LEARN TO PLAY A STRING INSTRUMENT
The Hawaii Youth Symphony offers its BEGINNING STRING ENSEMBLE class to students who want
to learn how to play the violin, viola, cello or bass. No experience is necessary, just interest and
commitment!
LOCATION:
Boys and Girls Club of Hawaii (BGCH)
Spalding Clubhouse, 2nd Floor
1704 Waiola Street
(Behind Washington Middle School, Corner of Waiola & Lokahi St)
TIME:
9:00 – 10:15 am
SEASON:
Every SATURDAY from Saturday, September 3, 2016 through April 22, 2017
*September 10 rehearsal is cancelled. BGCH is hosting a large event.
Winter Vacation: December 17, 24, & 31, 2016
Spring Vacation: March 18, 2017
INCLUDES:
♪
♪
♪
♪
Music retreat on Sunday, October 16, 2016
Winter Concert on Saturday, December 10, 2016
Music retreat on Sunday, March 5, 2017
Spring Concert on Saturday, April 22, 2017
CONDUCTOR:
Ms. Joan Doike
MINIMUM AGE:
All students must be at least 8 years old by 8/01/16 and entering grade 3
FEES:
Registration on or before August 24, 2016: $380 ($415 after August 24)
Instrument Rental for season: $135 – Violin/Viola; $180 – Cello/Bass
REGISTRATION DEADLINE: WEDNESDAY, AUGUST 24, 2016
The conductor will introduce students to the different instruments on the first day of class. Once students make their selection they will be sized for their
instrument. After sizing takes place, instrument pickup will be at the HYS office. We are open Monday – Friday from 9 am to 5 pm. The HYS office is located on
the second floor of the round, Varsity Building on University Avenue (where the Varsity Theater was located). Validated parking is available in the lot behind the
Varsity Building; lot entrance is on Coyne Street.
If funds are available, financial aid may be awarded for those who qualify. For more information and a financial aid application, please visit our website at
www.HiYouthSymphony.org/programs/financial-aid. We also offer Intermediate String Ensemble for students with at least one year of experience.
1110 University Avenue, Suite 200  Honolulu, Hawaii 96826
Phone: (808) 941-9706  Fax: (808) 941-4995
[email protected]  www.HiYouthSymphony.org
HYS ACADEMY: BEGINNING STRING ENSEMBLE
2016-2017 Registration Form
CHECKLIST OF ITEMS NEEDED FOR A COMPLETE APPLICATION:




HAWAII YOUTH SYMPHONY APPLICATION: Thr ee (3) pages complete with signatures.
BOYS & GIRLS CLUB APPLICATION: Four (4) pages complete with parent & child’s signatures where required.
Everyone, including current BGCH Club members, must turn in this form because a new ID card is made each year.
PROOF OF AGE: If you ar e a new student, submit a copy of your bir th cer tificate, gover nment –issued photo
ID or passport. (Proof of Age is NOT required if you were a member of BGCH during the 2015-2016 season.)
REGISTRATION FEE (See payment options below)
Please mail ALL forms listed above and fee to HYS, 1110 University Avenue, Suite 200, Honolulu, HI 96826-1598.
The completed forms & registration fees are due by Wednesday, August 24, 2016.
ANY FORMS POSTMARKED AFTER AUGUST 24 MUST INCLUDE A $35 LATE FEE.
Student Name ________________________________________________________________________________
first
middle initial
last
Address _____________________________________________________________________________________
Number
Street name
Apt #
City
Instrument you want to play:  Violin  Cello  Viola  Bass
State
Zip
 Male  Female
Gender:
Birthdate_____________ Grade in 2016-17_______________ School in 2016-17___________________________
Describe your music experience (e.g., years of lessons, classes, etc) ______________________________________
____________________________________________________________________________________________
Father/Guardian
Mother/Guardian
Salutation (i.e. Mr. or Ms.)
Name (First & Last)
Cell Phone
Email address
REGISTRATION FEES: (REGISTRATION FEES ARE NON-REFUNDABLE after the first rehearsal)
Registration Fees
Late Fee (if postmarked after August 24, 2016)
Optional: Instrument Rental Fee (in full)
Optional: Tax Deductible Donation
$380
$35
$135 violin/viola or $180 cello/bass
Mahalo for your donation
TOTAL
$
$
$
$
$
PAYMENT METHOD (choose only one)
 I am including full tuition payment with my registration forms.
