Join the Journey Step 1 of 11 9% Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Birth Date MM slash DD slash YYYY Gender Male Female Nickname Ethnicity African American Caucasian Native American Multi Racial Hispanic Other My Child Is A New Member Renewing Member Will Attend Year Round School Year Only Holidays/Summers Only School Name Medical/Allergies(Required)MedicationsPhysician Physicians Phone NumberBehavioral Problems/What Should We Know About Your Child? PARENT/GUARDIAN INFORMATION Name First Last Relationship Home PhoneCell PhoneEmployer Email SECONDARY/EMERGENCY CONTACTS (MUST BE DIFFERENT THAN ABOVE INFORMATION) Name First Last Relationship Home PhoneCell PhoneName First Last Relationship Home PhoneCell Phone THE FOLLOWING INFORMATION IS NECESSARY FOR OUR RECORDS AND THE FUNDING OUR ORGANIZATION RECEIVES. THE ANSWERS YOU PROVIDE ARE COMPLETELY CONFIDENTIAL. YOUR COOPERATION IN PROVIDING THIS INFORMATION IS BOTH APPRECIATED AND NECESSARY. MEMBERSHIP WILL NOT BE PROCESSED WITHOUT THIS INOFRMATION.MEMBER LIVES WITH (CHECK ALL THAT APPLY) BOTH PARENTS MOTHER FATHER STEP MOM STEP DAD AUNT UNCLE GRANDPARENT OTHER NUMBER OF ADULTS IN HOUSEHOLDNUMBER OF CHILDREN IN HOUSEHOLDANNUAL HOUSEHOLD INCOME $9,999 OR BELOW $10,000-$19,999 $20,000-$29,999 $30,000-$39,999 $40,000-$49,999 $50,000 AND ABOVE THE FOLLOWING PEOPLE HAVE MY PERMISSION TO PICK UP MY CHILD FROM THE CLUB (ID WILL BE REQUIRED);Name First Last PhoneName First Last PhoneName First Last PhoneName First Last PhoneName First Last PhonePARENT/GUARDIAN CONSENT(Required) I agree to the following:I HEREBY GIVE MY SON/DAUGHTER PERMISSION TO ATTEND AND PARTICIPATE IN ACTIVITIES SPONSORED BY THE BOYS AND GIRLS CLUB AND RELEASE THE BOYS AND GIRLS CLUBS OF HOCAK NISOC HACI, ITS EMPLOYEES, DIRECTORS, ASSOCIATES, AND CONTRIBUTORS FROM ANY INJURY, LOSS OR THEFT INCURRED BY MY CHILD WHILE PARTICIPATING. I FURTHER UNDERSTAND THAT THE BOYS AND GIRLS CLUB HAS AN “OPEN DOOR” POLICY WHICH MEANS MY CHILD MAY COME AND GO AT WILL. THE INFORMATION PROVIDED HERE MAY BY USED BY THE FUNDERS OF THIS PROGRAM FOR RESEARCH PURPOSES OR TO EVALUATE THE PROGRAM’S EFFECTIVENESS. ALL INFORMATION PROVIDED ON THIS FORM WILL BE KEPT CONFIDENTIAL. MY SIGNATURE INDICATES THAT I HAVE COMPLETED THIS APPLICATION AND UNDERSTAND THE STATEMENTS MADE WITHIN. ACTIVITIES AND PROGRAM PERMISSION SLIPMy child / children has permission to participate in the following activities listed Participate in Smart Moves Passport to Manhood Swimming at Winnebago Public Pool Walks to public parks and or Land of Wellness Gardening with Common Grounds PG Movies PG-13 Movies Participate in all outdoor sport and athletic activities Nutritional/Health Activities Local and out of town field trips Classes with Project Woska-pi Classes with Ho-Chunk Renaissance Select AllParent/Guardian your signature is required.(Required)It will indicate you have granted your permission for your child to be transported by Boys and Girls Club of the Hocak Nisoc Haci and to receive any necessary medical treatment in an emergency situation. Dear Parent/Guardian Please review the following traditions with your children. If you have any questions or concerns, please talk to the staff so that we can better assist you. The following traditions are to help insure a fun, safe and clean environment at the club for everyone: 1. Every member checks in at the front desk upon arrival. Members that have open door privileges must check out before they leave the club. 2. All food, snacks, and drinks must be consumed away from the computer area. 3. Members must not chew gum or eat sunflower seeds in the club. 4. Running is an outside activity. 5. Rough play or play fighting is not permitted. Play fights tend to lead to real fights and disciplinary action will be enforced. 6. Keep your hands and feet to yourself. Members must treat each other with respect. 7. Members remain inside unless with a staff member. When a staff member calls for an outside activity, members should line up quietly and wait for staff. Members with open door privileges must check out each time they leave. 8. Members must accept that some areas/activities have restricted entry depending on activity and member’s age. 9. Members do not fight, use profanity, or steal. Those who do will be suspended from the club. 10. Members keep valuables, money, and personal items with them at all times. We will not be responsible for broken, stolen, or lost items. All items are brought into the club at the member’s risk. 11. Staff is here to help all members. If you have a problem with another member, tell the staff. 12. Field trips are a privilege. Members must follow all club rules and etiquette. Field trip permission slips will be required for all field trips. Field trips have attendance criteria: sometimes there will be age requirements, attendance at classes/programs, or consistent weekly attendance at the club. 13. If members need to use the phone, ask a staff member for assistance. 