_THE CLUB MEMBERSHIP PACKET

Please Check One*

Youth (Grades 6-8)Teen (Grades 9-12)
THE CLUB MEMBERSHIP APPLICATION
Membership Application Packet The Club is a free middle school and high school drop-in afterschool program offered by the City of Santa Fe Springs' Community Services Department.

The objective of The Club is to promote healthy, age-appropriate development for teens and youth in Santa Fe Springs. The Club supports its students in developmental tasks by providing them a place within the community, other than home and school, where they can be involved in healthy socialization and gain experience in participating as a citizen in a productive manner. This is achieved by providing unique and tailored programing for both our middle school and high school students. In addition to afterschool activities, special events, and adventurous excursions, The Club is an awesome facility complete with the most popular video game consoles and games, pool tables, ping pong, foosball, air-hockey, a vending machine, and 2 large screen TVs. Additionally, we offer a free daily meal and snack program provided by Empowered 4 Life. Feel free to stop by and visit our facility, meet the staff, and explore what our program has to offer. We are here to serve.

Included in this application you will find:
- Membership Application/Photo Release Form
- Code of Conduct/Rules and Consequences
- CDBG Funding Letter CDBG Self-Certification Form
Please take the time to fill out and complete ALL of the attached forms as they promote the safety of your child. Forms may be submitted electronically online, or in person at:

Town Center Hall - The Club

11740 E. Telegraph Rd., Santa Fe Springs, CA 90670

(562) 409 - 7649

SANTA FE SPRINGS
THE CLUB
The Club Membership Application

INSTRUCTIONS: Please read the attached Code of Conduct before completing this form. Return completed form with signed behavior policy to The Club at 11740 Telegraph Road, Santa Fe Springs, CA 90670. The membership operates from September through August.
STUDENT/PARTICIPANT INFORMATION
Name*

First NameMiddle InitialLast Name
Address*

Address

Street Address Line 2

CityState / Province

Zip Code
Cell Phone*
Email Address*
example@example.com
Youth Lives With:

Both ParentsMom OnlyDad OnlyJoint CustodyGuardian (Relative/Other)
Date of Birth*
Age
Grade*
Name of School*
Allergies/Medical Conditions
Medications
PARENT/GUARDIAN INFORMATION
Name*

First NameLast Name
Address*

Address

Street Address Line 2

CityState / Province

Zip Code
Cell Phone: *
Home Phone
Work Phone
Email Address*
example@example.com
Name

Other Parent First NameOther Parent/Guardian Last Name
Address

Address

Street Address Line 2

CityState / Province

Zip Code
Cell Phone:
Work Phone
Work Phone
Email Address
example@example.com
LIMITATIONS OR RESTRICTIONS
Do you have any limitations to health or physical ability?*

YesNo
If yes, please explain
VOLUNTEER PROGRAM REGISTRATION (must also submit TB immunization record)
Would you like to register as a volunteer for the City of Santa Fe Springs (ages 13+)?*

YesNo
IN CASE OF EMERGECNY CONTACT
Emergency Contact Name*
Relation to Student*
Cell Phone*
Home Phone
Work Phone
CERTIFICATION OF PARENT/GUARDIAN
I certify that all statements on this application are true and complete. I understand that any false information or incomplete statements will void my child's privileges at The Club.
Name of Parent/Guardian*
Signature of Parent/Guardian*

Clear
Date*

MonthDayYear
Date
CERTIFICATION OF PARTICIPANT
I certify that all statements on this application are true and complete. I understand that any false information or incomplete statements will void my privileges at The Club. I understand that any violations of the code of conduct may void my privileges at The Club.
Name of Participant*
Participant Signature*

Clear
Date*

MonthDayYear
Date

WAIVER, RELEASE, HOLD HARMLESS, AND AGREEMENT NOT TO SUE
I, the undersigned, as the participant and the participant's parent or legal guardian if the participant is under 18 years old, fully understand that my participation in the City of Santa Fe Springs Recreation activity (hereinafter "event/class") exposes the participant to the risk of personal injury, death, communicable diseases, illnesses, viruses, or property damage. I hereby acknowledge that the participant is voluntarily participating in this event/class and agrees to assume any such risks. I hereby release, discharge and agree not to sue the City, its officials, officers, employees, contractors, agents, and volunteers for any injury, death or damage to or loss of personal property arising out of, or in connection with, participation in the event/class from whatever cause, including the active or passive negligence of the City, its officials, officers, employees, contractors, agents, and volunteers, or any other participants in the event/class. The parties to this Agreement understand that this document is not intended to release any party from any act or omission of "gross negligence," as that term is used in applicable case law and/or statutory provision. In consideration for the participant being permitted to participate in the event/class, I hereby agree, for myself, my heirs, administrators, executors and assigns, that I shall indemnify and hold harmless the City, its officials, officers, employees, contractors, agents, and volunteers from any and all claims, demands actions or suits arising out of or in connection with participation in the event/class.

ACKNOWLEDGEMENT RELATING TO CORONAVIRUS/COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is understood to be extremely contagious and is believed to be spread from person-to-person contact and contaminated surfaces/objects. People reportedly can become infected and show no symptoms and therefore, spread the disease. Evidence has shown that COVID-19 can cause serious and potentially life-threatening illness and even death. 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. The City has put in place preventative measures to reduce the spread of COVID-19; however, the City cannot guarantee that you or your child(ren) will not become exposed to or infected with COVID-19 while participating in City programming. Further, if you choose to participate in City programming, you may be increasing your risk and your child(ren)'s risk of contracting COVID-19. By signing below, I further acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and Imay be exposed to or infected by COVID-19 by participating in City programming. 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 in participating in City programming may result from actions, omissions, or negligence of myself and others, including, but not limited to, City employees, volunteers, and program participants and their families.

