Joe & Linda Aliberti Clubhouse (Scotts Valley)

Start date: August 17th, M-F 8am-6pm, $100.00/week

This is the registraion form for

Joe & Linda Aliberti Clubhouse ONLY!

We are working on finding more room for the possiblity of a morning group of 12 and an afternoon group of 12.

We can only accept children of Essential Care Workers. Priority is given to those students who have been in our summer program this year. BUT, things are changing quickly, so please fill out this form to be added to a waitlist

Please be patient and know that safety is our number one PRIORITY and we are working SO VERY hard to make sure that we follow all CDC and County Health Guidelines.....

Thank you my friends! Miss you all so much!!!!!!!!

Member and Family Information

Name of Member #1 (First and Last) *

Are you a current Club member? *

Yes

No

Any special needs or allergies that we need to be aware of? Anything you want us to know?

Name of Member # 2 (First and Last)

Are you a current club member?

Yes

No

Any special needs or allergies that we need to be aware of? Anything you want us to know?

Name of Member # 3 (First and Last)

Are you a current club member?

Yes

No

Any special needs or allergies that we need to be aware of? Anything you want us to know?

We are investigating the option of addition partial day care? If added, when would you be interested in attending? *

Full Day

Partial Day AM

Partial Day PM

Parent/Guardian Information

Parent/Guardian Name (First and Last) *

Contact Phone Number *

Work Location? *

Supervisor Name and Phone Number *

Email Address *

Address 1 *

City *

State *

Zip *

Parent/Guardian Name (First and Last)

Contact Phone Number

Work Location?

Supervisor Name and Phone Number

Email Address

Street Address

City

State

Zip Code

Days and times Options

COST: $100/week, Monday-Friday, 8am-6pm

There will be 2 groups (Group A and Group B) that will be split up based on ages and grades...

Money and Payments

In order to confirm and hold your space, you must pay for the first two weeks in advance. ($200.00)

Please insert your credit card information below. We will call you before collecting the first payment to confirm and also set up your dates of reaccuring payments.

If you do not have a credit card to put on file, you must call the club at 831-535-7017 or email Maci@boysandgirlsclub.info

If payment is not made by 2pm on August 13th, your space will be given to the next person on our waitlist. Thank you for understanding.....

Name on Card *

Credit Card Number *

Credit Card Type *

Expiration Date (mm/yy) *

CVV *

Scholarships

I will be applying for a BRAND NEW scholarship in person at the club (I will attend in person and provide the necessary documents) Due Date: August 13th 2020!

Yes

No

I have already applied for a scholarship in 2020

Yes

If you have already applied for a scholorship this year, you DO NOT need to re-apply (just click the box, yes)

If you are NEWLY applying for a scholarship please call Maci at 831-535-7017 or email maci@boysandgirlsclub.info

Liability and Waiver

PARENTS/GUARDIANS

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.

Boys & Girls Clubs of Santa Cruz County has put in place preventative measures to reduce the spread of COVID-19; however, the Club cannot guarantee that you or your child (ren) will not become infected with COVID-19. Further, attending the Club could increase your risk and your child(ren)’s risk of contracting COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending the Club and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Club may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Club employees, volunteers, and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the Club or participation in Club programming (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless the Club, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Club, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Club program.

Please sign *

clear

We will be contacting you directly via email or phone to confirm that you have a spot with us.....

YES! I would like to sponsor a member during this time of need.