BGC HHI Afterschool Program 2025-2026

2025 - 2026 AFTERSCHOOL PROGRAM APPLICATION

Please submit a separate Application for each child.
After School Program Dates: August 6, 2025 - May 29, 2026

Club Hours: 2:45 pm - 6:00 pm

First Time Applicant Registration Fee: $20

Annual Fee Due January 1, 2026: $5

Monthly Program Fees Due the 1st of Each Month:

1 Child $85

2 Children $115

3+ Children $145

Teen Monthly Rate (Grades 6-12) $42

**No Refunds Policy**

**Boys & Girls Club of Hilton Head Island After School Program: No Refund Policy**

**Overview**

We would like to express our gratitude for your registration in the Boys & Girls Club of Hilton Head Island After School Program (BGC HHI ASP). This document delineates the terms associated with cancellations and refunds.

**Policy Scope**

This policy is applicable to all purchases related to program participation.

**No Refunds**

All sales pertaining to event registrations are conclusive, and refunds will not be granted under any circumstances. This includes, but is not limited to, the following scenarios:

- Changes in plans or inability to attend.
- Dissatisfaction with the event experience.
Initials (No Refunds Policy)*
MEMBER INFORMATION

Please complete a separate Application for each Member / Child.
Get ready to save! By signing up for our auto-pay option, you can unlock an amazing discount on your Boys & Girls Club After School program. Enjoy the convenience of hassle-free monthly payments and keep the fun going all year long!*

YesNo
Did your child attend the 2024-2025 Afterschool Program*

YesNo
Member/Child's First Name*
First Name
Member/Child's Last Name*
Last Name
Current Date

MonthDayYear
Today's Date
Date of Birth*

MonthDayYear
Date
Age Day
Age/Year
Gender*
Child's Ethnicity*
Ethnicity
School Name*
School Name
Grade Level 2025-2026*
2025 / 26 School Year
WALK HOME PRIVILEDGES - GRADE 7 AND UP ONLY*

Yes, my child is in the 7th Grade or above and has permission to sign-out and walk home from the Boys & Girls Club. I understand the Boys & Girls Club of Hilton Head is not responsible for my child once they have signed themselves out.No, my child does not have permission to walk home from the Boys & Girls Club.
PARENT / GUARDIAN INFORMATION
Parent / Guardian First Name*
First Name
Last Name*
Last Name
Relationship to the Child*
Relationship
Are you the primary contact for the family?*

YesNo
Primary Home Phone Number*
Home Phone Number
Primary Email: This email will receive all Club communications.*
example@example.com
Re-enter Primary Email for validation*
example@example.com
Home Address*
Street Address
City*
City
State*
State
Zip Code*
Zip Code
Primary Parent / Guardian Place of Employment
Name
Primary Parent / Guardian Work Phone Number
Secondary Parent / Guardian First Name
First Name
Last Name
Last Name
Relationship to the Child
Secondary Parent / Guardian Phone Number
Secondary Parent / Guardian Email
example@example.com
Secondary Parent / Guardian Place of Employment
Name
Work Phone Number
HOUSEHOLD DATA

This information in aggregate is required for certain grants and other funding sources which helps the Club serve more children and obtain more resource materials while keeping costs low. Individual data remains strictly confidential.
Is another language other than English spoken at your Home?*

YesNo
If yes, what language?*
Child lives in primary household with? (Check all that Apply)*

MotherFatherStep-MotherStep-FatherGrandmotherFoster ParentOther
Number of adults living in the household?*
Number of children living in the household?*
Family Income*
Is there a member of the child's primary household who serves in the US Military?*

YesNo
EMERGENCY CONTACT INFORMATION

Please list 3 people (other than parents/guardians) who can be contacted in case of an emergency and who have permission to pick up from the Club.
First Name*
Last Name*
Relationship to Member*
Authorized to PIck Up*

YesNo
Emergency Contact's Phone Number*
First Name*
Last Name*
Relationship to Member*
Authorized to PIck Up*

