After School/Membership Application

Our After Care Program operates Monday-Friday from 3pm-6pm and the extended hours of 1pm-6pm for early dismissal days. BGCSM follows the CCPS calendar for closures, inclement weather, etc.

Our program is offered at a low cost of a once yearly $30 annual enrollment fee and a $30 membership weekly fee (which includes a daily snack). There are many benefits of becoming a member of BGCSM. We offer assistance with homework and studying and can also provide tutoring per request.

We also partner with other organizations such as 4-H, National Society of Black Engineers (NSBE), Omega Pi Omega and many more to provide the members with activities that teach cooking, arts and crafts, financial literacy, and engineering to name a few. BGCSM is family oriented!

We are involved in Town of North Beach Events such as the Holiday Parade and Plant the Town. We also host our own Family Dinners.

You can join BGCSM by completing an application and paying in person (cash, check, or money order) or by PayPal here on our website. If there are any additional questions, contact the Program Director at [email protected] or call 410-286-9880.

$30^.00

per week/child

Membership

First Name

Middle Name

Last Name

Gender

Date of Birth

Home Phone

home Address of Child

Address Line 1

Address Line 2

City

State

Zip Code

Parent Information

Cell Phone

Work Phone

Additional Child Information

Child's School

Child's Grade

First Name

Last Name

First Name

Last Name

First Name

Last Name

Guardian Relationship to Child

Emergency Contact

Contact Name	Contact Phone Number

My child will be a:

Authorized Pickup Information

Authorized Pickup Name	Authorized Pickup Phone Number

Name of Person(s) NOT Authorized to Pickup Child

Non Authorized Pickup Name	Relationship

Medical Information

Please describe any medical problems, allergies, conditions or special concerns regarding your child.

In the event of illness or injury, I expect to be consulted immediately, but in the event that a consultation is not possible, I hereby consent to whatever treatment of care is considered necessary in the best judgment of BGCSM and the attending physician and/or hospital staff and/ or facility furnishing medical or dental services. Accordingly, I absolve and hold harmless BGCSM with regards to any and all liability relating to said treatment or care. Further, I understand that I am solely responsible for providing medical insurance for my child and for the payment of any medical treatment expenses for my child that are incurred that are not covered by such insurance.

I hereby promise to adhere to the rules, regulations, and procedures as outlined in the Boys & Girls Clubs of Southern Maryland posted rules. I hereby give my permission for my child to participate in the OJ P Mentoring Program at the Boys & Girls Club. We give permission to the BGCSM to release the member's name and/or photograph to be used by BGCSM for the promotion of BGCSM or to be used by the media in reporting about a BGCSM program or event. I hereby give my permission for BGCSM to seek medical treatment for my child as necessary.

Please Note: The BGCSM is NOT responsible for any lost or stolen items. BGCSM reserves the right to terminate a membership contract based on inaccurate information or behavioral issues.

Signature

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First Week's Payment

$30.00

Coupon

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You do not need a PayPal account in order to make the payment.

After School/Membership Application

$30^.00

per week/child

Parent Information

Additional Child Information

Medical Information

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