 I am including the Installment Payment Agreement with my registration forms (for credit card use only)
To apply for financial aid, please complete the attached financial aid forms. All aid will be on a reimbursement basis.
PAYMENT TYPE
 CASH
CREDIT CARD:
 CHECK
 MASTERCARD
 VISA
 AMEX
 DISCOVER
Name on Card ___________________________________________________________________
Card # ___________________________________________ Exp Date ___/___ CVC #_________
Signature of card holder: ___________________________________________________________
(an $8 handling fee will be added to payments made by credit card)
CHECK:
Check Number ______Check Date______Check Amount _____(There is a $25 returned check fee)
Page 1 of 3
CONFIDENTIAL INFORMATION
Release for Emergency Care
To whom it may concern:
I hereby give my consent to any emergency facility and/or physician to administer
treatment that such facility or physician may deem necessary or appropriate to my
child.
In the event of an emergency during which I cannot be reached, I give consent to
transport by ambulance if the situation warrants it.
I understand that I will be responsible for all expenses associated with above medical
treatment. I will defend, indemnify and hold Hawaii Youth Symphony and its officers,
directors, agents, volunteers and attorneys harmless from and against any damages,
liabilities, claims, costs or expenses arising from any such medical treatment.
Student Name: ___________________________________________________________________
Physician's Name: __________________________________________Phone_________________
Physician’s Address_______________________________________________________________
Medical conditions (i.e. allergies, asthma, etc.):
_______________________________________________________________________________
_______________________________________________________________________________
Medications currently taking:_______________________________________________________
Medical Insurance Plan Covering Child: ______________________________________________
Policy #: _________________________ Policy Holder’s Name: ___________________________
______________________________________
Father/Guardian’s Signature & Date
___________________________________
Mother/Guardian’s Signature & Date
IT IS THE PARENT/GUARDIAN’S RESPONSIBILITY TO NOTIFY
HYS OF ANY CHANGES IN THE ABOVE INFORMATION.
Page 2 of 3
PARENTS/VOLUNTEERS/STUDENTS: PLEASE READ CAREFULLY!
Parents must understand and agree to the following:
One of the aims of HYS is to promote the musical and personal development of its members by providing
opportunities to learn and perform challenging orchestral music. My child has my permission to participate in
HYS events and concerts. I agree to waive all claims against HYS for any injury or property damage that my
child may incur. I also give permission for my child to participate in any HYS-sponsored recreational
activities. I waive any claim, suit, or other legal action against HYS in the event that my child suffers any
injuries as a result of his/her participation in any HYS concerts, events or recreational activities.
I understand that all reasonable safety precautions will be taken at all times by HYS. I also understand the
possibility of unforeseen hazards. In consideration of my child’s participation with HYS, I agree to indemnify
and hold harmless HYS, its employees, volunteers, and agents, contracted or otherwise, from any liability for
injury, diseases, or any damages resulting from said participation. My signature also binds my child and me
to the students’ agreement below.
Volunteers must understand and agree to the following:
I understand that parents and guardians are asked to volunteer with HYS related events. These events include,
but are not limited to, providing general assistance at weekly rehearsals and concert events. I realize that
volunteers may be asked to provide help in physically moving and setting up instruments and other orchestra
equipment prior to or after rehearsals and concerts. I also realize that volunteers may be asked to provide help
in the sales of merchandise, general office chores, taking attendance, running errands, answering questions
and providing scheduling information. I waive any claim, suit, or other legal action against HYS in the event
that I suffer any injuries as a result of participation in any HYS volunteer activities. I agree to release and
hold harmless the HYS employees, volunteers, and agents, contracted or otherwise, from any liability for
injury, diseases, or any damages resulting from my participation as a volunteer in any HYS sponsored
activities. I agree that the opportunity to participate in providing volunteer services at any HYS sponsored
events constitutes good consideration for this release. I also understand that, as a condition of volunteering, I
may be subject to a criminal or other background check. (Further information regarding this process is
available upon request.)