YesNo
Emergency Contact's Phone Number*
First Name*
Last Name*
Relationship to Member*
Authorized to PIck Up*

YesNo
Emergency Contact's Phone Number*
WAIVER OF LIABILITY AND PERMISSION STATEMENTS

Please read each section attentively. Should you have any inquiries regarding this waiver, do not hesitate to reach out to one of the following staff members. Area Director: Ryan Wise (ryan.wise@bgclowcountry.org) Unit Director: Jaala L. Miller (jaala.miller@bgclowcountry.org) Front Office/Data Specialist: Nilo Rosado (nilo.rosado@bgclowcountry.org)
WAIVER OF LIABILITY AND PERMISSION STATEMENTS

I understand that the Boys & Girls Club operates many programs that require physical activity from my child/children and that I am responsible for communicating to the Club any physical limitations or medical conditions that may inhibit his or her ability to participate. I also understand that there are outdoor activities at the Club year-round that my child/children may be required to participate in.

I understand that the Boys & Girls Club of Hilton Head does not provide transportation to or from the Club. It is my responsibility to either transport or arrange transportation to and from the Club.

I permit my child/children to participate in surveys, discussion groups, or other programs that may determine the success of Club programs. I also permit data and information gathered to be shared for program assessment.

I authorize the release of information from the school about my child/children, including report cards, progress reports, and academic test scores, in order for the Club to better serve my child/children academically.

I permit my child/children to ride in vehicles for field trips, special occasions, and rides to and from school to the Club. My initials also permit a blanket waiver for all trips from the Club.
I grant permission for photographs, audiotapes, and records of my child/children to be used by the Club and its agents for public relations, marketing, and/or program evaluation purposes on behalf of the Boys & Girls Club of the Lowcountry and Hilton Head.*

YesNo
Signature*
Type your name
Date*

MonthDayYear
Date
HEALTH HISTORY

Member's Information
Member/Child's Name*

First NameLast Name
Check all that apply to your child: (This Needs to be filled out for each child attending the club)

ADD/ADHDAsthmaAllergy to Peanuts/NutsEmergency Medication (EpiPen/Auvi-Q)Bleeding DisordersDiabetesEpilepsy/ConvulsionsSickle Cell AnemiaMovement ConsiderationVision ConsiderationHearing ConsiderationCommunication ConsiderationIntellectual/Developmental Disability
Food Allergies (Please List)*
Medications (Please List)*
I consent for the BGCHHI staff to administer the topical OTC medications that I have checked in the list below. NOTE: We do not administer oral medications.

Antibiotic Cream/Ointment (i.e., Neosporin/Bacitracin)Topical Antihistamine/Itch Relief (i.e., Caladryl/Benedryl)SunscreenInsect RepellentI do not give consent for topical OTC medications to be administered to my child.
HEALTH HISTORY
Chronic/Recurring Illness:*
Name of Physician*
Physician Phone Number*
Name of Dentist/Orthodontist*
Dentist Phone Number*
Health Insurance*

YesNo
Name of Insurance Provider:*
Policy/Group #:*
OUTDOOR ACTIVITIES REMINDER

The Boys & Girls Club provides indoor & outdoor activities year-round, including winter and summer months. As a member of the Club, your child/children will be required to participate in these activities unless a signed doctor's note is provided that prohibits them from doing so. As the Parent/Guardian, it is your responsibility to ensure that your child/children are prepared for such activities (appropriate clothing, sun block, jackets, etc.). We appreciate your support and cooperation.
EMERGENCY MEDICAL TREATMENT

In the event of an injury or situation requiring emergency medical care, I authorize Club Staff to seek emergency medical attention if I cannot be reached immediately by phone. I give permission for Club Staff to approve any physician-recommended medical care for my child/children up to and including X-rays, routine tests, injections, or surgery. I understand that my child/children may receive non-invasive, minor medical care from staff members who are trained in first aid. I understand this may also include medical transport.
Parent/Guardian Signature*
Type your name
Date*

MonthDayYear
Date
ACCEPTABLE USE POLICY & PROCEDURE FOR BOYS & GIRLS CLUB OF HILTON HEAD ISLAND TECHNOLOGY
The Boys & Girls Club of Hilton Head Island's IT resources and services are available to all members to enhance their club experience and promote digital literacy. The purpose of the Acceptable Use Policy is to foster appropriate use of those resources. In order to ensure maximum benefit, safety, and integrity of our users and network, visitors and members are expected to comply with the Technology Acceptable Use Policy.

