Programs

Medical Information

Emergency Contacts

Additional contacts if parents/guardians can't be reached:

Authorization to Leave Premises Unescorted:

Children younger than 12 years old may leave the Club with a relative so long as the relative is 12 years or older.

I give consent for photographs & video in which my child may appear, to be used in any way the Club may care to use them.

I understand the Club has adopted a Safe Passage Policy that prohibits members from coming and going as they please. I understand that once a child has entered the building, they are be allowed to leave until a parent/guardian/authorized adult arrives to retrieve them. I understand that the Club is not a licensed day care facility and that staff will not physically restrain children who insist on leaving without parent permission.

I have read and agree to abide by the policies stated in the Parent Handbook. I understand that failure to abide by the policies in the handbook may result in the removal of my child from Club programs.

I give permission for my child to participate in all Boys & Girls Clubs Programs. In consideration of said minor being permitted to enter any branch of the Terre Haute Boys & Girls Clubs (the “Club”) for observation, use of facilities and/or equipment or participation in any program, I hereby:

Acknowledge that (I) I have read this document, (ii) I have inspected the facilities and equipment, (iii) I accept them as being safe and reasonably suited for the purposes intended, and (iv) I voluntarily sign this document. Releases the Club, its directors, officers, employees, volunteers, governing board, agents, representatives from all liability to me for any loss or damage to property or injury or death to person, whether caused by Releases or by any person associated directly or indirectly with the Club, its officers, directors, employees or volunteers or otherwise while my child is in or near any Club branch or participating in any Club activity.

Agree not to sue releases for any loss, damage, injury or death described above and indemnify and hold harmless releases and each of them from any injury to persons or property sustained by any person caused by any act, neglect, default, or omission of the undersigned or of any person associated directly or indirectly by him upon or in connection with this activity or whether caused by the negligence of the Releases or otherwise, whether the said injury or damage occurs upon or adjacent to the property. The undersigned at his own cost, expense and risk shall defend any and all actions, suits or other legal proceedings that may be brought or
instituted against the Club on any such claim or demand, and pay or satisfy any judgment that may be rendered against the Club in any such action, suit or legal proceedings or result thereof.

I assume full responsibility for, and risk of, bodily injury, death or property damage due to the negligence of Releases or otherwise.

I do hereby authorize the Clubs as agent for the undersigned, to consent with respect to said minor, to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under general or special supervision of, any physician and surgeon licensed under the provisions of the Indiana Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of the physician or at the hospital. I understand that the Club is not responsible for costs incurred for medical care.

I intend this document to be as broad and inclusive as is permitted by the laws of the state of Indiana; if any portion hereof is held invalid, I agree that the balance shall continue in full force and effect.