Students must understand and agree to the following:
Student musicians of HYS are expected to maintain high standards of personal conduct. The following
behaviors are strictly prohibited: cigarette smoking; gambling; cohabitating; selling, possessing, consuming,
or being under the influence of illegal drugs, narcotics, hallucinogens, or alcohol. Such behavior will lead to
immediate expulsion from HYS. Conductors will not tolerate texting, phone calls or use of any electronic devices during rehearsals.
I give HYS permission to make, adapt, publish, distribute, publicly perform, transmit, display and/or
otherwise use audio and video recordings and photographic images of me for archival, fundraising and
publicity purposes. I hereby release HYS and its audio and video recorders and photographers from any and
all liability for use of my publicity rights, including my name, voice or likeness, whether alone or in
composite form. I understand that the audio and video recorders, photographers and HYS can use any artistic
procedure for composition needed to produce a product, publication or display, for promotional (including
fundraising) reasons.
I have read and understand all Hawaii Youth Symphony (HYS) policies outlined above. By signing below, I am indicating
that my parents and I have also read the 2016-17 HYS handbook, and fully understand its contents and implications.
_________________________________
_________________________________
Father/Guardian’s Signature & Date
Mother/Guardian’s Signature & Date
_________________________________
__________________________________
Student’s Signature & Date
PRINT Student’s Name
Page 3 of 3
Financial Aid Program FAQ
2016 – 2017 Season
Why was the financial aid program established?
The Financial Aid Program was established over twenty-five years ago to offer all of HYS’s young musicians
equal opportunities to participate in every aspect of the HYS program regardless of financial conditions. Because
of state, corporate, and private donations, all HYS students receive "financial aid" of sorts. The registration fee
required is only a fraction of the cost of running the HYS program, currently more than $1,200 per student.
However, HYS realizes there are families who may still find it difficult to cover the non-subsidized portion of the
fee. The Financial Aid Program ensures that all students will be able to benefit from our program.
Where do the funds come from?
The Michael Nakasone Legacy Scholarship Fund in Honor of Youth Symphony II was created in 2010 thanks to a
generous donation from the late Ms. Olivia De Jane. Financial aid awards draw from the Nakasone Legacy Fund,
and other funds, in hopes that no student will be turned away.
What expenses do these funds cover?
The financial aid program will subsidize financially deserving students on a reimbursement basis in one or more
of the following ways:
1. Partial aid for private lessons: up to $150 per semester
2. Partial aid for registration fees: up to 50% per person.
3. Partial aid for instrument rental fees: up to 50% per season (only for instruments rented from HYS).
On what factors are awards based?
Awards are based on financial need, not on the musical ability of the applicant. Consideration is given to each
student's attitude and evidence of responsibility (i.e. rehearsal attendance and preparedness). The majority of
recipients make the most of what the Financial Aid Program can offer, as reflected by teacher evaluations. Out of
hundreds of recipients, there have been only a few students in recent years whose subsidies have not continued
because of poor preparation, tardiness and/or poor attitude. In these cases, the amounts allocated were given to an
alternate applicant.
Can I declare my award as a scholarship award on my college application?
No. HYS's Financial Aid Program is not a scholarship program and should not be referred to as such. Selections
are based on financial need and not musical ability.
How can I apply for financial aid?
First, you must submit the appropriate Registration Forms for the class you want to apply the aid to, by the due
date on the Registration Forms. Then send a completed Financial Aid Application and return it to the office, with
a copy of the first two pages of your 2015 Federal Income Tax Return (Form 1040) by Saturday, September 17,
2016. More information may be requested from you at a later time to better assess your need.
Please note: If you are applying for the Financial Aid Program, payment is still required at the time of
registration. Financial aid awards will be granted after the registration deadline on a reimbursement basis. Refer to
the first page of the Registration Form for two payment options: 1) Full payment; or 2) Payment by installment
(you must fill out the installment agreement if choosing this latter option). If you choose full payment at the time
of registration and are awarded financial aid, a reimbursement check will be issued and mailed to the student. If
you choose payment by installment and are awarded financial aid, your credit card will only be charged for two of
the four installments. If private lessons are included as part of your financial aid package, the parents are still
responsible for paying the private teachers. A reimbursement check will be issued to the student once a semester.