The guidelines apply to any user at any time he/she is using a Boys & Girls Club of Hilton Head Island computer or other electronic device or using any computer or electronic device inside the club building or on the club network. Information technology and systems resources are for members and approved guests.

Network Purpose

The club reserves the right to place restrictions on materials and services that may be accessed through our network. Our network has been established for educational purposes and at any time may be limited to technology program activities, career development, or other appropriate subjects. All users must treat all equipment and materials respectfully and adhere to the Code of Conduct at all times. When in the Technology Center, all users must also follow the designated rules for the computer lab.

Unacceptable Uses of the Club's information system include, but are not limited to, the following:
- Social networking/media, chat, instant messaging, and email, unless granted Teen Facebook Exemption
- Posting personal or distinguishing information (yours or others)
- Installing, altering, or uploading software, software patches, or scripts
- Modifying, damaging, or making additions to the Club device hardware in any way
- Any form of piracy, plagiarism, or copyright violations
- Accessing, downloading, or disseminating any material that exhibits violence, nudity, inappropriate or inflammatory images or language, and/or defamation of character, religion, race, creed, sexual preference, or gender
- By-passing or attempting to bypass any security measures
- No cell phones are permitted except for teen members. Cell phone use for teens is a privilege that can be revoked at any time due to misuse or inappropriate behavior.
- Cell phones may be taken by Club Staff if they deem necessary. They will be returned to the member or their parent/guardian at an appropriate time or at the end of the day.
Network Access & Security

No user may attempt to gain unauthorized access to the Club network or network resources. This includes any attempt to log on through an administrative account, access to another person's files, or replication of data without proper authorization. Network file storage is provided to all Club members. This storage space is not private and is subject to Club Staff review at any time. Users are prohibited from altering or duplicating another user's files without permission.

No user shall make deliberate attempts to disrupt the network or breach the integrity of its data and services via viruses, worms, or any other means. The network may not be used to engage in any illegal activity, for commercial purposes, or to threaten the safety of another person. If you have identified or witnessed a possible security breach, notify a Club Staff person immediately.

Members who accidentally access inappropriate materials are to turn off their monitor and report it to a Club Staff person immediately.
MEMBER TECHNOLOGY AGREEMENT
Acceptable Use Policy & Procedures for Boys & Girls Club of Hilton Head Island.

I realize that the use of club computers and the internet is a privilege. I understand that any inappropriate behavior may lead to disciplinary action and/or denial of this privilege. I understand that using computers, electronics, and the internet at the Boy & Girls Club of Hilton Head Island means I agree to the following:
- I will follow the rules in this document and use the internet for program purposes.
- I will use good judgment and respectful, appropriate language at all times.
- I will respect the rights of copyright owners and will not reproduce any work protected by copyright.
- I will not try to gain unauthorized access to any website, program, system, or file.
- I will agree to the Nets Smartz rules and never give out personal information such as my address or phone number, send pictures, or agree to a personal encounter with someone I meet online.
- I will promptly report any messages/communications that are inappropriate or make me feel uncomfortable to Club Staff immediately.
- I will not attempt to bypass or shut off the security measures on the computers or network.
- I will obey the Computer Lab Rules in the Technology Center.
Parent/Guardian Name:*
Member/Child's Name*

First NameLast Name
PARENT/GUARDIAN INTERNET CONSENT

As a parent or guardian of this child/children, I have read the Acceptable Use Police of the Boys & Girls Club of Hilton Head Island and give my permission for this child/children to use the internet. I understand that access to the Boys & Girls Club technology Center and programs is designed for educational purposes, and the Boys & Girls Club has taken precautions to educate members on appropriate use.

