Carpinteria Unit- 4849 Foothill Road 684-1568
Westside Santa Barbara Unit- 602 W. Anapamu Street 966-2811
Goleta/ La Patera ASES- 5701 Hollister Avenue 967-1612
Lompoc Unit- 1025 W. Ocean Avenue- 736-4978
Hapgood Elementary- ASES- 324 S. A Street, Lompoc
Fillmore Elementary- ASES- 1211 E. Pine Avenue, Lompoc
The United Boys & Girls Clubs of Santa Barbara County does not administer medications.
If your child takes any medication or has any allergies, please tell us about all of them in case of emergency.
If your child needs an inhaler or epi pen, an Authorization for the Administration of Medication form is required. This form may be downloaded from our website at wwwunitedbg.org, or ask for a copy at our Membership Desk. If you do not provide this form for your child, they will not be allowed to attend until the form is provided.
I give my permission to the United Boys & Girls Clubs of Santa Barbara County to seek emergency medical treatment for my minor child if I cannot be reached. I will be responsible for any/all costs of medical attention and treatment. It is understood, however, that this membership includes a secondary insurance while taking part in the UBGC activities.
I give my permission for my child’s picture, moving pictures, or any other graphic depiction or likeness, to be used by the Boys & Girls Club and its activities.
I give permission for my son/daughter to attend any and all United Boys & Girls Clubs organized field trips. I agree that if injury to my child does occur, I hereby hold blameless and waive all claims against United Boys & Girls Clubs of Santa Barbara County, its officials, staff, or anyone who it may hire to appoint or to supervise said activities. In the event of an emergency the person in charge has my permission to see that proper action is taken and if deemed necessary, that medical treatment may be rendered. Your child will be under supervision where safety is of the utmost importance.
The following information is necessary for our records and the funding our organization receives. The answers you provide are confidential. Your cooperation in providing this information is both appreciated and necessary.
I, the parent/guardian of the minor child listed on this application, for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever discharge the United Boys & Girls Clubs, and Boys & Girls Clubs of America, their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organizations such as staff, directors or volunteers, from all liability, claims, demands, or causes of action for any and all loss, damage, injury or death and any claim of damages resulting from use of facilities owned or controlled by the above organizations, or participation in activities of said organizations either at or away from the Club.
I give my permission to the United Boys & Girls Clubs of Santa Barbara County to collect information via online or written surveys, questionnaires, interviews, and focus groups from the minor child listed on this application. Any and all information received will be kept strictly confidential. The aggregated results of these analyses may be shared with Club staff, Boys& Girls Clubs of American (BGCA), funders, and other community stakeholders to evidence program effectiveness and/or Club impact on our members.
I give my permission to the United Boys & Girls Clubs of Santa Barbara County to provide transportation to and from the Club for various activities including but not limited to; school transportation program, outreach program, field trips.
Code of Conduct/Discipline Policy:
All United Boys & Girls Clubs of Santa Barbara County staff and members are expected to uphold the code of conduct including; show respect to staff, volunteers, and peers, respect the facility and equipment, play fairly and be honest, avoid the use of improper language, walk indoors, resolve arguments positively, and maintain a bully-free zone.
The Boys & Girls Clubs discipline policy is only a guideline. Actual consequences are determined on a case-by-case basis and are at the discretion of the Club Director.
Minor Offenses: Examples of consequences for minor offenses include, but are not limited to; clean up duty, exclusion from a particular program or area, writing assignments, or Club service hours.
Major Offenses: can constitute an automatic suspension without warning. All major offenses include: fighting, disrespecting staff, inappropriate language, stealing, vandalism/destruction of property, inappropriate touch/behavior, multiple minor offenses within a certain time frame, and bullying.
I understand that the United Boys & Girls Clubs of Santa Barbara County is not responsible for lost or stolen items. As a drop-in facility, we are not responsible for Club members’ whereabouts. However, members are required to sign in and sign out daily. I understand there will be a late fee assessed if the minor is not picked up by closing. Authorities will be notified if the child is not picked up half an hour after closing.
I have read the completed application and this form, I understand the rules of the Boys & Girls Club and request my child be admitted into membership.
Please pay at the front desk of your local club!
Membership is good until 12/31/2017.
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