2021-2022 School Year Membership Form

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Member Information


Apellido del Miembro
Fecha de nacimiento
Origen étnico
Origen otro
Nombre de Escuela
Emergency Medical Information
Nombre del médico
Permiso para tratamiento por parte del médico/hospital
Compañía de seguros
Política #
Necesidades especiales/Problemas de salud

En caso afirmativo, explique

En caso afirmativo, explique
Salga del edificio con el personal en excursiones
Ver Películas PG 13
Caminar hacia casa
Ir en bicicleta a casa
Note: Only parents, guardians, and emergency contacts listed on the form will be allowed to pick up your child. Please list anyone (nannies, babysitters, siblings) that has permission to pick up your child in the emergency contact section. 
Parent/Guardian Information
Nombre del tutor legal
Dirección postal
Código postal
Dirección de correo electrónico
**Please provide a valid email address as email is the primary method of communication between the Club and parents. **
Nombre del empleador
Emergency Contacts/Infarmación de Contacto en caso de Emergencia

Please read the following carefully:


I, the parent/guardian of the minor child listed on this registration, hereby release, waive, acquit and forever discharge the Nantucket Boys & Girls Club and Boys & Girls Clubs of America, their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organization’s staff, directors or volunteers from all liability, claims, demands, or causes of action for any and all loss, damage, injury or death and any claim of damages resulting from use of facilities owned or controlled by the above organizations, or participation in activities of said organizations either at or away from the Club.


Medical Treatment

I give permission to the Nantucket Boys & Girls Club to seek emergency medical treatment for my minor child if I cannot be reached. I will be responsible for any/all costs of medical attention and treatment.


Data Collection

I give my permission to the Nantucket Boys & Girls Club to collect information via online or written surveys, questionnaires, interviews and focus groups from the minor child listed on the registration. Any and all information received will be kept strictly confidential. Data gathered through these means will be summarized in the aggregate and will exclude all reference to any individual responses. The results of these analyses may be shared with Club staff, Boys & Girls Clubs of America, funders, and other community stakeholders to evidence program effectiveness and/or Club impact on our members.



As a member of the Boys & Girls Club, your child will have access to the internet. See the attached Technology policy for signature.



I understand the Nantucket Boys & Girls Club is not responsible for lost or stolen items. Please encourage your child not to bring valuables to the Club.


Parents and Club members are responsible for their own transportation to and from the Club.


I understand I will be financially responsible for any intentional damage or vandalism to the Club caused by my child.


I give permission for my child’s picture, moving pictures, or any other graphic depiction or likeness, to be used by the Nantucket Boys & Girls Club and its partners.


I understand the Club is not, nor does it claim to be, a licensed day care center.


Nantucket Boys & Girls Club complies with regulations of the Massachusetts Department of Public Health and is licensed by Nantucket Health Department.  Parents may request copies of background checks, health care and discipline policies, by contacting the Executive Director.

COVID Assumption of Risk & Waiver Letter

Dear Parents, 

As you are certainly aware, COVID-19 is an extremely contagious communicable illness that is spread through person-to-person interactions. Not all individuals infected with COVID-19 display any symptoms, but such individuals may nonetheless be contagious and spread the infection. State and local authorities are closely monitoring the spread of COVID-19 in the Commonwealth of Massachusetts and on Nantucket, and have introduced mandatory quarantines, social distancing and other safety measures to prevent the spread of the disease. Please also note that the Club’s plans will also be subject to change based on evolving guidance and changes in federal, state and/or local mandates or guidance.

Click the link to be taken to all COVID protocols and regulations that we will be following this school year: 


Although NBGC will comply with all applicable safety requirements, so long as COVID-19 continues to spread by community transmission and until there is an effective vaccine, there will be a risk that members could become infected with COVID-19 despite those efforts.