I understand that regardless of close supervision and monitoring, there will always be the possibility of my child/children coming into contact with inappropriate material and I will not hold the Boys & Girls Club of Hilton Head Island, the Boys & Girls Club of the Lowcountry, and/or Club Staff and Volunteers responsible.

I also accept full responsibility for any damage or expenses incurred as a result of inappropriate use of the internet or technology resources and agree to reimburse the Club in that amount.
Parent/Guardian Signature*
Type your Name
Date*

MonthDayYear
Date
THE BOYS & GIRLS CLUB OF Hilton Head Island GUIDANCE AND DISCIPLINE POLICIES
The staff of the Boys & Girls Clubs of the Lowcountry has developed the following guidelines and consequences for infractions within the facility, during programs, and on Club property. We create a Club culture of safety, respect, and kindness. It is important that staff speak positively to members at all times and address any negative behavior quickly in order to maintain our positive Club culture, to ensure the safety, well-being, and ability of the Club member to enjoy their Boys & Girls Club experience.

The following behaviors listed below (but not limited to) may result in a member losing playing/participation privileges within the club:
- Not abiding by the posted Boys & Girls Club behavior Expectations
- Refusing to cooperate, talking back, etc.
- Dangerous horseplay and physical contact
- Inappropriate language
- Repeated running in the club
- Eating outside of designated areas
- Cell phone usage outside designated areas
- Abusing equipment or facilities
- Leaving the area without permission
- Playing in the bathroom
- Bringing electronic devices to the club
Staff in a program space are designated to address behavior issues. After repeated behavior issues, a parent/guardian conference will be requested, which may result in a suspension.

The following behavior, listed below (but not limited to), may result in immediate suspension:
- Bullying
- Inappropriate sexual behavior
- Possessing a dangerous substance
- Racist behavior
- Egregiously disrespecting staff
- Stealing from the Club or Club Members
- Gambling
- Fighting or other physical aggression
This behavior may result in an immediate short-term suspension, usually ranging in length from 2 to 4 days, depending on the seriousness of the offense and the number of prior offenses. Parents/ Guardians will immediately be notified, and the club member will be pulled from the program and will wait by the front desk for pick-up. Please note that the Boys & Girls Club reserves the right to search a Club member's bag at any time if they feel that a member may be carrying something dangerous. The Boys & Girls Club also reserves the right to call the police or DSS, as mandated reporters, if deemed necessary.

The following behavior, listed below (but not limited to), may result in indefinite suspension from the club:
- Possession of a dangerous weapon
- Verbal or written threats of bodily harm
- Assaulting a staff member
- Vandalism of equipment or property
- Distribution and/or use of drugs or alcohol
- Repeated suspensions with no improvement in behavior
For parents, members, as well as staff's privacy and protection, only Club Directors are approved to speak to parents regarding any discipline issues. Club Directors may invite a staff member to be present at the meeting to answer questions, and a parent or guardian may request that a particular staff member be present in a conversation with a Director regarding their child/children for any reason. Please note that if the club member is suspended from Hilton Head Boys & Girls Club, they are suspended from all other Lowcountry Clubs.

Please sign below that you have received a copy of these disciplinary guidelines developed to ensure the safety, well-being and ability of your child/children to enjoy their time at Boys & Girls Club.
Parent/Guardian Signature*
Type your name
Date*

MonthDayYear
Date
THE BOYS & GIRLS CLUB of Hilton Head Island Parental Authorization to Release Records Information to the Boys & Girls Club
Boys & Girls Club of Hilton Head Island

151 Gumtree Road

Hilton Head, SC 29926

Parental Authorization to Release Records

to the Boys & Girls Club of Hilton Head Island

Please select the records and documentation you agree to share with the Boys & Girls Club upon request.
TranscriptAttendanceCounselingReport CardDiscipline RecordsTest ScoresSP ED (IEP, Speech)Gifted & Talented Academic
My Signature or Electronic Signature below authorizes the Beaufort County School District to release all personally identifiable data as indicated above in reference to my child.

