Summer Membership Application

Membership Application

MEMBER INFORMATION

Please submit a separate application for each child.

Child Information

Child's Name

First Name *

Middle Name *

Last Name *

Child's Date of Birth *

Child's Primary Home Address

Address 1 *

City *

ZIP / Postal Code *

State *

School District *

School *

Report Card *

Please upload the child's current or most recent report card. For children entering kindergarten, please upload their enrollment confirmation or kindergarten screening.

HOUSEHOLD INFORMATION

BGCSTC receives public funding and is often required to provide basic information about the families we serve. Please help us to continue receiving these funds by providing information about your family. All information provided is kept confidential.

Family Information

Total Household Size *

Please include all family members, adults, and children living at the child's primary address.

Number of children under 18 years old in the household *

Details *

Please list the military branch and the status of the service:

Assitance programs (Check ALL that apply) *

Do you currently use or receive benefits from any assistance programs?

NONE

Medicaid

SSDI (Social Security Disability Insurance)

Unemployment Benefits

WIC (Women, Infants, and Children)

TANF (Temporary Assistance for Needy Families)

SNAP (Supplemental Nutrition Assistance Program/Food Stamps)

Public Housing/Section 8 Housing

PARENT/GUARDIAN INFORMATION

List the primary individual the child lives with.

Primary Parent/Guardian 1 Information *

Name

First Name *

Last Name *

Other relationship to child *

If you selected "Other," please describe your relationship to the child.

Cell Phone Number *

Work Phone Number

Email Address *

Parent/ Guardian 1 Address

Address 1 *

City *

ZIP / Postal Code *

State *

Job Title/Occupation *

Employer Company *

Employer Contact Name *

Employer Phone Number *

Employer Address

Address 1 *

City *

ZIP / Postal Code *

State *

Parent/Guardian 2 Information

Name *

First Name *

Last Name *

Other Relationship to Child *

If you selected "Other," please describe your relationship to the child.

Cell Phone Number *

Work Phone

Email Address *

Parent/Guardian 2 Address

Address 1 *

City *

ZIP / Postal Code *

State *

Job Title/Occupation *

Employer Company *

Employer Contact Name *

Employer Phone Number *

Employer Address

Address 1 *

City *

ZIP / Postal Code *

State *

EMERGENCY CONTACTS & AUTHORIZED TO PICK-UP

Emergency Contacts

Emergency Contact 1

A photo ID is required for pick-up and must match the name provided below. The names listed for emergency contact must be different from the parents/guardians listed on page 3.

First Name *

Last Name *

Mobile Phone Number *

Work Phone Number

Other (Please Describe) *

If you selected "Other," please describe the relationship to the child.

Emergency Contact 2

A photo ID is required for pick-up and must match the name provided below. The names listed for pick-up must be different from the parents/guardians listed on page 3.

First Name *

Last Name *

Mobile Phone Number *

Work Phone Number

Other (Please Describe) *

If you selected "Other," please describe the relationship to the child.

Permission for Self-Sign Out and Independent Departure *

Daily Check-out Time *

Please specify what time they are allowed to leave daily, and we will ensure they check out and are sent home safely.

Agreement *

Please check the box below to indicate your agreement:

I acknowledge that by granting permission for my child to sign themselves out and leave the program independently, I am agreeing that Boys & Girls Clubs of St. Charles County (BGCSTC) is not liable for any incidents or accidents that may occur once my child has signed themselves out, and I am responsible for ensuring that my child gets home safely.

Additional Individuals Authorized to Pick Up

Additional Person 1

Please list individuals who are authorized to pick up your child but are not considered emergency contacts. Add individuals other than the parents/guardians listed on page 1 and the emergency contacts provided above. A photo ID is required for pick-up.

First Name

Last Name

Mobile Phone Number

Comments or Notes

Additional Person 2

First Name

Last Name

Mobile Phone Number

Comments or Notes

Additional Person 3

First Name

Last Name

Mobile Phone Number

Comments or Notes

List any individuals who should not be allowed to sign out the child.

Individuals Restricted to Pick Up

Restricted Individual 1

First Name

Last Name

Comments or Notes

Restricted Individual 2

First Name

Last Name

Comments or Notes

Technology Acceptable Use Policy

By checking this box, I acknowledge that I have read and understood the statement below.

As the parent/guardian of a Boys & Girls Clubs of St. Charles County (BGCSTC) member, I have read the following:
CLICK HERE TO VIEW The Technology Acceptable Use Policy 2025
Parental Consent & Agreement: I have read and understand the Technology Acceptable Use Policy, and I give my consent for my child to use technology and internet access at the Club in accordance with these guidelines.
Safe & Responsible Use: I acknowledge that BGCSTC is committed to promoting safe and responsible technology use and that my child is expected to follow all Club policies regarding device usage.
Supervision & Monitoring: I understand that the Club monitors and manages technology use on Club-owned devices and networks and may inspect personal devices when necessary, with parental notification.
Internet & Device Use: I give permission for my child to use Club devices and personal devices (if applicable) at the Club and understand that all internet access will be filtered and monitored.
Appropriate Behavior: I acknowledge that my child must use technology respectfully and responsibly, avoiding cyberbullying, harassment, or inappropriate content.
Personal Device Responsibility: I understand that if my child brings a personal device, they are responsible for it, and the Club is not liable for loss, damage, or theft.
Training & Education: I support my child’s participation in digital citizenship and technology safety training provided by the Club.
Consequences for Misuse: I acknowledge that if my child violates the Technology Acceptable Use Policy, their technology privileges may be revoked, and disciplinary action may be taken.
CLICK HERE TO VIEW The Technology Acceptable Use Policy 2025

Technology Permission *

By submitting this agreement online, I confirm that I have read and agree to the terms above.