14. Members are not allowed in staff offices or other areas unless supervised by a staff member. 15. If a staff member suspects that a member is under the influence of drugs or alcohol, they will call the parent/guardian to inform them. If necessary, law enforcement will also be notified. This is for the safety of all club members. I have read and clearly understand the rules and traditions listed above and agree to adhere to all conditions.Dear Parent/Guardian Boys and Girls Club of Hocak Nisoc Haci runs an open door policy program, which means that members can come and go at will. Boys and Girls Club of Hocak Nisoc Haci will not be held liable for any member leaving the facility. We have created this permission slip to help us know which children are expected to stay at the club, and which ones have permission to come and go at will. By signing YES to this permission slip, you are stating that your child has permission to come and go as he/she desires to the Boys and Girls Club, with no questions asked. You are also stating that you understand your child is not being supervised during their time away from the club. By signing NO to this permission slip, you are stating that you do not want your child to leave the club until you pick them up. You are stating that your child will stay at the club because you say so, not because we do. You are also stating that if your child tries to leave that you understand that we will encourage your child to stay, but we cannot force him/her to stay. You also understand that we cannot be held liable if your child does leave without your permission. We will notify you if your child leaves without your permission.Please Mark One(Required) Yes No I have read and understand the information above and I agree to adhere to all conditions.(Required) The SMART Moves (Skills Mastery and Resistance Training) prevention/education program addresses problems such as drug and alcohol use and premature sexual activity. The program uses a team approach involving Club staff, peer leaders, parents and community representatives. More than simply emphasizing a "Say No" message, the program teaches young people ages 6 to 15 how to say no by involving them in discussion and role-playing, practicing resistance and refusal skills, developing assertiveness, strengthening decision-making skills and analyzing media and peer influence. The ultimate goal: to promote abstinence from substance abuse and adolescent sexual involvement through the practice of responsible behavior. It has three target age groups 6-9, 10-12, 13-15 The goal is to reach as many number of these age groups though Alt. ED. It is a nine week course that meets once a week. For 45 minutes to an hour. The Smart Kids program is for 6-9 year old students female and male. The Start Smart program is for 10-12 year old students female and male. The Stay Smart program is for 13-15 year old students female and male. The program is broken into units and they are divided into sessions based on every unit. With this course I hope the students will get a new perspective about their community and have some tools for better decision making. ***These programs also include age-appropriate components on physical and emotional development during peradolescence, such as puberty, sexual myths vs. truths, and resistance to early sexual activity. Childs Name First Last Date of Birth MM slash DD slash YYYY Parent/Guardian Name First Last Signature I understand that I must follow the rules. I will watch for cars in the parking lot when I get on and off the van. I will put my seat belt on. I will keep my hands to myself. I will have an “indoor voice”.Member Signature(Required)Please check the days of the week your child intends to utilize this service: Monday Tuesday Wednesday Thursday Friday Select AllI give permission to the Boys and Girls Club of Hocak Nisoc Haci to transport my child from their school to the designated drop-off location. On regular school days, the drop-off location will be Winnebago Public School. On some scheduled days, the drop-off location will be the Boys and Girls Club. I agree to indemnify or hold harmless all employees, volunteer instructors, sponsors, officials, and directors of the Boys and Girls Club for any injury that my child might incur while participating in this program. I understand my child’s participation in the transportation program may be revoked at any time due to failure to follow the rules or meet the participation requirements. I have read and understand the Transportation Policy and agree to follow all rules and procedures stated. Parent/Guardian Signature(Required) Thank you for registering your child