemptto t yourchildintotheprogran:.Wethmk youfor yop.sc)opomlion
Hfi*#
FOITMTO I}N COMil'L TNN BY THN PARHST/G{.]ARI}IANI{:ARCIVIR
A
Parenf/Guardian/CaregiverI nfo
- I*ir reet/lrlnma#t be wnryleted ln lts entlrely.
n-arneof Parenv0uardianlCnregiver
{l,a"st,First,M
SocialSecurityNumber
$treetAddress
+Optional,
brrtknowthat if youreceiveanyBGCNG
discpunted
services,
we
C i t y " * * . . - . - * . . * S t a t e . . - - ' . . - - -Z*i -pC
ode
-*T***-.
I"lomePhone#
Youth/ClubMemberInf'ormation* Thts
Cell#
auditedbv
DH$.
n u$l bg canrytleledln lts sntlrcg].
rrf'Youth
Nanrc
(Last,First,Ml)
Participant
SocialSpcurity
Number
Male
Fernale
Dateof Birth (mmidd/yy);
ttf ftl.oM $ll$*-We are nshingfor
$ocinlSccuritynumber(r)because
any psruoilapplyi4gfur ur
rec*ivingfederal bene$tsmurl give hi* on hen$ocinl $ei:urity nurnber. Fedennllnw {09{a} (4} nf fh+ Sorinl
Sncurity Act anrl fedcral regulations 45 CFR 264.10)allsw us to collect this informEtion.
llv signing
thisapplicatir:n,
r
I swear,underpenalry
*f perjury,thatm t
thisapplication
aretrue.&nd
hestof m1'kttowledgeatltlreinfirrmation
andstatenents
in
['ve prnvielud
r
I prot]liseto cooperatewith a*y eflbrt lo
pr*vided.
ify theinfrrrmalion
r
lf selected
to participatcin the pr*grom,I
i$: ta abideby all rule* andguidelines,
ParcnU()ar*giv*rl(iuardian
Pri*rcd Nsnre
Date
ParenfiC
aregiver/Cua
rdian Signature
D*te
PageIlofltt
A.
I]
Istheyouthparticipantlillub
member
n Yes n Nt:
ls &e youthpnrticipan#{-lub
menrber$eorgiaresiclsnl?
rYes INo
Dosstheyouthpartiffiparr#Club
rvithone{ l) or rnorenf the threecttegorirslnltlrv?
r icientily
(AnsrverYHS or NO andcheckall
Youthparticipant
is
is l8
Youthparlicipnnt
equivalut'rt0r fJost
rieslhnt apply):?
nYes nNa
theageof5 qndl? yearsold;
old nnrlcuNrsiltly
enmll*d in school(high school,GBn progratnor
ndaryinstitution)
andwill beenrull*{l
in ANDsnendschoql
duringthe
year;fi$
academic
Youthparticipant
is l8- Qyearsoldandhosa d*pendent
parenl
childAND isthecustotiial
If you an$wsreds'Yss"to A, $
C in Sectio*I, ple*seproeeedt,o$ection2-PartOnt
Doesl,$ur clrild recsiveFree CIrRoducedllunchss
at uchool?it Yes
nNo
ff&ei
*heStiC
lvly chilc{,*
fionn
below,I authorizea representtrtive
get verbaland/orwritten verif"icationof
P*rentlGuardinnNnme
rrfRe
, receivpseitherflee or reducsdmealsat schnol, $y sigrring
ti)
tiy'stcnr
& Oirls Clubsof Nortlr Oeorgia,inc. to contectthe schor,:J
ving this service,
Pnrent/Gusrdisg$ign*tnre
llste
,Sw*:a *e.1
Pagel 2 of l,f
D* von currentlyrcceivebenefitsor
ycu will har,'e
lerprovideoffici*l verifica
s underany*f the programslistedbclorv(Fleasel{ote.:
to the lloys & fiirls Cluh;:
l. 1'A1.,{r.
,, r";Yes n No
2. F"*odStarnps..
Yes n l\i'o
Pcrachcare,
3, Meclic$kl.