Have more questions?
If you are looking for other payment options or have any general financial aid questions, call our office at
941-9706 or e-mail [email protected].
1110 University Avenue, Suite 200  Honolulu, HI 96826-1508  Phone: (808) 941-9706  Fax: (808) 941-4995
www.hiyouthsymphony.org  [email protected]
1110 University Avenue, Suite 200  Honolulu, HI 96826-1508
Phone: (808) 941-9706  Fax: (808) 941-4995  E-mail: [email protected]
2016-2017 FINANCIAL AID APPLICATION
DEADLINE: Saturday, September 17, 2016
PLEASE NOTE: Financial Aid funds are limited. In order to effectively award funds to
musicians, the Financial Aid Committee asks that you seriously consider your need for assistance
prior to submitting this application. Each applicant will be notified in writing of the Committee’s
decision. All information provided will be held in strictest confidence. HYS reserves the right to
request additional information if needed. Please note:
No person shall receive 100% tuition assistance.
All applicants can expect to pay, at minimum, 50% tuition to participate in HYS.
Please refer to the two tuition payment methods on the first page of the registration form.
PERSONAL INFORMATION
Student Name ________________________________ Phone _________________ Group ________
Address __________________________________________________________________________
City
Zip Code
School ________________________________ Grade _______ Instrument ____________________
Father/Guardian
Mother/Guardian
Name
Marital Status
Occupation
Place of Employment
Work Phone
Work Fax
Cellular Phone/Pager
E-mail
Please note: If you are awarded financial aid and chose the full tuition payment method, a reimbursement check
will be issued to the student and mailed to the address listed above. If you are awarded financial aid and chose the
installment payment method, your credit card will only be charged for two of the four installments. If private
lessons are included in your financial aid package, the parents are responsible for paying the private teachers. A
reimbursement check will be issued to the student once a semester.
Continue to next page
Confidential Information
Student Name: _______________________________________________________________________
I am applying for assistance with: (You may check more than one)

Private lessons
up to $150/semester

Registration fees
up to 50%

Instrument rental
up to 50%
Is this a single parent/guardian household?  Yes  No
Including the student, how many children under the age of 18 are living in your household? _________
Other dependents?  Yes  No
Please Specify: _________________________________________
Do you qualify for the Federal Free and Reduced Price School Meal Program?  Yes
Do you currently take private lessons?  Yes
 No
 No
Are there any special financial circumstances you feel the Committee should consider while evaluating
your application? Attach additional pages, if necessary.
In order to be considered for financial aid, please submit a copy of the first two pages of your 2015
Federal Income Tax Return (Form 1040). If married, but filing separately, please submit copies of
each return.
I certify that the above information is true and correct. If awarded financial assistance, we agree to
participate in a HYS orchestra for the full 2016 – 2017 season and understand that, if we do not fulfill
this obligation, we will be asked to repay all financial aid funds awarded.
_____________________________________________________________
Parent/Guardian Signature
____________________________________
Date
Mail completed application with a copy of the first two pages of your 2015 Federal Income Tax
Return (Form 1040) by Saturday, September 17, 2016 to:
HYS
c/o Financial Aid Program
1110 University Avenue, Suite 200
Honolulu, HI 96826-1508
Membership Information Form
For Office Use Only
KidTrax ID
Charles C. Spalding Clubhouse
1704 Waiola Street
Honolulu, HI 96826
Member Status Active
 New
 Renewing
 Former
HYS Academy Students only:
The Annual Membership Fee ($25) will be paid by HYS.
Membership is complete only with an attached copy of PROOF OF AGE 
(ie birth certificate or ID) and with a signed GUIDELINE FORM. 