I give permission for my child to use technology at BGCSTC.

I do not give permissio for my child to use technology at BGCSTC

PROGRAM PERMISSIONS

All programs listed below are approved and funded by the Community and Children’s Resource Board of St. Charles County, the Missouri Alliance, Missouri Department of Health and Senior Services, Boys & Girls Clubs of America, and/or the Department of Juvenile Justice & Delinquency Prevention.

If you have any questions about these programs and your child’s participation, please contact Rick Daleen, Director of Club Operations, at (636) 688-8561 or at rdaleen@bgcstc.org.

Program Permissions

By checking this box, I acknowledge that I have read and understood the program description below.

The Journeys program is for members ages 10 to 14. It is part of healthy lifestyles education, focused on healthy relationships, abstinence from sexual relations, and caring for our bodies. The programs include topics such as physical and emotional change and growth, self-esteem, body image, the influence of media, healthy eating, the importance of physical fitness, the importance of regular health exams, and learning about our identity and roles in life.

Journeys Permission *

Yes, I give permission for my child to participate in Journeys

No, I do not give permission for my child to participate in Journeys

By checking this box, I acknowledge that I have read and understood the program description below.

SMART Moves is a suite of research-based programs designed to help young people develop healthy decision-making skills and attitudes. This program is designed for all members to participate in and has curriculum for each grade. SMART Moves includes topics such as personal values, social interactions, social media, social-emotional wellness, and healthy relationships with friends, significant others, and family.

SMART Moves Permission *

Yes, I give permission for my child to participate in SMART Moves

No, I do not give permission for my child to participate in SMART Moves

Too Good for Drugs *

By checking this box, I acknowledge that I have read and understood the program description below.

Too Good for Drugs is a science-based prevention program designed to reduce risk factors and enhance protective factors related to alcohol, tobacco, and other drug use. The program is designed for all members to participate in and has curriculum for members in grades K-2, 3-5, and 6-8. The program teaches essential character development skills to build self-efficacy and promote healthy development.

Too Good For Drugs Permission *

Yes, I give permission for my child to participate in Too Good For Drugs

No, I do not give permission for my child to participate in Too Good For Drugs

SUBMIT

Certification of Accuracy and Legal Compliance *

By checking this box, I acknowledge that I have read and understood the statement below.

This organization is supported by Federal and State funding. According to Title 18, Section 1001 of the U.S. Code, it is a felony for any person to knowingly and willingly make false or fraudulent statements to any department of the United States Government. By signing this document, I certify under penalty of perjury, that all the information on this application is correct to the best of my knowledge and belief, and I acknowledge that such information is subject to verification by CDA, HUD or their representatives.

Completion of Memebership Paperwork *

By checking this box, I acknowledge that I have read and understood the statement below.

I understand that membership will not be granted until all paperwork is completed in full, including reviewing the Parent Member Handbook and paying the annual membership fee. BGCSTC will review your application, and send an invoice to pay the annual membership fee.

Membership Consent *

By checking this box, I acknowledge that I have read and understood the statement below.

I have read the completed application and this form, agree that membership is governed by the rules of Boys & Girls Clubs of St. Charles County (BGCSTC), and request that my child be admitted into membership.

Parent or Legal Guardian Signature *

By signing, you acknowledge that you understand and agree to the terms outlined in this application and verify that all information provided is accurate and complete.

10%

Summer Camp Deposit

Save My Spot Deposit

A $15.00 deposit per child is available to secure a summer camp spot. This OPTIONAL deposit confirms your commitment to submitting the required paperwork. If your child attends camp, the deposit will be applied to the first week they attend. However, if they do not attend, the deposit will not be refunded.

O'Fallon Unit

$15 per child

NOTE: By selecting the button below you will leave our website and be transferred to Stripe which is the payment processing tool used by our merchant provider.

If you are paying for more than one child, edit the quantity on the payment page and list both children in the field.

Pay Deposit

St. Charles Unit

$15 per child

NOTE: By selecting the button below you will leave our website and be transferred to Stripe which is the payment processing tool used by our merchant provider.

If you are paying for more than one child, edit the quantity on the payment page and list both children in the field.

Pay Deposit

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Membership Application

Membership Application

MEMBER INFORMATION

HOUSEHOLD INFORMATION

PARENT/GUARDIAN INFORMATION

MEMBER MEDICAL & HEALTH INFORMATION

EMERGENCY CONTACTS & AUTHORIZED TO PICK-UP

PROGRAM PERMISSIONS

PERMISSIONS & ACKNOWLEDGEMENTS

SUMMER CAMP

SUBMIT

Save My Spot Deposit

O'Fallon Unit

St. Charles Unit

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