Amerigroup. ellCare.
nr S*cislS*curitylncome(SSl).....".. Y*s n N o
If you,
:ii
subrnii
ap
.ketsw
h# j
Tlie:
ST0P ANDs$lslS*WSH,
lff'ffi
lTr'*ornplete
ill!fu for rtre
{li$qp- itt
* freftre procueding,pleusere!'ert* the
detines 't*mily anil" and upltlic$ble lncrmrp
pqy *f tlris application pucket (an the hac*) to vicw the ANS .fbrm thtll
.''"
**Pleu,ye
fu udvised,incomevurifitaliCIn itemslistsd in Section3 andSeilion 4 mustbe ahtwinedunt{u t'unt
nru*tbeatt*chedto tke respectiveyautk's 'onreeli gibi Ii t1t rm und CI uh memhw"vl,tip u11p
I i mt dun,
"fb
(I)
F*rnllylJnitliks
ANI) GrosslHousetrotd
M0ilthly
t2) Pleassreview the clrsrt
below
.lncunrc
Numhern{'Psrsons
in FarnilyIJnit
DH$S
MnnthlyHnu
mcomeS
(3) lf yo,qrtotalgrosshouseholtl
nfSnF$Xl,Vinronrc
isrudlWffiSWl&Sffi
YOUR CHILD TSNEEMEI} TNCOMMXI,IGIBI.Ii
* *{ * {rr! rt* ***
-t
6
7
I
l;i;ir;AIiti.]r.'al-*ndd
theamount
tistcrt
r'
the chart to the left, accordingto ths # of perstxrsirr
yorr housrholtl),plwse circle thc nppropriatc rorv {t*
tho left) and fhen proceetlto Sectinn#4.
* * * *tr * ****9r*
* *tr ** * * tl tt
If your total groru
lncomeis gfrater than thr:
amount listed nn the chart, accordingto the numher
of peruon*ir your househuld,y'ourchitd is NO'l'
'I'hc
In*onre &ligihle.
memberrhip appli*ati*n is nnrv
complete**plensesign below and r*tnrlr it ta ths CIuh
to ge.tyour chikl oflicinlly registered".
STOP AN} $TSN HERK:
P a g e1 3o f I 4
'l'his
xectio*tn hecompleted
OIJI,Yif ygur
is equaltr:ror belowth* affisunts
listedonthechartin $ection3.
Please
c*mplete
Scction
4 by listingyourlnam(thensmesf thephild(reniwholivewithyou,zurdrheoth+rparenr
of'thc
child(r'en)if slhelives,r.l,ith
yr:u.:List anf gros monthlyin*omefor ench.
deducti0ns.
crosslffi$*ffi
l-lorvottenpaid'l
Inccme
Income veriliciltioefor itemt tisqd inlSection 3 and Section4 must be abtr,inednnd & copy nruts{hd
uttucherlto the respecliveyowth's inclme eligibilityform nnd Club ttemberskip *pptiration, '!'hunlt;1
you for t*king time to help w get *dd+ional tunding for aar progr*m! Vpur chitd ir deemedinmmA,
eligible. Pleasesuhn it
lhe apylrcfttanl*nd verific*tian farm(s) to a BGC staff mernberin order to gel
yoar chilrlofficiallyregistwed,
oq
A# [Jffi.Qtr'iLY
r'ned
ber'
arrd,rhis
meni
:ffi*ffi*fi
ir
:
I
Does-mlrneettheDH$
l
i.:t:')
Auth*riaedProgra*rt
:l
rli
p.Hfls{ss,n$,snfi
eslef_u${T
Ifnge Id qrfl,{
l'ir;: $cprrrrrn*ntnl' l{uirr*n $ervices'l'r;:rngror*ry
A
f,,'il',resl*d
nndccrtainrxh*r inrlividualslirring i6 {iq
lirr iricorlyFaimills$definiti()nof fbmily includesthe r1ependent
child lbl wholrt iliisislnrrrr is
witlr th{e{hild rvhn qrrsrequirrd to be includsdin thBfanrily
l'h* f'slluwingindividuals$rsr:on$id$rccl
membeps
of
r
pur*rrrof the
A hrological
or adoptive
r
r\n eligibl*ninor sihling,iwh*le. hnlf rrr
F*mily I"lnit:
rhild for rvhrlruasslsxance
is reqilested;
r
r
{)therchildrrxliving in tlrehonrewho $rr;ll
liuniiy tJnit:and
A non.fnrsntr{lttlivo who ,isthe cxrr*teiftor
il'
lncornerverificsti(ln mu$the
lir*mples ol's$rnodincrmc vcrificntion *rut
.
