General

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.

I, the parent/guardian of the minor child listed on this registration, am aware of and agree to the verbiage outlined in the NBGC Parent Member Handbook.

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.

Miscellaneous

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.

Sharing of Information with Nantucket Public Schools

I hereby allow permission for the Nantucket Boys and Girls Club to share information with appropriate Nantucket Public School faculty (classroom teachers, school administrators, and school clinicians), and for appropriate school faculty to share information with Nantucket Boys & Girls Club for enrolled program participants. Sharing of information may look like but is not limited to: communication with school guidance counselors and teachers regarding collaborative approaches to behavior, school performance, and academic support.

CONSENT FOR RELEASE OF STUDENT INFORMATION 

This consent form is for students participating in the Nantucket Public Schools/Nantucket Boys and Girls Club community partner program. The purpose of this document is to authorize the Nantucket Public Schools and the Nantucket Boys and Girls Club to share information about students/participants. Sharing information between the Nantucket Public Schools and the Nantucket Boys and Girls Club allows both parties to provide better support for a student/participant’s well-being, health and academic success. 

I. School Information About My Child 

I authorize the Nantucket Public Schools to provide the following types of information to the Nantucket Boys and Girls Club when it requests information from Nantucket Public Schools: 

• Aggregate Student Data, i.e., grade, race, sex, free/reduced lunch, special education, English language learner. 
• School Attendance Information. 
• Report Cards/Progress Reports/Grades. 
• Test Scores and Test Reports. 
• Discipline Reports. 
• Teacher Reports about Student Academic and Social Performance. 
• Individual Education Plans. 
• Behavior Plans. 

II. Club Information About My Child 

I authorize the Nantucket Boys and Girls Club to provide the following types of information when requested by the Nantucket Public Schools: 

• Program Attendance. 
• Program Reports of Progress. 
• Behavior Plans. 
• Teacher, Parent and Participant Survey Data. 

I certify that I have carefully read this form; that I fully understand its contents and implications; that I have had the opportunity to ask any questions; and that I freely, knowingly, and without duress or inducements of any kind consent to