into our summer program. We understand that having your child attend the Boys and Girls of the Hocak Nisoc Haci may be a new experience for many parents. A positive club environment is critical to help us insure the best possible experience for your child. For that reason, we have established certain behavior policy guidelines. Club members are expected to conduct themselves in a manner that is consistent with the vision, goals and beliefs of the Boys and Girls Club of Hocak Nisoc Haci. Accordingly, members are prohibited from engaging in behavior (1) that obstructs, disrupts, or interferes with any club program or activity, (2) that endangers or threatens the safety of any person, or (3) that inflicts or threatens to inflict damage on property of Club members, Club employees of the Club’s facilities. Members who fail to abide by the general behavioral expectation will be subject to appropriate discipline. Any violation of the General Bahvior Policy or any Phohibited Behaviors (listed below) may result in the following consequences: The member will receive a warning about the unwanted behavior. The member may be isolated from other members. The member may lose privileges, i.e. not permitted to attend a field trip or other off-site activity. The member may be required to assist staff members, i.e. club maintenance. Parents may be contacted. The member will make restitution, if necessary. The member may be suspended from club premises and activities. For repeated or serious violations, the member may have membership revoked. Consistent with the General Behavior Expectations, the following specified behaviors are prohibed on Club poroperty, including Club vehicles, on field trips or any other off-site activity. Each situation will have individual attention and disciplinary decisions will be made dependent of the severity of the incident. Disciplianry actions are at the discretion of the Branch Director and Unit Director and will be connected to the misconduct in a logical and timely manner. Bullying/Harassment-includes any actions or words that make another member feel threatened, uncomfortable or unsafe. These actions or words become harassment when the victim has make it clear that the actions and/or words are offensive. Theft/Stealing – includes the unauthorized taking or possession of the property of another without the consent of the owner. Fighting/Horseplay- includes two or more persons engaged in any violent of physically hostile behavior directed toward each other. “Horseplay” includes roughhousing and other playful behavior or play-fighting that, though not intended to harm, presents a reasonable risk of harm or otherwise threatens the safety of students or others. Anyone who encourages or directs another to engage in any violent of physically hostile behavior, i.e. “egging on the fight” may be subject to the same disciplinary action as in the person who engages in the action. Vehicle Misconduct-includes failure to abide by the General Behavior Policy while being transported in a vehicle owned or operated by the Boys & Girls club or Tribal Vehicles, or failure to observe any of the following specific rule while riding in a vehicle owned or operated by the Club or Tribe. Follow the driver’s instructions. Remain seated with the seatbelt fastened. Keel all body parts inside the vehicle. Talk quietly using respectful language. Be courteous at all times. Do not throw anything inside the vehicle or from the vehicle. Do not eat or drink. BOYS & GIRLS CLUB OF HOCAK NISOC HACI Defiance- includes refusing to obey a reasonable directive issued by any club employee, including club volunteers. Disruptive, Obscene or Disrespectful Behavior – “disruptive behavior” includes any behavior that distracts from or interrupts the club programs or activities. “Obscene behavior” includes the use of profanity, the use of vulgar or offensive gestures, or the depiction, display or distribution of material that are offensive to the commonly accepted standards or decency. “Disrespectful behavior” includes any behavior that is discourteous, rude, insolent, deceptive, or otherwise fails to show appropriate regard for the personal dignity of another. Included in this category is indecent exposure, regardless of the ages of the child. Vandalism – includes damaging, destroying, defacing, significantly altering or mutilating objects, property, or materials belonging to club members, club employees or materials that are property of the club. Destructions of club bathrooms or facilities, including intentional flooding of toilets is considered vandalism. Please sign indicating you have read and agree with Boys and Girls Club of Hocak Nisoc Haci Policy. Child Signature(Required)Parent/Guardian Signature(Required)EmailThis field is for validation purposes and should be left unchanged.