Pn)'stubs
or receiptsfor $e rnostr*csnl four
*
!V-2 liomrr:
r
hlmployrsr"g
issueij,signcdnnddntecidqc
r
lJcrsolnlinc*mul*clgerrrrtllblsl {e.g"s{Sl
I
Quarterl! ifiu)$o tnx returns;
r
Annutl incrnr* iar returnswhsrtrFfe.ienrrldin
I
l.,extitrAtatement
fltrm employetl
r
Doturn*nlnlionlronr o*er DPCS xtnf'l'$unlh
n*
r
l;'oxn li09 ol itrrmizetlst$ternsntconrplrltudby
ve) olirh* duprmdtmtchild I'trrwhom assisrancu
is retlu*sied;
n the spcc:ifiuddtgruDnl'relationtlhipto the grililxeerslutivebut who nro not msnrb-rrsnl"tlre
is no pnrentin ihn horneor if tho *nly p*rent in the h$rfiereccivr:sS$ll.
rils$.M
$,nReft
nfipt&qns
r$d n cofly rllu$tbe anachedto rheyoutlr'$ incomc e,ligibiliryfbrrr.
s ol'earningr;
uary * March clurul$rl
*l igibi lit,vCtvl; ansl/or
elnplnyer,
Exrnrplcr of unenrneelincomeverillcnllon srcl
I
Colrl'ofsurent 0he0kwith {heck stubs(rvithi la"\t4 *-eeks);
r
4.,r,*rdlcttcrsor rvritten.sign*d and da.lpd
t ot"pa.ver;
r
StrcialSecurit.r,
llecords,
r
!Volker'sc(llupen$ationrecurds;
r
l'rrnn ll-{)^ Conlributionstatsrnent:
|
l.jucmploytrrsntin$ufnnc{gclairn
retorcls{;
r
SUCCIIS$screcninl'ornrationtund/or
r
ii'I'AR|li,
l:lnchof the I'ol
souroesol'inrrorne
is consid$rpd
in de{ernrining
eligihility:
l.''it$tqd
'
.
r
Wages
or sal*ry* Orossincornerf lh* tpp
$ietlnunnre
Ii'onr$elf:llnrployrnent
lrin\rloy*ecurrrnrigsion
t
.lur1l.)uty
* ifengagoclin r,irarnggerncnt
,icntitllndono* {regulmnndongoingplny
ol'properly for on averag$oJ'?0hoursor rgoreper rreekr
I{oofior lncome- (regulorand ong$ilxgp*!.me
I
t i$ u$udto d$l$rmiil'religibility
LhsiN.m{id
?
t
t
t
t
a
I
I
I
t
h'lilitary r\1l$tnrenl
s
C*rihgilis {llraritalrle
gilt irxceeding
iinm and orgimir,ationrcceivirrgsttrteor l'rcderolfturd$
$300re**i
lnherititnces
lnsurance
$*nclitsdue1o[.o;rsof lncofie *
pnliuyduetr: lossoll incnrne
iits pnirlllronrnn insurunce
$ocial$ecaritylSen*lils
t.lnemplovmenl
Cornpcn*ution
Workrrl''ti (onrpento{ion
,{lirn*ny* {r'cgulnrzurdongoingpttynlstll$)
('hild Support
- (regular
arrdongoingpr!.vnrrnt
llili'nl Allr)tn)*nt * Faylncnls rete ive<l trr,lrn
pr{}S$rnl$.
nt-$pon:iored
suclrasAgricultulnl$tnhilir..ttir:n
nnd(.)onssrv*ri{}u
$er'\.iLr$
Veteran'slletulits
t
Ilr*tion
(l*pital ilains
I
TrustI
Irferostr'Ann{rit"v
I
ili$abili 'Payntenl
{)npilnl0ainsr'Dividcncls
I
ll*nrcler n{;ome* {rr:gillnrand onsr}iltgpaymsnl$)
* {r*gular snd $ttgoin$
I
l!ental
F$ymenls- il'eng*geclin
Fln$ags
cf pr*perty{br an*vetageuil?0hoursor hssperrveuk}
conrpensltionthlsugfl rrstiremenlplnrr