PHOTOGRAPHY/VIDEO RELEASE

I hereby grant the City of Santa Fe Springs and its representatives' permission to use and/or publish photographic pictures or video inwhich or, the individual(s) named herein, may be included for promotion or other City purposes. I hereby release, discharge, and agree to hold harmless the City of Santa Fe Springs and its representatives from any liability, including but not limited to, claims for libel or invasion of privacy. I, the undersigned, as the participant and the participant's parent or legal guardian if the participant is under 18 years old, fully understand that my participation in the City of Santa Fe Springs Recreation activity (hereinafter "event/class/program") exposes the participant to the risk of personal injury, death, communicable diseases, illnesses, viruses, or property damage. I hereby acknowledge that the participant is voluntarily participating in this event/class and agrees to assume any such risks.

THAVE CAREFULLY READ THIS RELEASE, HOLD HARMLESS AND AGREEMENT NOT TO SUE AND FULLY UNDERSTAND ITS CONTENTS. IAM AWARE THAT IT IS A FULL RELEASE OF ALL LIABILITY AND SIGN IT ON MY OWN FREE WILL.

By signing, I declare under penalty of perjury under the laws of the State of California that I am the parent or legal guardian of the participant and agree to all the terms set forth above.
Name of Participant*
Age of Participant*
Name of Parent/Guardian*
Signature of Parent/Guardian*

Clear
Date*

MonthDayYear
Date

CODE OF CONDUCT

The Code of Conduct and Rules and Consequences have been prepared to make each member’s experience a positive and enjoyable time at The Club. Please take time to read the Code of Conduct carefully.
Parents are encouraged to “partner” with The Club staff in providing the best experience for our youth.

The Club’s Code of Conduct is in accordance with the “Six Pillars of Character” philosophy.

TRUSTWORTHINESS	Be honest; Do not deceive, cheat, or steal; Build a good reputation; Be reliable; Be loyal
RESPECT	Be tolerant of differences; Use good manners, not bad language; Be considerate of the feelings of others; Do not threaten, hit, or hurt anyone; Deal peacefully with anger, insults, and disagreements
RESPONSIBILITY	Do what you are supposed to do; Persevere; Always do your best; Use self-control; Be self-disciplined; Think before you act; Be accountable for your choices
FAIRNESS	Play by the rules; Take turns and share; Be open minded; Do not take advantage of others
CARING	Be kind; Be compassionate and show you care; Express gratitude; Forgive others; Help people in need
CITIZENSHIP	Do your share to make your community better; Cooperate; Stay informed; Be a good neighbor; Obey laws and rules; Respect authority; Protect the environment; Have the courage to do the right thing

RULES AND CONSEQUENCES
Community Services staff are in charge and have the authority to make decisions pertaining to inappropriate behavior. Students are expected to adhere to the Code of Conduct and abide by the following rules.

Immediately upon arrival, members must sign in.
All food and drink distributed by The Club MUST remain indoors and be eaten at appropriate tables.
All trash must be thrown away immediately after use and in appropriate bins.
Members must use equipment and facility correctly and with respect.
Video Game Usage:
1. Students are not allowed to use personal gaming discs on consoles
2. Students are allowed to be on each console for 20 minutes at a time
The use or possession of drugs, alcohol, tobacco, and/or related paraphernalia is strictly prohibited and disallowed both indoors and outdoors.
Any gesture, which displays or clearly hints at close physical intimacy (i.e. kissing, cuddling, etc.), is NOT acceptable at any time within The Club.
Use of profanity, suggestive, or vulgar language is prohibited.
The use of cycling equipment (e.g. skateboards, bicycles) is not allowed indoors. If brought to The Club, these items must be left in the designated storing area until departure.
Students must be appropriately dressed. Dress code will be in compliance with local schools.
It is recommended that all valuables be left at home. The City of Santa Fe Springs and The Club are not responsible for lost or stolen items.

In all cases, the following consequences will happen:

Violation #1: Warning will be given.
Violation #2: Incident will be written up, kept on file, and a warning will be given.
Violation #3: Members will be written up and asked to leave for the remainder of the day.
Violation #4: Depending on the severity of the violation, member may be suspended for a period of time appropriate to the violation. The suspension will be determined by the Community Services Coordinator/Supervisor. In addition, parents will be contacted.
Please note, if an incident is very serious in nature, a suspension may be given for the 1st violation.

Participant Acknowledgement

We have read and understand The Club’s Code of Conduct and Rules and Consequences and agree to abide by its policies.
Participant Print Name*
Parent/Guardian Print Name*
Participant Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

	Extremely Low Income	Low Income	Moderate Income	Above Moderate Income
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THE CLUB MEMBERSHIP APPLICATION

SANTA FE SPRINGS

THE CLUB

STUDENT/PARTICIPANT INFORMATION

PARENT/GUARDIAN INFORMATION

LIMITATIONS OR RESTRICTIONS

VOLUNTEER PROGRAM REGISTRATION (must also submit TB immunization record)

IN CASE OF EMERGECNY CONTACT

CERTIFICATION OF PARENT/GUARDIAN

CERTIFICATION OF PARTICIPANT

WAIVER, RELEASE, HOLD HARMLESS, AND AGREEMENT NOT TO SUE

CODE OF CONDUCT

PUBLIC SERVICE SELF-CERTIFICATION FORM 2022-23