ENROLL TODAY | The SHINE Program | Boys & Girls Center

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):

After-School Program

Summer Camp

Mentor / Leader Training

Educational Workshop

Child's Information

First Name:

Middle Name(s):

Last Name:

Gender:

Male

Female

Birthday:

School:

Current Grade:

If other, please specify:

Primary Language (check one):

English

Spanish

Other

If other, please specify:

If other:

School Lunch Program Eligibility:

Free

Reduced

Not Eligible

If other, please specify:

If available, would child benefit from working with a tutor:

Yes

History of/or current placement in special education?:

Yes

Has child ever been suspended?

Yes

If yes, why?

Reason for need/interest in our Program(s)? (Check all that apply)

Child Care

Learn New Skills

Other

If other, please specify:

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?

Yes

Are you a client/resident of Housing Authority City of Yuma?

Yes

First Name:

Last Name:

Relationship:

Address:

City:

State:

Zip:

Phone Number:

Cell

Work

Home

Phone Number (alternate):

Cell

Work

Home

Email:

Employer:

Occupation:

Work Number:

How many members are in your household, including yourself?

How many members will be attending the Center?

Email:

Work Number:

Additional adult authorized to pick up child:

First Name:

Middle Name(s):

Last Name:

Relationship:

Address:

City:

State:

Zip:

Phone Number:

Cell

Work

Home

Phone Number (alternate):

Cell

Work

Home

Email:

Child's Medical History

Date of last physical exam:

Are immunizations up to date?:

Yes

Allergies?

Yes

Allergy medication?

Yes

If yes, please specify:

Is child currently taking prescription or over the counter medications?:

Yes

If yes, please specify (provide name and reason):

Does your child have AHCCCS Health Insurance?:

Yes

Do you need assistance applying for it?:

Yes

If other, please specify:

Please list any known or possible medical conditions (check all that apply):

If other, please specify:

Member's Insurance Company:

Member's Primary Physician:

Phone Number:

Emergency Contact

First Name:

Middle Name(s):

Last Name:

Relationship:

Address:

City:

State:

Zip:

Phone Number:

Cell

Work

Home

Phone Number (alternate):

Cell

Work

Home

Email:

Transportation and Release

Child will arrive to the Center by way of (check all that apply):

Walking

Parent/Guardian

School Bus

Other

If other, please specify:

Child is authorized to leave the center by way of (check all that apply):

Walking / Bike

Picked up by parent/guardian and authorized adults on this form ONLY

If walking / bike, what time?:

My child is authorized to be picked up by:

Relationship:

Phone Number:

Cell

Work

Home

First Name:

Last Name:

Relationship:

Phone Number:

Cell

Work

Home

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:

Date:

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.*

I have reviewed the Discipline Policy with my child. My child will follow the rules and follow the consequences of misconduct. I understand and agree to all the terms on this Policy.

Child's Name:

Parent/Guardian Name

Signature

Date:

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

I understand SHINE Boys and Girls Center will update my invoice with any applicable fees as described above.

I understand full payment must be made on or before the 5th of each month.

I understand that the monthly payment for the Afterschool Program and weekly payment for Summer Camp are to be paid fully regardless of the day(s) my child can/will miss.

Child's Name:

Parent/Guardian Name:

Signature:

Date:

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.

Child will participate in Homework First Program

Child will not participate

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.

Parent/Guardian Name:

Signature:

Date:

First Name:

Last Name:

Middle Name:

First Name:

Middle Name:

Last Name:

Relationship:

Address

City

State

Zip

Phone Number:

Cell

Work

Home

Phone (alternate):

Cell

Work

Home

Employer:

Occupation:

MEMBERSHIP APPLICATION

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.

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.*

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

This is not a tutored class

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.

​

​

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

Respect
Health and Wellness Sportsmanship

Bullying
Fighting
Failure to follow rules/instructions

Profanity
Vandalism

No refunds or credits will be issued upon member being dismissed from the program.

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

Check
Card