MEMBERSHIP APPLICATION

Please complete all forms. Applications with missing information will not be accepted. Information gathered from this application will only be used to improve our services, ensure state/federal compliance and funding.

Youth Membership Types (check all that apply):

Child's Information

Gender:
Ethnicity / Race:
Primary Language (check one):
Child Lives With:
School Lunch Program Eligibility:
Does the child participate in any of the following school and private programs? (Check all that apply):
If available, would child benefit from working with a tutor:
History of/or current placement in special education?:
Has child ever been suspended?
Reason for need/interest in our Program(s)? (Check all that apply)

Parent / Guardian Information

Please fill out both sections if child lives with two parents/guardians.

Are you or any member of your household on active military duty?
Are you a client/resident of Housing Authority City of Yuma?

Additional adult authorized to pick up child:

Child's Medical History

Are immunizations up to date?:
Allergies?
Allergy medication?
Is child currently taking prescription or over the counter medications?:
Does your child have AHCCCS Health Insurance?:
Do you need assistance applying for it?:
Please list any known neurodevelopmental disorders (check all that apply):
Please list any known or possible medical conditions (check all that apply):

Emergency Contact

Transportation and Release

Child will arrive to the Center by way of (check all that apply):
Child is authorized to leave the center by way of (check all that apply):
Child will participate in Program(s) the following day(s):

My child is authorized to be picked up by:

I understand that if I allow my child to walk/bike home alone, SHINE Boys and Girls Center is not responsible for my child’s actions, safety, and whereabouts. SHINE will not release children unless the option above is checked.
I understand I need to give SHINE Boys and Girls Center one (1) day notice to any changes of authorized and unauthorized adults. Notice must be via email, mail, or written letter.
I understand my child must be picked up no later than 5:30 PM. I will pay a late fee of $25 applicable after 5:35 PM if I fail to pick up my child on time.

Your Signature:

Discipline Policy

Members of the SHINE Boys and Girls Center shall adhere to its fundamental principles to ensure an environment conducive to a peaceful and productive learning experience.
The SHINE Boys and Girls Center principles include the following core values:
Self-Discipline
Honesty
Perseverance
Kindness
Fairness
Leadership
Respect
Health and Wellness Sportsmanship
Responsibility
Courage
Citizenship
Members who demonstrate exemplary behavior will be recognized with a SHINING STAR AWARD. This award allows your child to earn points and redeem them for prizes.
Offenses include, but are not limited to:
Bullying
Fighting
Failure to follow rules/instructions
Possession of illegal or otherwise threatening items
Violence
Disrespect
Destruction of Property
Profanity
Vandalism
Inappropriate/disruptive behavior
If members conduct themselves in a disorderly fashion and disregard the Program’s rules and/or endanger their fellow members consequences will include at least one or a combination of the following:
  • Verbal warning
  • Clean-up duty (tables, chairs, trash, equipment, supplies, etc.)
  • Time out (write and reflect on their actions and how it affected others)
  • Report sent to parents/guardians
  • Meeting with parents/guardians to create Behavioral Support Plan for child
  • Suspension or termination of membership
  • *No refunds or credits will be issued upon member being dismissed from the program.*

Signature

Rate & Payment Agreement

AFTER-SCHOOL PROGRAM
Monthly Fee:
  • Child 1 = $75.00
  • Child 2 = $60.00
  • Child 3 = $40.00
Additional Children Each = $30.00
MILITARY DISCOUNT
After-School Program: $40.00 per child
SHINE van / walk with staff: $10
SUMMER BREAK
Weekly Fee:
  • Child 1 = $100
  • Child 2 = $80
  • Child 3 = $60
Additional children each = $50
TRANSPORTATION (per child)
Walk with Staff (OC Johnson) = $20.00
SHINE van pick-up = $20.00*
*Check availability with staff.
OTHER FEES
One-Time Enrollment Fee: $15
Late Pick-up: $25 per child after 5:35 PM
Late Payment Fee:
$10 per day after the 5th of the month
Returned check Fee: $40.00
PAYMENT INFORMATION
Acceptable forms of payment:
Check
Card
Money Order
PayPal

Signature:

Homework First Program

This is not a tutored class
Members registered for this Program will be required to complete their homework before participating in other recreational activities. Assistance may be available on occasion, but all members are expected to work on their own assignments.

Parent/Guardian Signature:

iPad Agreement

The SHINE Boys and Girls Center is aware that iPads are being issued for educational purposes. While we support the use of iPads for educational purposes, it is imperative that we outline the rules concerning our usage of iPads at our facility for our members and their parents.
The rules are as followed:
  • iPads are to be used for homework ONLY.
  • If using an iPad for homework, this must be used in the computer lab. When outside the computer lab, all iPads must remain in the backpack.
  • WIFI will be provided for HOMEWORK purposes ONLY.
If the above rules are not adhered to; your child will face the following consequences as listed below:
  • 1st Offense: Verbal Warning will be given to the member (child).
  • 2nd Offense: Member will lose iPad privileges for the day and the parent will be notified immediately.
  • 3rd Offense: Loss of privilege to use iPad at the facility entirely until further notice.

Parent/Guardian Signature:

Application Agreement

SHINE Boys and Girls Center, its sponsors, and all associate personnel reserve the right to photograph facilities, activities, and program participants for potential future use. All photos will remain the property of SHINE and may be used for publicity, reporting purposes, grant applications, and promotional or media use. I understand that if I disagree, I must provide SHINE with a written request to not photograph my child.
I hereby release SHINE Boys and Girls Center, its sponsors, and all associated personnel (managers, assistants, coaches, volunteers, etc.) of any liability that my child might incur while participating in SHINE. It is further understood that my child will respect and follow program rules and codes of conduct.
I have read the complete application and understand the rules of the SHINE Boys and Girls Center and request that my son/daughter be admitted into membership.
Additionally, I confirm I read and agree with all the forms included in this application:
  • Child’s Information
  • Parent/Guardian Information
  • Child’s Medical History
  • Emergency Contact
  • Transportation and Release
  • Discipline Policy
  • Rate and Payment Agreement
  • Homework First Program
  • Application Agreement
 
By signing below, you claim that you have completed the application, reviewed it with your child, and agreed to the above terms.

Signature:

©2020 The SHINE Program, a division of the Arizona Housing Development Corporation (AHDC). All Rights Reserved.

Created by Dutch & Dapper

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