Member ID
 Active
 Inactive
Data Entry
Rec’d:
Entered:
ID Issued:
Comment:_________________
__________________________
__________________________
__________________________
Membership Dates
Service:
Termination:
Initial:
Renewal:
Please Print in Ink or Type
First Name:
Member
(Please Print)
Name of Person Member Lives With:
Middle Name:
Last Name:
Home Phone Number:
Emergency Contact Name & Relation:
Home Address:
Emergency Phone & Extension:
City:
State:
Postal Code:
Email Address:
Demographic
Gender:
 Female
 Male
School Name:
Birthdate:
Age:
Ethnicity:
Grade:
Family Totals - Sisters:
Brothers:










African American
Cambodian
Caucasian
Chinese
Filipino
Hawaiian/Pt. Haw’n
Hispanic
Japanese
Korean
Laotian










Marshallese
Micronesian
Native American
Pacific Islander
Portuguese
Samoan
Thai
Tongan
Vietnamese
Other
Lives With: (Circle One)
Household:
Member before?  Yes
 No
Both Parents Mother Father Sister/Brother Grandparent Aunt/Uncle Guardian Other
Number of Years:
Name of Clubhouse:
Parent/Guardian Information: (Please Print)
Father’s First Name:
Father’s Last Name:
Father’s Employer:
Father’s Occupation:
Mother’s First Name:
Mother’s Last Name:
Mother’s Employer:
Mother’s Occupation:
Guardian’s First Name:
Guardian’s Last Name:
Guardian’s Employer:
Guardian’s Occupation:
Father’s Work Phone & Ext:
Mother’s Work Phone & Ext:
Guardian’s Work Phone & Ext:
Medical/Emergency
Medical Problems/Allergies:
Medications:
Physician:
Physician Phone:
Preferred Hospital or Clinic:
Hospital Phone:
Insurance Company:
Insurance Policy Number:
Can Member Swim?
General Information
 Yes
 No
Notes
Participation in other Youth Programs: Hobbies:
Military Branch:
Status:
Start Date:
End Date:
Phone number:
E-mail:
Mother’s Maiden Name:
Nickname:
Confidential The following information is necessary for our records and the funding our Organization receives. The answers you provide are completely
confidential. Your cooperation in providing this information is both appreciated and necessary.
Medicaid Number:
Check all that Apply:
Annual Family Income: (Circle One)
$23,000 or below
$23,001 - $30,000
*Income data is confidential
and used to secure grant
funding to keep membership
cost to a minimum.
$30,001 - $42,750
 SSDI
 SSI
 TANF
 Day Care Voucher
 Food Stamps
 General Assistance
 Free School Lunch
 Vet. Compensation
 Medicaid
Child’s Labor Force Status:
Employed
Not in Labor Force
Unemployed
Unknown
Child’s Family Setting:
1 Parent Family
2 Parent Family
Extended Family
Other
Unknown
Disability:
$42,751 - $79,250
Hearing Impaired
Vision Impaired
Other: __________________________
$79,251 - $99,999
$100,000 and above
Confidential
 Foster Child
 Adjudicated
 Status Offender
Care not to Provide*
Education:
Held Back
Poor Attendance
Poor Grades
Drop Out
I have read the completed application, understand the rules of the Boys & Girls Club of Hawaii and request that my son/daughter/ward be admitted into membership. I have
explained the rules to my son/daughter/ward and agree that the Boys & Girls Club of Hawaii will not be responsible for any accident to my child while on the premises or while
engaged in any of its activities. I hereby give permission for images on my son/daughter/ward, captured during regular and special activities through video, photo, and digital camera,
to be used solely for the purposes of Boys & Girls Club of Hawaii promotional material and publications, and waiver any rights of compensation or ownership thereto.
I give permission for my child to participate in a survey to measure the effectiveness of the Life Skills Training program. This survey will be given at the beginning and ending of the
program and will ask questions about tobacco, alcohol, and drug use by my child and his/her knowledge and attitudes concerning alcohol, tobacco and drug use. I UNDERSTAND
THAT MY CHILD’S ANSWERS TO THESE SURVEY QUESTIONS ARE STRICTLY CONFIDENTIAL.
Parent or Guardian Signature
Youth’s Signature
Date: Month ______ Day ______ Year ______
Applicant Information.8/1/10
Subject to change.
Charles C. Spalding Clubhouse – Member & Parent Guidelines
Drop-In Policy
The Charles C. Spalding Clubhouse offers a drop-in program with an Open Door Policy. Members are asked to scan in and out with their
membership card when they enter and exit the facility. Members are allowed to come and go at will throughout the program day, but
they may only enter and exit the facility once. Youth will not be allowed to re-enter the Club once they choose to leave for the day.