If records are being received by the Boys & Girls Club of Hilton Head Island, my signature or electronic signature gives the Boys & Girls Club of Hilton Head Island Learning Coaches permission to assist with my child’s education.
Member/Child's Name*

First NameLast Name
Parent/Guardian Signature*
Type your name
Date*

MonthDayYear
Date
THE BOYS & GIRLS CLUB OF Hilton Head Island Mass Text Messaging Program Term and Conditions
Mass Text Messaging (MTM) Program Terms and Conditions

Service Description:
- Our Mass Text Messaging Service Program is used to maintain open communication lines quickly and effectively. The MTM program provides updated information to the Families of our members through the use of a Mass Text Messaging service. This provides critical information in emergency circumstances, updates to program structures and operational changes within the facility, reminders on current events and special events, changes to daily operations when they arise, and various other communication needs.

Agreement:
- By agreeing to opt in to BGCHHI’s MTM Program, participants agree to receive communications through text messages. BGCHHI will not share user data with external marketing groups, other members, or companies without the expressed permission of the user. BGCHHI will never sell users' personal data under any circumstances.
- BGCHHI does not charge a separate fee for receiving Text Messages through our MTM program; service provider charges may apply, to which BGCHHI is not responsible.
- Users can “OPT-OUT” of this service at any time by texting the word “STOP” to the short code from which users receive their messages. Additionally, Users can “OPT-IN” by texting “BGCHHI” to our 6-digit short code (484848).

Messaging Frequency:
- Text Messages will not exceed 10 messages per month unless an occurrence creates reasons to exceed that amount (weather threat, building security, early closures, etc.)Changes to the MTM Program:
- BGCHHI reserves the right to make changes to our MTM Program at any time. These changes will be communicated to users through this agreement. Users agree to periodically review this agreement to ensure that they are aware of any changes as they arise. Help Procedures:
- Should users need to contact support for help with BGCHHI’s MTM Program, they can find support at the contacts below:

• Ryan Wise
Area Director
ryan.wise@bgclowcountry.org

• Jaala L. Miller
Unit Director
jaala.miller@bgclowcountry.org

•Nilo Rosado
Data Specialist/Front Office
nilo.rosado@bgclowcountry.org

• Nitzeha Garcia
Front Office Manager
Office: 843-689-3646
nitzeha.garcia@bgclowcountry.org

Agreement Inclusion for Membership Application

I have read and agree to the Terms and Conditions of the BGCHHI MTM (Mass Text Messaging) program and agree to receive text messages from BGCHHI regarding weather emergencies, new updates, potential risks, and various other operational information (Standard service provider messaging rates apply).

Please list the best Mobile Number (capable of receiving text messages) below.
Best Phone Number for Text Messages Do not add spaces extra characters*
Should be Empty:

2025 - 2026 AFTERSCHOOL PROGRAM APPLICATION

MEMBER INFORMATION

PARENT / GUARDIAN INFORMATION

HOUSEHOLD DATA

EMERGENCY CONTACT INFORMATION

WAIVER OF LIABILITY AND PERMISSION STATEMENTS

HEALTH HISTORY

HEALTH HISTORY

ACCEPTABLE USE POLICY & PROCEDURE FOR BOYS & GIRLS CLUB OF HILTON HEAD ISLAND TECHNOLOGY

MEMBER TECHNOLOGY AGREEMENT

THE BOYS & GIRLS CLUB OF Hilton Head Island GUIDANCE AND DISCIPLINE POLICIES

THE BOYS & GIRLS CLUB of Hilton Head Island Parental Authorization to Release Records Information to the Boys & Girls Club

THE BOYS & GIRLS CLUB OF Hilton Head Island Mass Text Messaging Program Term and Conditions