  • That risk extends to the families of members as well.
  • By electing to send your child to the Nantucket Boys & Girls Club this school year, you acknowledge and agree that the safety policies and procedures outlined above are reasonable under the circumstances, and that there is nonetheless a risk that your child could contract COVID-19 and/or become a symptomatic and/or asymptomatic carrier of COVID-19 despite the above safety policies and procedures.
  • By signing below, you knowingly and voluntarily assume that risk, as well as the risk that such infection could spread to other members of your child’s household or family.
  • By signing below, you are aware that the Club may need to close unexpectedly and inconveniently for positive cases and close contacts. 
  • By signing below, you hereby agree, on your own behalf and on that of your child, and of your heirs, executors, administrators, personal representatives, and/or assigns (“Releasors”), to forever release, acquit, discharge, and covenant to hold harmless Nantucket Boys & Girls Club, its trustees, employees, volunteers, representatives, and agents (“Releasees”) from any and all claims, suits, liabilities, and actions, including, but not limited to, any negligence of Releasees, which Releasors may have, now or in the future, which relate in any way to your child contracting COVID-19, or any symptoms or complications arising from COVID-19, as a result of attending any NBGC programs.

Further, by signing below, you agree that you, your child and anyone in your immediate household will abide by applicable terms of the Club’s plans, including without limitation, a 10-day self-quarantine if you travel out of state, and/or if anyone newly arrives to reside in your household from out of state. Questions about travel out of the country or out of the state will be addressed to you throughout the school year, as part of the Club’s plans.

Finally, in these uncertain times, you understand and agree that the duties and obligations of the Club may be modified or suspended immediately and without notice because of causes beyond the Club’s control, such as threats to the health and safety of members and staff, including the Covid-19 pandemic or actions by Government officials or health officials regarding the pandemic. If such an event occurs, you acknowledge and agree that the Club is not obligated to provide any refunds of payments made to the Club.


Jamie Foster

Executive Director


Parent & Member Permission Form Electronic Device Code of Conduct

Any parent who wishes their child used a personally owned or school owned electronic device with the Nantucket Boys & Girls Club must read and sign this agreement and submit to Club staff.


  1. The member will take full responsibility for his or her device and keep it with himself or herself at all times. Members may not lend their device to any other Club member or staff. The Club is not responsible for the security of the device or the loss/damage/theft of personal device.
  2. The member is responsible for the proper care of their personal device, including any costs of repair, replacements or any modifications needed to use the device at the Club.
  3. Members should only use their device to access services, networks, and files relevant to Club sanctioned programs. Members should only use the features of their device, including (but not limited to) taking or transmitting photos, video, location information, or other features in accordance with program offerings.
  4. Members may not use the devices to record, transmit or post photos, video or other information of or about a person or persons at the Club. Nor can any images, video or other information recorded at the Club be transmitted or posted at any time without the express permission of Club staff.
  5. The Club reserves the right to inspect a member’s personal device. Parents/guardians will be notified and allowed to be present before any such inspection takes place. Parents/guardians are free to refuse to all Club Staff to inspect a device; however, the member may be barred from bringing personally-owned devices to the Club in the future. This decision will be at the Club’s discretion.
  6. Members must comply with staff requests to shut down or turn off the device when asked. Failure to so may result in the member being barred from bringing personal device in the future.
  7. Violation of any Club policies, administrative procedures, or Club rules involving a member’s personal device may result in the loss of use of the device at the Club and/or disciplinary action.
  8. Members agree to use the internet safely and responsibly; members will not contact website they know are inappropriate; members will not give out personal information of any kind, including full name, address, or age. Members will not fill out any online forms without permission; members will never agree to go anywhere with anyone they meet through the internet. If someone, the member does not know, encourages them to meet somewhere, call them, or give them their phone number, they will tell a staff member.

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Financial Aid

¿Le gustaría completar un formulario de ayuda financiera para ser considerado para una beca?
If you would like to be considered for financial aid, email jasmine@nantucketbgc.org to request a financial aid application. We will require your most recent 1040 tax form. 

Payment Options

Total Cost

Payment Information