Youth must wait inside the Club for their parents or leave the premises to walk home - they may not wait outside for their parents.
Parents must wait for their children at the front desk and are not allowed past the front desk without a prior appointment and visitor
pass. The BGCH is not a licensed daycare agency.
Front Desk Fines
If members do not have their ID with them when they enter the Club, they must pay $1.00 to enter. If members do not have $1.00 they
will receive an IOU note and the parents will be notified. Fines will increase for each day they do not have a dollar or their ID card. If
they have lost/damaged their ID and need a new one, new IDs are $5.00. Parents are encouraged to have youth pay fines with their
allowance or own money to help them learn responsibility and accountability. For every 15 minutes after the Club closes that a parent
is late to pick up his/her child, they will be charged $5. After 1 hour, the police will be called to pick up the child.
What the Club Offers
The Club is a positive place that offers many educational, recreational and social activities. More specifically, our programs promote
Academic Success, Good Character & Citizenship, and Healthy Lifestyles. Any youth who becomes a member may participate in all
programs and activities offered by the Club (although some age restrictions may apply for certain programs). Caring and trained youth
development professionals and outcome-based programs provide guidance in helping members to: discover needs, set goals, pursue
interests and nurture talents, as well as broaden viewpoints, dissolve prejudices and resolve conflicts.
The Five Main Rules of the Club
· Respect the adult leaders
•Follow instructions, be polite and kind, and listen when adults are speaking to you
· Respect your peers
•Keep your hands to yourself - physical aggression is absolutely unacceptable
•Teasing, threatening, intimidation and other forms of bullying are not allowed
•Leave your peers’ belongings alone - do not steal or take what is not yours
· Respect yourself
•Behave in a way that makes you proud of yourself - no swearing or abusive language
•Be honest and tell the truth when solving conflicts
· Respect the place
•Recognize that the Club is a positive environment used by many youth that needs to be safe
•Take care of program equipment - use it gently, put it back after using it, and use it as intended
•Keep program spaces neat - throw out trash and clean up after yourself
•Weapons of any kind (or items that are used to injure another person) are not allowed
•Possession of (or paraphernalia related to) alcohol, tobacco or illegal drugs on site is prohibited
HAVE FUN!
•Try new programs, get involved and participate and be open to things that are different
Consequences
Consequences at the Club depend on how the member was being disrespectful. If there is an opportunity to remedy the situation, the
member will be asked to do that first. Disagreements and conflicts between children are handled with conflict resolution guided by a
program staff. Additionally, members may be asked to complete community service to give back to the Club. If the issue is more
severe, parents will be notified of the situation and the consequences that were applied to create a solution. If the child repeatedly
demonstrates the same problem, they may be asked to leave the Club for a period of time. Any issues relating to physical violence,
possession of weapons or possession of illegal substances will result in automatic suspension. The Club member will be asked to leave
the Club for a period of time determined by the Club Director and a parent meeting will be required with a behavioral contract before
the member may participate at the Club again.
Club Tee Shirts
All children participating in a Club-sponsored activity off-site are expected to wear a Club tee shirt. If they are not wearing a Club tee
shirt, they will not be permitted to attend the excursion. Parents may verbally agree to cover the cost of the shirt when they pick their
child up at the end of the day and the Club will provide the child with a new tee shirt.
Lost and Damaged Items
The Boys & Girls Club of Hawaii and the Spalding Clubhouse will not be responsible for any lost or damaged items. Youth members are
encouraged to leave all valuables at home.
Parent Signature: ____________________________
Member Signature: _________________________
Date: _________
National Youth Outcomes Initiative Survey
Our Club takes part in an annual survey that is used to track the wellbeing of members in Boys & Girls Clubs nationally. Our Club is one of
a group of Clubs across the country participating in this survey that asks how members feel about the activities and time they spend at the
Club, education plans, and involvement in community service and work.
Additionally, the survey asks about the attitudes and health behaviors of Club members, including questions about nutrition and physical
activity. Only teen members aged 13 and older are asked additional questions around alcohol, tobacco and other drug use, fighting,
arrests, and whether teens are sexually active.
Members will be asked to fill out one survey in the spring during regular Club hours. The survey takes 30-45 minutes to complete, and will
be administered online. Participating in this survey will cause no risk to your child. The only potential risk is that some teen members might
find certain questions to be sensitive. The survey has been designed to protect your child’s privacy. Members will not put their names on
the survey, and no member will ever be mentioned by name in a report of the results. All information from the survey is being used to
assess the wellbeing of Boys & Girls Clubs members and will be kept completely confidential. Only the Boys & Girls Clubs of America
national organization that is conducting the survey will have access to the data. Others will see only reports of the information combined for
groups of youth in the study or all youth at a Club. No reports will be shared that show your child’s answers on the survey.
Your child will get no benefit right away from taking part in the survey. The results of this survey will help your child and other members of
Boys & Girls Clubs in the future by assisting all national Boys & Girls Clubs to develop programming that best meets members’ needs. We
would like all members at our Club to take part in the survey, but the survey is voluntary. No action will be taken against the Club, you, or
your child if he/she does not take part. Additionally, survey participants can skip any questions they do not wish to answer and may stop
participating in the survey at any point without penalty. If you would like to see the survey, a copy is available at the front desk. You may
review the survey at the Club during regular Club hours between 11:00am-7:00pm.
___ I give permission for my child to participate in the BGCA National Youth Outcomes Initiative Survey.
___ I do not give permission for my child to participate in the BGCA National Youth Outcomes Initiative Survey.
Project Learn Mentoring Program
With the support of funding from the BGCA national office the Spalding Clubhouse implements the comprehensive Project Learn Mentoring
Program. Project Learn provides the framework for nearly all programs in the Club to provide our youth members with opportunities for
learning and education through high yield learning activities, or programs that educate youth through fun and engaging activities. All
programs within the Project Learn framework are led by knowledgeable adult staff members that serve as mentors to the youth in the small
group program. Project Learn aims to enhance youth development in the following areas: health & well-being, positive self-identity, civic
and community involvement, moral compass and competencies (education, employment, social, emotional and cultural).
The following programs at the Spalding Clubhouse are examples of programs that fall within the Project Learn Framework:
Power Hour is a homework help and guidance program that creates time and space for youth to complete their assignments and other
additional learning exercises with the assistance of our trained program staff and volunteer tutors.
Healthy Habits is a program designed to teach youth healthy eating habits, dietary guidelines and how to make simple recipes for
breakfast, lunch and dinner.
Girl Power is a program for girls ages 7-12 that encourages girls to make positive choices in their life, how to maintain healthy friendships
and relationships, and to explore a variety of career options.
Man Hour is aimed toward Club boys ages 10-14 to give them guidelines to understand what it means to be a responsible, respectable
man in the Club, in their communities and within their families.
weRead is a read-aloud, read-along program for elementary youth that promotes increased literacy in a pressure-free environment with a
focus on non-fiction books to increase understanding in the sciences.
Charlie’s Snack Shop is a job training program for Club youth to introduce them to the world of employment in the Club snack shop.
Youth must complete an application, interview and training to become staff members of Charlie’s.
Mad Science encourages youth to exercise their curiosity and learn more about physics, chemistry and biology through a variety of handson experiments.
Media programs in the iMac computer lab are aimed to increase computer literacy and introduce youth to a variety of digital arts including
photography, graphic design and filmmaking.
Financial Literacy teaches teen youth the foundations of budgeting, creating a savings, spending wisely and making financial decisions for
their future.
Torch Club and Leaders in Training (for teens) are service-learning programs that connect Club youth to their communities and broaden
their world views.
To best implement our mission, all youth in the Club will be encouraged to participate in programs such as these on a regular basis to
enable them to become responsible citizens.
I, the parent or legal guardian for ____________________________________ hereby give my permission for my child to participate in the
Project Learn Mentoring program at the Boys & Girls Club. I understand that my child will be guided by paid staff and/or volunteer mentors,
all of which have been screened (including a criminal background check) and trained before beginning the program. I give the Boys & Girls
Club Unit Director permission to obtain my child’s academic and attendance records from my child’s school.
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Signature of Parent/Guardian
Printed Name of Parent/Guardian
Date